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Maurer MS, Soman P, Hernandez A, Garcia-Pavia P, Signorovitch J, Wei LJ, Hanna M, Ruberg FL, Kittleson M, Kazi D, Dorbala S, Hsu K, Lousada I, Adigun R, Dunnmon P, Kelly J, Gillmore J. Advancing Transthyretin Amyloidosis Drug Development in an Evolving Treatment Landscape: Amyloidosis Forum Meeting Proceedings. Adv Ther 2024; 41:2723-2742. [PMID: 38833142 DOI: 10.1007/s12325-024-02891-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/29/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Hereditary transthyretin amyloidosis (ATTRv, also referred to as hATTR; ORPHA 271861) and wild-type ATTR amyloidosis (ATTRwt; ORPHA 330001) are rare, progressive, systemic protein misfolding disorders with heterogeneous clinical presentations. ATTRv and ATTRwt amyloidosis are characterized by the deposition of amyloid fibrils in multiple organs including the heart, nerves, eyes, and soft tissues. The management of ATTR amyloidosis is complex because of its multisystemic nature and progression despite available treatment options. Morbidity is high and there are many unmet medical needs for patients. While contemporary ATTR amyloidosis cohorts are diagnosed earlier, have lower risk disease and lower mortality compared with the previous era, these advances coupled with the emergence of effective disease-modifying therapies have confounded the design of future prospective clinical trials and interpretation of historical control data. MAIN BODY The Amyloidosis Forum is a public-private partnership between the US Food and Drug Administration Center for Drug Evaluation and Research and the nonprofit Amyloidosis Research Consortium ( www.arci.org ). This article summarizes proceedings from the 21 June 2023 Amyloidosis Forum on advancing drug development in ATTR amyloidosis in an evolving treatment landscape. The Forum focused on elements of clinical trial design to address these challenges and discussed their strengths and weaknesses from multiple stakeholder perspectives (i.e., patient, sponsor, statistician, clinician, and regulatory authorities). CONCLUSION Given rapid evolution of natural history in ATTR amyloidosis, the utility of historical control data is limited. Leveraging contemporary real-world data is essential for clinical trial design. Evidence generation from clinical trials should address clinically relevant questions. Key factors in successful trial design must be informed by up-to-date data on natural history, prognostic factors, clinically meaningful thresholds, and sharing available clinical trial data. The Amyloidosis Forum includes the community of patients with ATTR amyloidosis, the physicians who treat them, and the sponsors and regulators who collectively stand ready to support further studies in order to develop novel effective therapies.
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Affiliation(s)
- Mathew S Maurer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Prem Soman
- University of Pittsburgh Medical Center, UPMC Heart and Vascular Institute, Cardiac Amyloidosis Center, Pittsburg, PA, USA
| | - Adrian Hernandez
- Duke University School of Medicine, Duke Clinical Research Center, Durham, NC, USA
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain
- Spanish National Cardiovascular Research Institute (CNIC), Madrid, Spain
| | | | - L J Wei
- T.H. Chan School of Public Health, Biostatistics, Harvard University, Boston, MA, USA
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Frederick L Ruberg
- Chobanian and Avedisian School of Medicine, Department of Medicine, Boston University, Boston, MA, USA
| | | | - Dhruv Kazi
- Beth Israel Deaconess Medical Center, Cardiac Critical Care Unit; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Health Economics, Boston, MA, USA
| | - Sharmila Dorbala
- Brigham and Women's Hospital, Cardiovascular Medicine, Nuclear Radiology, Boston, MA, USA
| | - Kristen Hsu
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA
| | - Isabelle Lousada
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA.
| | - Rosalyn Adigun
- Center for Drug Evaluation and Research, Division of Cardiology and Nephrology, US Food and Drug Administration, Silver Spring, MD, USA
| | - Preston Dunnmon
- Janssen Research and Development Data Sciences, Cardiovascular/Metabolic and Pulmonary Hypertension, Raritan, NJ, USA
| | - Jeffery Kelly
- Department of Chemistry, Scripps Research Institute, San Diego, CA, USA
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Alcantara M, Mannan S, de la Cruz J, Bril V. Value of multi-modality small fiber assessments in a genotypically diverse cohort of transthyretin-related amyloidosis in the early stages of disease. Med Clin (Barc) 2024; 162:e64-e69. [PMID: 38616431 DOI: 10.1016/j.medcli.2024.02.012] [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: 09/01/2023] [Revised: 02/10/2024] [Accepted: 02/17/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Transthyretin-related amyloidosis (ATTRv) is a progressive multisystem disorder, predominantly involving the peripheral nerve system (PNS) and heart. Quantification of small fiber damage may help guide treatment decisions, as amyloid deposits frequently affect those fibers early in disease course. Corneal confocal microscopy (CCM) is a promising method to monitor patients with ATTRv, due to similarities between corneal nerves and PNS, as the cornea is innervated by Aδ and C fibers. METHODS We compared CCM measures from ATTRv patients to a group of healthy individuals, matched by age and gender. We then investigated the correlations between small fiber tests (SFT): CCM, LDI-Flare and CDT, COMPASS-31 and disability scales (RODS and ONLS) in patients. RESULTS Of 20 patients (6 with V30M), mean age 50.3±15.3Y, 7 female (35%), six (30%) had polyneuropathy and 10 (50%) carpal tunnel syndrome. CDT was abnormal in 9 and LDI-flare in 6 patients. CCM was abnormal in 19 tested patients and significantly reduced when compared to controls (CNFL: 6.31±0.31 vs. 15.21±1.02mm/mm2, p<0.001). Mean COMPASS-31-scores were 22.27±22.84; RODS and ONLS were 38.15±12.33 and 2.05±2.3, with no significant differences between sub-group scores. Disease duration was significantly correlated with ONLS (0.43, p=0.05) and RODS (0.46, p=0.03). There were no significant correlations between measures of disability and SFT. CONCLUSIONS In a diverse cohort of ATTRv patients, CCM was the most frequent abnormal measurement. CCM can be a useful test to triage patients in the early disease stages and with few or equivocal symptoms.
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Affiliation(s)
- Monica Alcantara
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Shabber Mannan
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - James de la Cruz
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Prosserman Family Neuromuscular Clinic, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.
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Agarwal N, Sharma S, Sultan J. Chemistry, Biological Properties, and Bio-analysis of Tafamidis, a New Transthyretin Stabilizer: A Systematic Review. Cardiovasc Hematol Agents Med Chem 2024; 22:121-130. [PMID: 38031770 DOI: 10.2174/0118715257250153231011062855] [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: 03/16/2023] [Revised: 07/25/2023] [Accepted: 08/15/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Cardiomyopathy is a global health crisis that affects people all over the world. Consequently, scientists felt compelled to look for and develop ever-more-powerful pharmaceuticals. For ATTR-CM, the only drug currently recommended by the European Society of Cardiology is Tafamidis. OBJECTIVES The primary aim of this review article is to understand the chemistry, pharmacodynamic, pharmacokinetic, and bio-analytical methods available for Tafamidis. METHODS A systematic review of the existing resources was accomplished up to 2022, comprising existing studies forming the database covering the existing resources from Web of Science, ScienceDirect, and PubMed. RESULTS The review was based on a systematic review of all the existing studies used to formulate the database. The study also illustrated the PRISMA design that systematically analyses the prevalent resources. CONCLUSION Minimal analytical techniques are observed for quantifying the Tafamidis and transthyretin kinetic stabiliser. Therapeutic, pharmacological, and analytical considerations for the novel drug Tafamidis are discussed in this review. Particular attention is paid to the many different analytical and bioanalytical methods currently available for estimating Tafamidis, and the need is highlighted to develop a straightforward, validated technique that meets green chemistry standards.
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Affiliation(s)
- Nikhil Agarwal
- Department of Quality Assurance, Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS Deemed to be University, Vile Parle West, Mumbai, Maharashtra, 400056, India
| | - Sanjay Sharma
- Department of Quality Assurance, Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS Deemed to be University, Vile Parle West, Mumbai, Maharashtra, 400056, India
| | - Jasira Sultan
- Department of Quality Assurance, Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKM's NMIMS Deemed to be University, Vile Parle West, Mumbai, Maharashtra, 400056, India
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Frizziero L, Salvalaggio A, Cosmo E, Cipriani A, Midena E, Briani C. Ophthalmological involvement in wild-type transthyretin amyloidosis: A multimodal imaging study. J Peripher Nerv Syst 2023; 28:586-596. [PMID: 37552555 DOI: 10.1111/jns.12589] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND AND AIMS Ophthalmological abnormalities have been reported in hereditary transthyretin-related amyloidosis (ATTRv, v for variant) but not in wild-type transthyretin-related amyloidosis (ATTRwt). METHODS Patients with ATTRwt, ATTRv, and light chain amyloidosis (AL) and healthy subjects (controls) underwent complete eye examination, including optical coherence tomography (OCT), OCT angiography (OCTA), and in vivo corneal confocal microscopy (CCM). RESULTS Seventeen ATTRwt, nine ATTRv, two ATTRv carriers, and seven AL patients were enrolled. Compared with other groups, ATTRwt patients had 10 letters lower visual acuity and a higher prevalence of glaucoma, cataract, and retinal pigment epithelium alterations. In the whole group of patients, especially in ATTRwt, we observed (1) a reduced corneal nerve fiber length and more tortuous stromal nerves at CCM, (2) a reduced macular volume and peripapillary nerve fiber layer thickness at OCT, and (3) impairment of peripapillary and macular vascularization at OCTA. INTERPRETATION Ophthalmological abnormalities are common in ATTRwt, significantly impairing visual acuity. Noninvasive imaging modalities allow for the identification of small nerve fibers and small vessel damage, which may represent further warning signs for early diagnosis of ATTRwt.
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Affiliation(s)
- Luisa Frizziero
- Department of Neuroscience-Ophthalmology Unit, University of Padova, Padova, Italy
| | | | - Eleonora Cosmo
- Department of Neuroscience-Ophthalmology Unit, University of Padova, Padova, Italy
| | - Alberto Cipriani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, Cardiology Unit, University of Padova, Padova, Italy
| | - Edoardo Midena
- Department of Neuroscience-Ophthalmology Unit, University of Padova, Padova, Italy
- IRCCS-Fondazione Bietti, Rome, Italy
| | - Chiara Briani
- Department of Neuroscience-Neurology Unit, University of Padova, Padova, Italy
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Tsai FJ, Jaeger M, Coelho T, Powers ET, Kelly JW. Tafamidis concentration required for transthyretin stabilisation in cerebrospinal fluid. Amyloid 2023; 30:279-289. [PMID: 36691999 PMCID: PMC10363573 DOI: 10.1080/13506129.2023.2167595] [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: 10/06/2022] [Revised: 12/21/2022] [Accepted: 01/07/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Hereditary transthyretin (TTR) amyloidosis (ATTRv) initially presents as a polyneuropathy and/or a cardiomyopathy. Central nervous system (CNS) pathology in ATTRv amyloidosis, including focal neurological episodes, dementia, cerebrovascular bleeding, and seizures, appears around a decade later. Wild-type (WT) TTR amyloidosis (ATTRwt) causes a cardiomyopathy. CNS pathology risk likely also increases in these patients as cardiomyopathy progresses. Herein, we study tafamidis-mediated TTR kinetic stabilisation in cerebrospinal fluid (CSF). METHODS Varying tafamidis concentrations (50-1000 nM) were added to CSF from healthy donors or ATTRv patients, and TTR stabilisation was measured via the decrease in dissociation rate. RESULTS Tafamidis meglumine (Vyndaqel) can be dosed at 20 or 80 mg QD. The latter dose is bioequivalent to a 61 mg QD dose of tafamidis free acid (Vyndamax). The tafamidis CSF concentration in ATTRv patients on 20 mg Vyndaqel is ∼125 nM. By linear extrapolation, we expect a CSF concentration of ∼500 nM at the higher dose. When tafamidis is added to healthy donor CSF at 125 or 500 nM, the WT TTR dissociation rate decreases by 42% or 87%, respectively. CONCLUSIONS Tafamidis stabilises TTR in CSF to what is likely a clinically meaningful extent at CSF concentrations achieved by the normal tafamidis dosing regimen.
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Affiliation(s)
- Felix J. Tsai
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Marcus Jaeger
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Teresa Coelho
- Unidade Corino de Andrade, Centro Hospitalar do Porto, Porto, Portugal
| | - Evan T. Powers
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Jeffery W. Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
- The Skaggs Institute for Chemical Biology, The Scripps Research Institute, CA, USA
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Casasnovas C, Lladó L, Borrachero C, Pérez-Santamaría PV, Muñoz-Beamud F, Losada-López IA, Baliellas-Comellas MC, González-Moreno J. A narrative review and expert recommendations on the assessment of the clinical manifestations, follow-up, and management of post-OLT patients with ATTRv amyloidosis. Ther Adv Neurol Disord 2023; 16:17562864231191590. [PMID: 37655225 PMCID: PMC10467168 DOI: 10.1177/17562864231191590] [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: 03/15/2023] [Accepted: 07/17/2023] [Indexed: 09/02/2023] Open
Abstract
Orthotopic liver transplantation (OLT) was the first treatment able to modify the natural course of hereditary transthyretin (ATTRv) amyloidosis, which is a rare and fatal disorder caused by the accumulation of misfolded transthyretin (TTR) variants in different organs and tissues and which leads to a progressive and multisystem dysfunction. Because the liver is the main source of TTR, OLT dramatically reduces the production of the pathogenic TTR variant, which should prevent amyloid formation and halt disease progression. However, amyloidosis progression may occur after OLT due to wild-type TTR deposition, especially in the nerves and heart. In this review, we discuss the disease features influencing OLT outcomes and the clinical manifestations of ATTRv amyloidosis progression post-OLT to improve our understanding of disease worsening after OLT and optimize the follow-up and clinical management of these patients. By conducting a literature review on the PubMed database, we identified patient characteristics that have been associated with worse post-OLT outcomes, including late-onset V50M and non-V50M variants, age >40 years, long disease duration, advanced neuropathy and autonomic dysfunction, and malnutrition. Regarding post-OLT mortality, deaths occurring within the first year after OLT were mainly associated with fatal graft complications and infectious diseases, whereas cardiovascular-related deaths usually occurred later. Considering the diverse clinical manifestations of ATTRv amyloidosis progression post-OLT, including worsening neuropathy and/or cardiomyopathy, autonomic dysfunction, and oculoleptomeningeal involvement, we present advice on the most relevant tests for assessing disease progression post-OLT. Finally, we discuss the use of new therapies based on TTR stabilizers and TTR mRNA silencers for the treatment of ATTRv amyloidosis patients post-OLT.
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Affiliation(s)
- Carlos Casasnovas
- Neuromuscular Unit, Department of Neurology, Bellvitge University Hospital-IDIBELL, C/ Feixa Llarga s/n, 08906 l’Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Lladó
- Liver Transplant Unit, Department of Surgery, Bellvitge University Hospital, IDIBELL, Barcelona, Spain
| | - Cristina Borrachero
- ATTRv Unit, Department of Internal Medicine, Juan Ramón Jiménez Hospital, Huelva, Spain
| | | | | | | | | | - Juan González-Moreno
- Department of Internal Medicine, Son Llàtzer University Hospital, Palma de Mallorca, Spain
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Takahashi Y, Oguchi K, Mochizuki Y, Takasone K, Ezawa N, Matsushima A, Katoh N, Yazaki M, Sekijima Y. Distribution and progression of cerebral amyloid angiopathy in early-onset V30M (p.V50M) hereditary ATTR amyloidosis. Amyloid 2023; 30:109-118. [PMID: 36178174 DOI: 10.1080/13506129.2022.2128331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cerebral amyloid angiopathy (CAA) is becoming the most common and serious complications in long-lived hereditary ATTR amyloidosis patients. It is therefore imperative to elucidate the characteristics of ATTR-type CAA and develop useful biomarkers. METHODS We enrolled 34 ATTRv amyloidosis patients with the V30M (p.V50M) variant for analysis with three-dimensional stereotactic surface projection z score imaging of Pittsburgh compound B (PiB)-PET. RESULTS Eight patients exhibited central nervous system (CNS) symptoms. Seven patients suffered transient focal neurologic episodes, and 2 patients each experienced cerebellar haemorrhages or cognitive decline. The amount of 11C-PiB accumulation increased as a function of disease duration. 11C-PiB-PET abnormalities were seen at 8 years from onset and were associated with CNS manifestations from 12 years. The annual increase rate of the standardised uptake value ratio (SUVR) in female patients was significantly higher than in male patients. CNS amyloid deposition started in the upper middle surface of the cerebellar cortex, and then spread out over the entire surface of the cerebellum, Sylvian fissure, and anterior part of the longitudinal fissure of the cerebrum. CONCLUSIONS PiB-PET is a useful biomarker for the early detection and treatment evaluation of ATTR-type CAA. Female gender is associated with more rapid progression of ATTR-type CAA.
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Affiliation(s)
- Yusuke Takahashi
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | | | - Yusuke Mochizuki
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Ken Takasone
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Naoki Ezawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Akira Matsushima
- Department of Neurology, JA Nagano Koseiren Kakeyu Misayama Rehabilitation Center Kakeyu Hospital, Matsumoto, Japan
| | - Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Masahide Yazaki
- Department of Biomedical Laboratory Sciences, Shinshu University School of Health Sciences, Matsumoto, Japan.,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Jisenkai Brain Imaging Research Center, Matsumoto, Japan.,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
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Falcão de Campos C, Conceição I. Updated Evaluation of the Safety, Efficacy and Tolerability of Tafamidis in the Treatment of Hereditary Transthyretin Amyloid Polyneuropathy. Drug Healthc Patient Saf 2023; 15:51-62. [PMID: 36824481 PMCID: PMC9942506 DOI: 10.2147/dhps.s338577] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/26/2023] [Indexed: 02/19/2023] Open
Abstract
Hereditary amyloid transthyretin (ATTRv) amyloidosis is a devastating hereditary multisystemic disease affecting predominantly the peripheral and autonomic nervous systems and the heart. ATTRv is caused by mutations in the transthyretin (TTR) gene, leading to extracellular deposition of amyloid fibrils in multiple organs including the peripheral nervous system. If untreated, it is associated with a fatal outcome 10-12 years after disease onset. Different treatments are available for patients with ATTRv polyneuropathy. Tafamidis 20 mg is approved in Europe since 2011 for early stages of ATTRv polyneuropathy (stage I - able to walk without support) and it is recommended as first-line therapy in these patients. Tafamidis is a TTR stabilizer that selectively binds to TTR and kinetically stabilizes both wild-type native TTR and mutant TTR. Consequently, it has the potential to prevent the amyloidogenic cascade initiated by TTR tetramer dissociation into its monomers and subsequent misfolding and aggregation. Tafamidis is an oral drug, taken once per day, with proved efficacy, safety and tolerability in ATTRv-PN patients as demonstrated in different clinical trials and open-label extension studies as well in clinical practice setting with around 10 years of experience. Tafamidis treatment started in the earliest stages of the disease is associated with better neurological outcomes. A multidisciplinary approach in referral centres is also fundamental for monitoring patients to assess individual response to treatment.
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Affiliation(s)
- Catarina Falcão de Campos
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal,Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal,Correspondence: Catarina Falcão de Campos, Department of Neurosciences, Hospital de Santa Maria, Av. Professor Egas Moniz, Lisbon, 1648-028, Portugal, Tel/Fax + 351 21 780521, Email
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, Centro Hospitalar Universitário de Lisboa-Norte, Lisbon, Portugal,Instituto de Fisiologia, Instituto de Medicina Molecular, Centro de Estudos Egas Moniz, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Razvi Y, Porcari A, Di Nora C, Patel RK, Ioannou A, Rauf MU, Masi A, Law S, Chacko L, Rezk T, Ravichandran S, Gilbertson J, Rowczenio D, Blakeney IJ, Kaza N, Hutt DF, Lachmann H, Wechalekar A, Moody W, Lim S, Chue C, Whelan C, Venneri L, Martinez-Naharro A, Merlo M, Sinagra G, Livi U, Hawkins P, Fontana M, Gillmore JD. Cardiac transplantation in transthyretin amyloid cardiomyopathy: Outcomes from three decades of tertiary center experience. Front Cardiovasc Med 2023; 9:1075806. [PMID: 36741843 PMCID: PMC9894650 DOI: 10.3389/fcvm.2022.1075806] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/23/2022] [Indexed: 01/20/2023] Open
Abstract
Aims Transthyretin cardiac amyloidosis (ATTR-CM) is a progressive and fatal cardiomyopathy. Treatment options in patients with advanced ATTR-CM are limited to cardiac transplantation (CT). Despite case series demonstrating comparable outcomes with CT between patients with ATTR-CM and non-amyloid cardiomyopathies, ATTR-CM is considered to be a contraindication to CT in some centers, partly due to a perceived risk of amyloid recurrence in the allograft. We report long-term outcomes of CT in ATTR-CM at two tertiary centers. Materials and methods and Results We retrospectively evaluated ATTR-CM patients across two tertiary centers who underwent transplantation between 1990 and 2020. Pre-transplantation characteristics were determined and outcomes were compared with a cohort of non-transplanted ATTR-CM patients. Fourteen (12 male, 2 female) patients with ATTR-CM underwent CT including 11 with wild-type ATTR-CM and 3 with variant ATTR-CM (ATTRv). Median age at CT was 62 years and median follow up post-CT was 66 months. One, three, and five-year survival was 100, 92, and 90%, respectively and the longest surviving patient was Censored > 19 years post CT. No patients had recurrence of amyloid in the cardiac allograft. Four patients died, including one with ATTRv-CM from complications of leptomeningeal amyloidosis. Survival among the cohort of patients who underwent CT was significantly prolonged compared to UK patients with ATTR-CM generally (p < 0.001) including those diagnosed under age 65 years (p = 0.008) or with early stage cardiomyopathy (p < 0.001). Conclusion CT is well-tolerated, restores functional capacity and improves prognosis in ATTR-CM. The risk of amyloid recurrence in the cardiac allograft appears to be low.
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Affiliation(s)
- Yousuf Razvi
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Aldostefano Porcari
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
- Cardiovascular Department, Centre for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Concetta Di Nora
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Rishi K. Patel
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Adam Ioannou
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Muhammad U. Rauf
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Ambra Masi
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Steven Law
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Liza Chacko
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Tamer Rezk
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Sriram Ravichandran
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Janet Gilbertson
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Dorota Rowczenio
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Iona J. Blakeney
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | | | - David F. Hutt
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Helen Lachmann
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Ashutosh Wechalekar
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - William Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Sern Lim
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Colin Chue
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Carol Whelan
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Lucia Venneri
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Ana Martinez-Naharro
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Marco Merlo
- Cardiovascular Department, Centre for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Centre for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Ugolino Livi
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Philip Hawkins
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
| | - Julian D. Gillmore
- Division of Medicine, National Amyloidosis Centre, Royal Free Hospital, University College London, London, United Kingdom
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10
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Dardiotis E, Kyriakides T. Drug and Gene Therapy for Treating Variant Transthyretin Amyloidosis (ATTRv) Neuropathy. Curr Neuropharmacol 2023; 21:471-481. [PMID: 36366846 PMCID: PMC10207904 DOI: 10.2174/1570159x21666221108094736] [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: 04/30/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Variant Transthyretin Amyloidosis (ATTRv) neuropathy is an adult-onset, autosomal dominant, lethal, multisystemic disease due to the deposition of mutated transthyretin (TTR) in various organs, commonly involving the peripheral nerves and the heart. Circulating TTR tetramers are unstable due to the presence of mutated TTR and dissociate into monomers, which misfold and form amyloid fibrils. Although there are more than 140 mutations in the TTR gene, the p.Val50Met mutation is by far the commonest. In the typical, early-onset cases, it presents with a small sensory fibre and autonomic, length-dependent, axonal neuropathy, while in late-onset cases, it presents with a lengthdependent sensorimotor axonal neuropathy involving all fibre sizes. Treatment is now available and includes TTR stabilizers, TTR amyloid removal as well as gene silencing, while gene editing therapies are on the way. Its timely diagnosis is of paramount importance for a better prognosis.
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Affiliation(s)
- Efthimios Dardiotis
- Laboratory of Neurogenetics, Department of Neurology, School of Health Sciences, Faculty of Medicine, University Hospital of Larissa, Larissa, Greece
| | - Theodoros Kyriakides
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
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11
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Carberry N, Yu S, Fayerman RN, Dugue R, Miller M, Tanji K, Goyal T, Canoll P, Brannagan TH. Leptomeningeal Disease Secondary to Thr60Ala Transthyretin Amyloidosis: Case Report and Review of the Literature. Neurohospitalist 2023; 13:90-95. [PMID: 36531853 PMCID: PMC9755614 DOI: 10.1177/19418744221127849] [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: 01/03/2024] Open
Abstract
A 31-year-old woman with transthyretin (TTR) amyloidosis secondary to a Thr60Ala mutation developed recurrent stroke-like episodes with fluctuating mental status. Evaluation for stroke and seizures was unrevealing. She was found to have leptomeningeal contrast enhancement on magnetic resonance imaging, which was confirmed to be CNS TTR amyloidosis on histopathology following brain and dura biopsy. While leptomeningeal disease has rarely been known to be associated with TTR amyloidosis, this is the first documented case of leptomeningeal disease secondary to a Thr60Ala mutation in the TTR gene. A literature review of TTR amyloidosis is presented with special focus on the treatment of leptomeningeal TTR amyloidosis.
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Affiliation(s)
- Nathan Carberry
- Department of Neurology, Neuromuscular Division, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Sun Yu
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Raisy N. Fayerman
- Department of Neurology, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Rachelle Dugue
- Department of Neurology, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Michael Miller
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Kurenai Tanji
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Tarini Goyal
- Department of Neurology, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Peter Canoll
- Department of Pathology, Columbia University Irving Medical Center, New York, NY, USA
| | - Thomas H. Brannagan
- Department of Neurology, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
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12
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Cambieri C, Marenco M, Colasanti T, Mancone C, Corsi A, Riminucci M, Libonati L, Moret F, Chimenti C, Lambiase A, Conti F, Garibaldi M, Inghilleri M, Ceccanti M. Does Patisiran Reduce Ocular Transthyretin Synthesis? A Pilot Study of Two Cases. Curr Neuropharmacol 2023; 21:2543-2549. [PMID: 37357518 PMCID: PMC10616919 DOI: 10.2174/1570159x21666230623094710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Variant transthyretin-mediated amyloidosis (ATTR-v) is a well-characterized disease affecting the neurologic and cardiovascular systems. Patisiran has been approved for neurologic involvement as it reduces hepatic synthesis of transthyretin (TTR). Eye involvement is a lateonset feature increasing the risk of glaucoma and cataracts in patients. AIMS The aim of this case series was to assess whether patisiran can effectively reduce TTR synthesis in such a barrier-protected organ as the eye. METHODS Two patisiran-treated ATTR-v patients underwent serum and aqueous humor sampling to measure TTR levels detected by SDS-PAGE and immunoblotting. Serum samples were compared to healthy control (HC), whereas aqueous humor samples were compared to non-amyloidotic subjects affected by cataracts and glaucoma. RESULTS Serum TTR levels representative of hepatic synthesis were sharply lower in treated patients if compared to the HC (-87.5% and -93.75%, respectively). Aqueous humor TTR levels showed mild-tono reduction in treated patients compared to non-amyloidotic subjects with cataracts (-34.9% and +8.1%, respectively) and glaucoma (-41.1% and -2.1%). CONCLUSION Patisiran does not seem to be as effective in inhibiting ocular TTR synthesis as it is in inhibiting hepatic synthesis. Re-engineering the envelope could allow the drug to target RPE cells thus avoiding any ocular involvement.
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Affiliation(s)
- Chiara Cambieri
- Department of Human Neuroscience, Centre for Rare Neuromuscular Disease, Sapienza University of Rome, Rome, Italy
| | - Marco Marenco
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Tania Colasanti
- Department of Clinical Internal, Rheumatology Unit, Anesthetic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Carmine Mancone
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Corsi
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Mara Riminucci
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Libonati
- Department of Human Neuroscience, Centre for Rare Neuromuscular Disease, Sapienza University of Rome, Rome, Italy
| | - Federica Moret
- Department of Human Neuroscience, Centre for Rare Neuromuscular Disease, Sapienza University of Rome, Rome, Italy
| | - Cristina Chimenti
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy
| | | | - Fabrizio Conti
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Matteo Garibaldi
- Department of Neuroscience, Mental Health, and Sensory Organs (NESMOS), Sant’Andrea Hospital, Sapienza University, Rome, Italy
| | - Maurizio Inghilleri
- Department of Human Neuroscience, Centre for Rare Neuromuscular Disease, Sapienza University of Rome, Rome, Italy
| | - Marco Ceccanti
- Department of Human Neuroscience, Centre for Rare Neuromuscular Disease, Sapienza University of Rome, Rome, Italy
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13
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Ando Y, Adams D, Benson MD, Berk JL, Planté-Bordeneuve V, Coelho T, Conceição I, Ericzon BG, Obici L, Rapezzi C, Sekijima Y, Ueda M, Palladini G, Merlini G. Guidelines and new directions in the therapy and monitoring of ATTRv amyloidosis. Amyloid 2022; 29:143-155. [PMID: 35652823 DOI: 10.1080/13506129.2022.2052838] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The recent approval of three drugs for the treatment of amyloid transthyretin (ATTR) amyloidosis, both hereditary and wild-type, has opened a new era in the care of these diseases. ATTR amyloidosis is embedded in its pathophysiology, and the drugs target critical steps of the amyloid cascade. In addition to liver transplant, which removes the pathogenic variants, the introduction of gene silencers has allowed the suppression of both wild type and mutant transthyretin (TTR), thus extending the potential therapeutic range to wild-type cardiac amyloidosis. The kinetic stabilisation of TTR using small molecules has proved to be clinically effective both for amyloid neuropathy and cardiomyopathy. Gene silencers and kinetic stabilizers were recently approved on the basis of the outcome of phase III trials; however, comparative trials have not been performed, making it difficult to draw recommendations. Indications for liver transplantation have narrowed considerably. Here, guidelines for therapy are proposed based on expert consensus, acknowledging that the several drugs currently undergoing clinical trials will probably change in the near future the therapeutic armamentarium and, consequently, the therapeutic strategy. Indications for monitoring disease progression and drug efficacy are also provided for the management of these complexes, but now very treatable, diseases.
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Affiliation(s)
- Yukio Ando
- Department of Amyloidosis Research, Nagasaki International University, Sasebo, Japan
| | - David Adams
- Department of Neurology, French National Reference Centre for Familial Amyloidotic Polyneuropathy, CHU Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Merrill D Benson
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.,RLR Veterans Affairs Medical Center, Indianapolis, IN, USA
| | - John L Berk
- Amyloidosis Center, Boston Medical Center, Boston University, Boston, MA, USA
| | - Violaine Planté-Bordeneuve
- Department of Neurology and Amyloid Network, Hospital Henri Mondor, APHP, East-Paris University, Créteil, France
| | - Teresa Coelho
- Andrade's Center, Centro Hospitalar Univerisitário do Porto - Hospital de Santo António, Porto, Portugal
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, CHULN - Hospital de Santa Maria and Faculdade de Medicina, Instituto de Fisiologia, Universidade de Lisboa, Lisbon, Portugal
| | - Bo-Göran Ericzon
- Division of Transplantation Surgery, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Laura Obici
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Claudio Rapezzi
- Cardiologic Center, University of Ferrara, and Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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14
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Takahashi Y, Ohashi N, Takasone K, Yoshinaga T, Yazaki M, Roberts M, Glidden PF, Sekijima Y. CSF/plasma levels, transthyretin stabilisation and safety of multiple doses of tolcapone in subjects with hereditary ATTR amyloidosis. Amyloid 2022; 29:190-196. [PMID: 35352593 DOI: 10.1080/13506129.2022.2056011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
PURPOSE To investigate the effect of tolcapone on cerebrospinal fluid (CSF) transthyretin (TTR) tetramer stability in patients with hereditary transthyretin (ATTRv) amyloidosis. METHODS A total of 9 patients were enrolled in the study (3 men, 50.3 ± 14.4 years old). Three patients had central nervous system (CNS) involvement. Patients were assigned to receive tolcapone 300 mg/day or 600 mg/day for 7 days. Plasma and CSF were collected at baseline and 2 h after the final tolcapone dose. RESULTS The mean CSF tolcapone and 3-O-Methyltolcapone (3-OMT) concentration were 39.4 ± 36.3 ng/mL and 26.0 ± 4.9 ng/mL, respectively, after 7 days of tolcapone dosing. Tolcapone and 3-OMT were detected in the CSF of patients with or without CNS symptoms. The mean total study drug (tolcapone + 3-OMT) to TTR molar ratio in CSF was 1.15 ± 0.59. Orally administered tolcapone significantly increased CSF TTR concentration and decreased monomer content under semi-denaturing conditions. Eight adverse events (AEs) were reported in 6 patients. All AEs were mild in severity and resolved. CONCLUSIONS Tolcapone was able to cross the blood brain-barrier, highlighting its potential to decrease CNS manifestations of ATTRv amyloidosis. Tolcapone was well tolerated by patients with ATTRv amyloidosis.
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Affiliation(s)
- Yusuke Takahashi
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Nobuhiko Ohashi
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Ken Takasone
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Tsuneaki Yoshinaga
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Masahide Yazaki
- Department of Biomedical Laboratory Sciences, Shinshu University School of Health Sciences, Matsumoto, Japan.,Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
| | | | | | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Department of Biomedical Laboratory Sciences, Shinshu University School of Health Sciences, Matsumoto, Japan
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15
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Treatment of Transthyretin Amyloid Cardiomyopathy: The Current Options, the Future, and the Challenges. J Clin Med 2022; 11:jcm11082148. [PMID: 35456241 PMCID: PMC9031576 DOI: 10.3390/jcm11082148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 12/13/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressively debilitating, rare disease associated with high mortality. ATTR-CM occurs when TTR amyloid protein builds up in the myocardium along with different organs, most commonly the peripheral and the autonomic nervous systems. Managing the cardiac complications with standard heart failure medications is difficult due to the challenge to maintain a balance between the high filling pressure associated with restricted ventricular volume and the low cardiac output. To date, tafamidis is the only agent approved for ATTR-CM treatment. Besides, several agents, including green tea, tolcapone, and diflunisal, are used off-label in ATTR-CM patients. Novel therapies using RNA interference also offer clinical promise. Patisiran and inotersen are currently approved for ATTR-polyneuropathy of hereditary origin and are under investigation for ATTR-CM. Monoclonal antibodies in the early development phases carry hope for amyloid deposit clearance. Despite several drug candidates in the clinical development pipeline, the small ATTR-CM patient population raises several challenges. This review describes current and future therapies for ATTR-CM and sheds light on the clinical development hurdles facing them.
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16
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Smerikarova M, Bozhanov S, Maslarska V, Tournev I. Determination of Tafamidis Plasma Concentrations in Amyloidosis Patients with Glu89Gln Mutation by HPLC-UV Detection. J Chromatogr Sci 2021; 60:840-847. [PMID: 34897414 DOI: 10.1093/chromsci/bmab132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Indexed: 11/14/2022]
Abstract
Present study describes a high-performance liquid chromatography method for the determination of the potent kinetic stabilizer-Tafamidis in human plasma. It was approved for medical use in European Union in 2011. Ultra violet (UV) detection mode and isocratic elution of the mobile phase were set and made the analytical procedure fast and widely applicable. Chromatographic determination was performed on a Purospher® RP-18 column. The mobile phase consisted of 0.1% trifluoroacetic acid in water and acetonitrile in the ratio 42:58 v/v and the flow rate was 1.0 ml/min. All analyses were carried at a room temperature and the detector was set at 280 nm. Calibration curve over a range of 1.00-10.00 μM was constructed for the purposes of linearity method validation. The specificity and effectiveness of the developed method made it suitable for observation of patients' plasma Tafamidis concentration with time and drug therapy monitoring.
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Affiliation(s)
- Miglena Smerikarova
- Department of Chemistry, Faculty of Pharmacy, Medical University, Dunav Str. no. 2, Sofia 1000, Bulgaria
| | - Stanislav Bozhanov
- Department of Chemistry, Faculty of Pharmacy, Medical University, Dunav Str. no. 2, Sofia 1000, Bulgaria
| | - Vania Maslarska
- Department of Chemistry, Faculty of Pharmacy, Medical University, Dunav Str. no. 2, Sofia 1000, Bulgaria
| | - Ivailo Tournev
- Clinic of Nervous Diseases, UMBAL Aleksandrovska, Department of Neurology, Medical University, Sv. Georgi Sofiiski Str. no. 1, Sofia 1431, Bulgaria
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17
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Marques JH, Coelho J, Menéres MJ, Beirão JM. Progressive vitreous deposits during treatment with inotersen for hereditary ATTR amyloidosis. Amyloid 2021; 28:275-276. [PMID: 34498503 DOI: 10.1080/13506129.2021.1975673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- João Heitor Marques
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - João Coelho
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria João Menéres
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - João Melo Beirão
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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18
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Cechin L, Gasmelseed J, Bashford J, Rowczenio D, Reilly MM, Gillmore JD, Coutinho E. Early-Onset Leptomeningeal Manifestation of G47R Hereditary Transthyretin Amyloidosis. Neurol Clin Pract 2021; 11:e757-e759. [PMID: 34840900 DOI: 10.1212/cpj.0000000000001054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/06/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Laura Cechin
- King's College Hospital (LC, JG, JB, EC), London; National Amyloidosis Centre (DR, JDG), Centre for Amyloidosis & Acute Phase Proteins, Division of Medicine, University College London; and Centre for Neuromuscular Diseases (MMR), UCL Queen Square Institute of Neurology, United Kingdom
| | - Jihad Gasmelseed
- King's College Hospital (LC, JG, JB, EC), London; National Amyloidosis Centre (DR, JDG), Centre for Amyloidosis & Acute Phase Proteins, Division of Medicine, University College London; and Centre for Neuromuscular Diseases (MMR), UCL Queen Square Institute of Neurology, United Kingdom
| | - James Bashford
- King's College Hospital (LC, JG, JB, EC), London; National Amyloidosis Centre (DR, JDG), Centre for Amyloidosis & Acute Phase Proteins, Division of Medicine, University College London; and Centre for Neuromuscular Diseases (MMR), UCL Queen Square Institute of Neurology, United Kingdom
| | - Dorota Rowczenio
- King's College Hospital (LC, JG, JB, EC), London; National Amyloidosis Centre (DR, JDG), Centre for Amyloidosis & Acute Phase Proteins, Division of Medicine, University College London; and Centre for Neuromuscular Diseases (MMR), UCL Queen Square Institute of Neurology, United Kingdom
| | - Mary M Reilly
- King's College Hospital (LC, JG, JB, EC), London; National Amyloidosis Centre (DR, JDG), Centre for Amyloidosis & Acute Phase Proteins, Division of Medicine, University College London; and Centre for Neuromuscular Diseases (MMR), UCL Queen Square Institute of Neurology, United Kingdom
| | - Julian D Gillmore
- King's College Hospital (LC, JG, JB, EC), London; National Amyloidosis Centre (DR, JDG), Centre for Amyloidosis & Acute Phase Proteins, Division of Medicine, University College London; and Centre for Neuromuscular Diseases (MMR), UCL Queen Square Institute of Neurology, United Kingdom
| | - Ester Coutinho
- King's College Hospital (LC, JG, JB, EC), London; National Amyloidosis Centre (DR, JDG), Centre for Amyloidosis & Acute Phase Proteins, Division of Medicine, University College London; and Centre for Neuromuscular Diseases (MMR), UCL Queen Square Institute of Neurology, United Kingdom
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19
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Dohrn MF, Medina J, Olaciregui Dague KR, Hund E. Are we creating a new phenotype? Physiological barriers and ethical considerations in the treatment of hereditary transthyretin-amyloidosis. Neurol Res Pract 2021; 3:57. [PMID: 34719408 PMCID: PMC8559355 DOI: 10.1186/s42466-021-00155-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/09/2021] [Indexed: 01/14/2023] Open
Abstract
Hereditary transthyretin (TTR) amyloidosis (ATTRv) is an autosomal dominant, systemic disease transmitted by amyloidogenic mutations in the TTR gene. To prevent the otherwise fatal disease course, TTR stabilizers and mRNA silencing antisense drugs are currently approved treatment options. With 90% of the amyloidogenic protein produced by the liver, disease progression including polyneuropathy and cardiomyopathy, the two most prominent manifestations, can successfully be halted by hepatic drug targeting or-formerly-liver transplantation. Certain TTR variants, however, favor disease manifestations in the central nervous system (CNS) or eyes, which is mostly associated with TTR production in the choroid plexus and retina. These compartments cannot be sufficiently reached by any of the approved medications. From liver-transplanted patients, we have learned that with longer lifespans, such CNS manifestations become more relevant over time, even if the underlying TTR mutation is not primarily associated with such. Are we therefore creating a new phenotype? Prolonging life will most likely lead to a shift in the phenotypic spectrum, enabling manifestations like blindness, dementia, and cerebral hemorrhage to come out of the disease background. To overcome the first therapeutic limitation, the blood-brain barrier, we might be able to learn from other antisense drugs currently being used in research or even being approved for primary neurodegenerative CNS diseases like spinal muscular atrophy or Alzheimer's disease. But what effects will unselective CNS TTR knock-down have considering its role in neuroprotection? A potential approach to overcome this second limitiation might be allele-specific targeting, which is, however, still far from clinical trials. Ethical standpoints underline the need for seamless data collection to enable more evidence-based decisions and for thoughtful consenting in research and clinical practice. We conclude that the current advances in treating ATTRv amyloidosis have become a meaningful example for mechanism-based treatment. With its great success in improving patient life spans, we will still have to face new challenges including shifts in the phenotype spectrum and the ongoing need for improved treatment precision. Further investigation is needed to address these closed barriers and open questions.
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Affiliation(s)
- Maike F Dohrn
- Department of Neurology, Medical Faculty of the RWTH Aachen University, Neuromuscular Outpatient Clinic, University Hospital Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
- Dr. John T. Macdonald Foundation, Department of Human Genetics and John P. Hussman Institute for Human Genomics, University of Miami, Miller School of Medicine, Miami, FL, USA.
| | - Jessica Medina
- Dr. John T. Macdonald Foundation, Department of Human Genetics and John P. Hussman Institute for Human Genomics, University of Miami, Miller School of Medicine, Miami, FL, USA
| | | | - Ernst Hund
- Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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20
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The discovery and development of transthyretin amyloidogenesis inhibitors: what are the lessons? Future Med Chem 2021; 13:2083-2105. [PMID: 34633220 DOI: 10.4155/fmc-2021-0248] [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: 11/17/2022] Open
Abstract
Transthyretin (TTR) is associated with several human amyloid diseases. Various kinetic stabilizers have been developed to inhibit the dissociation of TTR tetramer and the formation of amyloid fibrils. Most of them are bisaryl derivatives, natural flavonoids, crown ethers and carborans. In this review article, we focus on TTR tetramer stabilizers, genetic therapeutic approaches and fibril remodelers. The binding modes of typical bisaryl derivatives, natural flavonoids, crown ethers and carborans are discussed. Based on knowledge of the binding of thyroxine to TTR tetramer, many stabilizers have been screened to dock into the thyroxine binding sites, leading to TTR tetramer stabilization. Particularly, those stabilizers with unique binding profiles have shown great potential in developing the therapeutic management of TTR amyloidogenesis.
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21
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Marques JH, Coelho J, Malheiro J, Pessoa B, Beirão JM. Subclinical retinal angiopathy associated with hereditary transthyretin amyloidosis - assessed with optical coherence tomography angiography. Amyloid 2021; 28:66-71. [PMID: 32996337 DOI: 10.1080/13506129.2020.1827381] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Retinal angiopathy is a known ocular manifestation of hereditary transthyretin amyloidosis (ATTRv). Optical coherence tomography angiography (OCT-A) is a recent noninvasive imaging technique, used in other retinal vascular diseases. Our purpose was to analyse subclinical changes in retinal vessels, with OCT-A, in patients with ATTRv amyloidosis. METHODS Observational cross-sectional study in Centro Hospitalar e Universitário do Porto in the cohort of patients with genetic diagnosis of ATTRv. Patients were included if they had just one eye with scalloped iris (the other eye without scalloped iris), postulating eyes were at different stages, in the same patient. Patients were excluded if they had other manifestations of ocular ATTRv amyloidosis, namely clinical retinal angiopathy and/or vitreous opacities. The group of eyes with scalloped iris were compared with eyes without scalloped iris, using paired tests. Values are shown as Δ = mean difference between groups; p = p-value, d = Cohen's d for effect size measurement. RESULTS Twenty-four patients (24 eyes in each group) were included. Mean age was 46.5 ± 5.0 years. Eyes with scalloped iris showed attenuated retinal vascular network: larger foveal avascular zone (FAZ) area (Δ = +0.02 mm2, p = 0.002, d = 0.70); decreased foveal vascular density (Δ = -3.57%, p = 0.001, d = -0.75); superficial (Δ = -1.50%, p = 0.049, d = -0.43) and deep (Δ = -2.53%, p = 0.023, d = -0.50) plexus vascular density. Acircularity index was superior in scalloped iris eyes (Δ = 0.04, p = 0.004, d = -0.65), representing an abnormal FAZ morphology. CONCLUSION Scalloped iris in ATTRv eyes are associated with a more advanced subclinical retinal angiopathy, than eyes without scalloped iris. Our results identify for the first time and in vivo, early changes in retinal vessels in ATTRv amyloidosis. Henceforward, OCT-A may play a role in the evaluation of ATTRv patients oculopathy and the effectiveness of future eye targeting treatments.
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Affiliation(s)
- João Heitor Marques
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - João Coelho
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Jorge Malheiro
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Bernardete Pessoa
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - João Melo Beirão
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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Nelson LT, Paxman RJ, Xu J, Webb B, Powers ET, Kelly JW. Blinded potency comparison of transthyretin kinetic stabilisers by subunit exchange in human plasma. Amyloid 2021; 28:24-29. [PMID: 32811187 PMCID: PMC7952025 DOI: 10.1080/13506129.2020.1808783] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Transthyretin (TTR) tetramer dissociation is rate limiting for aggregation and subunit exchange. Slowing of TTR tetramer dissociation via kinetic stabiliser binding slows cardiomyopathy progression. Quadruplicate subunit exchange comparisons of the drug candidate AG10, and the drugs tolcapone, diflunisal, and tafamidis were carried out at 1, 5, 10, 20 and 30 µM concentrations in 4 distinct pooled wild type TTR (TTRwt) human plasma samples. These experiments reveal that the concentration dependence of the efficacy of each compound at inhibiting TTR dissociation was primarily determined by the ratio between the stabiliser's dissociation constants from TTR and albumin, which competes with TTR to bind kinetic stabilisers. The best stabilisers, tafamidis (80 mg QD), AG10 (800 mg BID), and tolcapone (3 x 100 mg over 12 h), exhibit very similar kinetic stabilisation at the plasma concentrations resulting from these doses. At a 10 µM plasma concentration, AG10 is slightly more potent as a kinetic stabiliser vs. tolcapone and tafamidis (which are similar), which are substantially more potent than diflunisal. Dissociation of TTR can be limited to 10% of its normal rate at concentrations of 5.7 µM AG10, 10.3 µM tolcapone, 12.0 µM tafamidis, and 188 µM diflunisal. The potency similarities revealed by our study suggest that differences in safety, adsorption and metabolism, pharmacokinetics, and tissue distribution become important for kinetic stabiliser clinical use decisions.
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Affiliation(s)
- Luke T Nelson
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Ryan J Paxman
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Jin Xu
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Bill Webb
- Center for Metabolomics, The Scripps Research Institute, La Jolla, CA, USA
| | - Evan T Powers
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Jeffery W Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA.,The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, CA, USA
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23
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Marques JH, Malheiro L, Malheiro J, Oliveira L, Menéres MJ, Beirão JM. Pupillometry: An objective test to assess endocular hereditary transthyretin amyloidosis. Eur J Ophthalmol 2021; 32:637-642. [PMID: 33601896 DOI: 10.1177/1120672121997294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To automatically study the pupillary light reflex in patients with hereditary transthyretin-associated amyloidosis (hATTR). METHODS Prospective cross-sectional observational study in patients with hATTR with unilateral scalloped iris. Pupillary light reflex of scalloped iris eyes (21 eyes) were compared with non-scalloped iris eyes (21 eyes, paired eyes of the same patients) and also with a control group of 20 healthy eyes, using static and dynamic pupillometry with the Metrovision® MonPack One. RESULTS No patient presented evident neurological involvment of the cranial nerves. No significant differences were found in the pupillary diameters under standardized lighting conditions (static pupillometry) among groups. In dynamic pupillometry, the amplitude of contraction, the velocity of contraction and the velocity of dilation were statistically significantly lower in eyes with scalloped iris, comparing both with the contralateral non-scalloped iris eyes (p < 0.001 for all) and with eyes from healthy subjects (p < 0.05 for all). CONCLUSION A scalloped iris reflects a more advanced endocular hATTR and it is associated with an altered pupillary light reflex. Pupillometry may be a quick, simple, and portable test to objectively evaluate ocular amyloid deposition in hATTR eyes. Pupillary light reflex may not be reliable to evaluate neurological dysfunction in these patients.
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Affiliation(s)
- João Heitor Marques
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Luísa Malheiro
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Jorge Malheiro
- Nephrology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Luís Oliveira
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria João Menéres
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - João Melo Beirão
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
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24
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Rapezzi C, Aimo A, Emdin M. Tafamidis is entering the clinical arena for the treatment of transthyretin-related cardiomyopathy: certainties and unmet needs. Eur J Heart Fail 2021; 23:286-289. [PMID: 33443315 DOI: 10.1002/ejhf.2104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Claudio Rapezzi
- Cardiovascular Center, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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25
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Dohrn MF, Ihne S, Hegenbart U, Medina J, Züchner SL, Coelho T, Hahn K. Targeting transthyretin - Mechanism-based treatment approaches and future perspectives in hereditary amyloidosis. J Neurochem 2020; 156:802-818. [PMID: 33155274 DOI: 10.1111/jnc.15233] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 12/19/2022]
Abstract
The liver-derived, circulating transport protein transthyretin (TTR) is the cause of systemic hereditary (ATTRv) and wild-type (ATTRwt) amyloidosis. TTR stabilization and knockdown are approved therapies to mitigate the otherwise lethal disease course. To date, the variety in phenotypic penetrance is not fully understood. This systematic review summarizes the current literature on TTR pathophysiology with its therapeutic implications. Tetramer dissociation is the rate-limiting step of amyloidogenesis. Besides destabilizing TTR mutations, other genetic (RBP4, APCS, AR, ATX2, C1q, C3) and external (extracellular matrix, Schwann cell interaction) factors influence the type of onset and organ tropism. The approved small molecule tafamidis stabilizes the tetramer and significantly decelerates the clinical course. By sequence-specific mRNA knockdown, the approved small interfering RNA (siRNA) patisiran and antisense oligonucleotide (ASO) inotersen both significantly reduce plasma TTR levels and improve neuropathy and quality of life compared to placebo. With enhanced hepatic targeting capabilities, GalNac-conjugated siRNA and ASOs have recently entered phase III clinical trials. Bivalent TTR stabilizers occupy both binding groves in vitro, but have not been tested in trials so far. Tolcapone is another stabilizer with the potential to cross the blood-brain barrier, but its half-life is short and liver failure a potential side effect. Amyloid-directed antibodies and substances like doxycycline aim at reducing the amyloid load, however, none of the yet developed antibodies has successfully passed clinical trials. ATTR-amyloidosis has become a model disease for pathophysiology-based treatment. Further understanding of disease mechanisms will help to overcome the remaining limitations, including application burden, side effects, and blood-brain barrier permeability.
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Affiliation(s)
- Maike F Dohrn
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany.,Dr. John T. Macdonald Foundation, Department of Human Genetics and John P. Hussman Institute for Human Genomics, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Sandra Ihne
- Interdisciplinary Amyloidosis Center of Northern Bavaria, University Hospital of Würzburg, Würzburg, Germany.,Department of Internal Medicine II, Hematology, University Hospital Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center (CHFC), University and University Hospital Würzburg, Würzburg, Germany
| | - Ute Hegenbart
- Amyloidosis Center Heidelberg, Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jessica Medina
- Dr. John T. Macdonald Foundation, Department of Human Genetics and John P. Hussman Institute for Human Genomics, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Stephan L Züchner
- Dr. John T. Macdonald Foundation, Department of Human Genetics and John P. Hussman Institute for Human Genomics, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Teresa Coelho
- Andrade's Center for Familial Amyloidosis, University of Porto, Porto, Portugal.,Department of Neurosciences, Hospital de Santo António, Centro Hospitalar Do Porto, University of Porto, Porto, Portugal
| | - Katrin Hahn
- Department of Neurology, Charité University Medicine, Berlin, Germany.,Amyloidosis Center Charité Berlin (ACCB), Charité University Medicine, Berlin, Germany
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26
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Baerveldt glaucoma drainage implant surgery for secondary glaucoma in patients with transthyretin-related familial amyloid polyneuropathy. Jpn J Ophthalmol 2020; 64:533-538. [DOI: 10.1007/s10384-020-00753-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 05/14/2020] [Indexed: 01/10/2023]
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27
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Pinheiro F, Varejão N, Esperante S, Santos J, Velázquez-Campoy A, Reverter D, Pallarès I, Ventura S. Tolcapone, a potent aggregation inhibitor for the treatment of familial leptomeningeal amyloidosis. FEBS J 2020; 288:310-324. [PMID: 32324953 DOI: 10.1111/febs.15339] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/31/2020] [Accepted: 04/17/2020] [Indexed: 12/22/2022]
Abstract
Hereditary transthyretin amyloidosis (ATTR) is a disease characterized by the extracellular deposition of transthyretin (TTR) amyloid fibrils. Highly destabilizing TTR mutations cause leptomeningeal amyloidosis, a rare, but fatal, disorder in which TTR aggregates in the brain. The disease remains intractable, since liver transplantation, the reference therapy for systemic ATTR, does not stop mutant TTR production in the brain. In addition, despite current pharmacological strategies have shown to be effective against in vivo TTR aggregation by stabilizing the tetramer native structure and precluding its dissociation, they display low brain permeability. Recently, we have repurposed tolcapone as a molecule to treat systemic ATTR. Crystal structures and biophysical analysis converge to demonstrate that tolcapone binds with high affinity and specificity to three unstable leptomeningeal TTR variants, stabilizing them and, consequently, inhibiting their aggregation. Because tolcapone is an FDA-approved drug that crosses the blood-brain barrier, our results suggest that it can translate into a first disease-modifying therapy for leptomeningeal amyloidosis. DATABASES: PDB codes for A25T-TTR, V30G-TTR, and Y114C-TTR bound to tolcapone are 6TXV, 6TXW, and 6XTK, respectively.
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Affiliation(s)
- Francisca Pinheiro
- Departament de Bioquímica i Biologia Molecular, Institut de Biotecnologia i Biomedicina, Universitat Autònoma de Barcelona, Spain
| | - Nathalia Varejão
- Departament de Bioquímica i Biologia Molecular, Institut de Biotecnologia i Biomedicina, Universitat Autònoma de Barcelona, Spain
| | | | - Jaime Santos
- Departament de Bioquímica i Biologia Molecular, Institut de Biotecnologia i Biomedicina, Universitat Autònoma de Barcelona, Spain
| | - Adrián Velázquez-Campoy
- Department of Biochemistry and Molecular & Cellular Biology, Institute for Biocomputation and Physics of Complex Systems (BIFI), Joint Units IQFR-CSIC-BIFI and GBsC-CSIC-BIFI, Universidad de Zaragoza, Spain.,Aragon Institute for Health Research, Zaragoza, Spain.,Biomedical Research Network Center in Hepatic and Digestive Diseases (CIBERehd), Madrid, Spain.,ARAID Foundation, Gobierno de Aragón, Zaragoza, Spain
| | - David Reverter
- Departament de Bioquímica i Biologia Molecular, Institut de Biotecnologia i Biomedicina, Universitat Autònoma de Barcelona, Spain
| | - Irantzu Pallarès
- Departament de Bioquímica i Biologia Molecular, Institut de Biotecnologia i Biomedicina, Universitat Autònoma de Barcelona, Spain
| | - Salvador Ventura
- Departament de Bioquímica i Biologia Molecular, Institut de Biotecnologia i Biomedicina, Universitat Autònoma de Barcelona, Spain
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Bunod R, Adams D, Cauquil C, Francou B, Labeyrie C, Bourenane H, Adam C, Algalarrondo V, Slama M, Darce-Bello M, Barreau E, Labetoulle M, Rousseau A. Conjunctival lymphangiectasia as a biomarker of severe systemic disease in Ser77Tyr hereditary transthyretin amyloidosis. Br J Ophthalmol 2020; 104:1363-1367. [PMID: 31949094 DOI: 10.1136/bjophthalmol-2019-315381] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 12/10/2019] [Accepted: 12/26/2019] [Indexed: 12/12/2022]
Abstract
AIMS To investigate the relationship between the ophthalmic and systemic phenotypes in patients with hereditary transthyretin amyloidosis with the S77Y mutation (ATTRS77Y). METHODS In this cross-sectional study, patients with genetically confirmed ATTRS77Y amyloidosis were enrolled. All patients underwent complete neurological examination, including staging with the Neuropathy Impairment Score (NIS), Polyneuropathy Disability (PND) score; complete cardiological evaluation, including echocardiography, cardiac MRI and/or cardiac scintigraphy and complete ophthalmic evaluation, including slit lamp examination and fundus examination. Ocular ancillary tests (fluorescein and indocyanine green angiography, and anterior segment optical coherence tomography) were performed in cases with abnormal findings. The Kruskal-Wallis test was used for quantitative outcomes and Fisher's exact test for qualitative outcomes. Statistical significance was indicated by p<0.05 (two tailed). RESULTS The study sample was composed of 24 ATTRS77Y patients. The mean patient age was 58.4±12.4 years. None of the patients presented with amyloid deposits in the anterior chamber, secondary glaucoma or vitreous amyloidosis. Retinal angiopathy was observed in four patients, complicated with retinal ischaemia in one patient. Conjunctival lymphangiectasia (CL) was detected in 13 patients (54%), associated with perilymphatic amyloid deposits. The presence of CL was statistically associated with more severe neurological disease (NIS=43.3±31.9 vs 18.9±20.4; PND=2.6±1.0 vs 1.4±0.7 in patients with and without CL, respectively; both p<0.05) and amyloid cardiomyopathy (p=0.002). CONCLUSION In ATTRS77Y patients, CL is common and could serve as a potential biomarker for severe systemic disease. There were neither anterior chamber deposits, secondary glaucoma nor vitreous deposits in ATTRS77Y patients.
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Affiliation(s)
- Roxane Bunod
- Ophhalmology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
| | - David Adams
- Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
| | - Cécile Cauquil
- Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
| | - Bruno Francou
- Molecular Biology and Genetics, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
| | - Céline Labeyrie
- Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
| | - Halima Bourenane
- Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
| | - Clovis Adam
- Pathology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
| | - Vincent Algalarrondo
- Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Diderot University, French Reference Center for FAP (NNERF), Paris, France
| | - Michel Slama
- Cardiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Diderot University, French Reference Center for FAP (NNERF), Paris, France
| | - Martha Darce-Bello
- Plateforme d'expertise Maladies Rares, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, Le Kremlin-Bicêtre, France
| | - Emmanuel Barreau
- Ophhalmology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
| | - Marc Labetoulle
- Ophhalmology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
| | - Antoine Rousseau
- Ophhalmology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Sud University, French Reference Center for Familial Amyloid Polyneuropathies (NNERF), Le Kremlin-Bicêtre, France
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Dammacco R, Merlini G, Lisch W, Kivelä TT, Giancipoli E, Vacca A, Dammacco F. Amyloidosis and Ocular Involvement: an Overview. Semin Ophthalmol 2019; 35:7-26. [PMID: 31829761 DOI: 10.1080/08820538.2019.1687738] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Purpose: To describe the ophthalmic manifestations of amyloidosis and the corresponding therapeutic measures.Methods: The 178 patients included in the study had different types of amyloidosis, diagnosed at a single internal medicine institution (Bari, Italy). To provide a comprehensive review of the types of amyloidosis that can be associated with ocular involvement, the images and clinical descriptions of patients with amyloidosis structurally related to gelsolin, keratoepithelin and lactoferrin were obtained in collaborations with the ophthalmology departments of hospitals in Mainz (Germany) and Helsinki (Finland).Results: Overall, ocular morbidity was detected in 41 of the 178 patients with amyloidosis (23%). AL amyloidosis was diagnosed in 18 patients with systemic disease, 3 with multiple myeloma, and 11 with localized amyloidosis. AA amyloidosis was detected in 2 patients with rheumatoid arthritis and 3 with Behçet syndrome, and transthyretin amyloidosis in 4 patients. The treatment of AL amyloidosis is based on chemotherapy to suppress the production of amyloidogenic L-chains and on surgical excision of orbital or conjunctival masses. AA amyloidosis is managed by targeting the underlying condition. Vitreous opacities and additional findings of ocular involvement in patients with transthyretin amyloidosis indicate the need for pars plana vitrectomy. Gelsolin amyloidosis, characterized by lattice corneal amyloidosis and polyneuropathy, results in recurrent keratitis and corneal scarring, such that keratoplasty is inevitable. In patients with lattice corneal dystrophies associated with amyloid deposits of keratoepithelin fragments, corneal transparency is compromised by deposits of congophilic material in the subepithelial layer and deep corneal stroma. Patients with established corneal opacities are treated by corneal transplantation, but the prognosis is poor because recurrent corneal deposits are possible after surgery. In patients with gelatinous drop-like dystrophy, the amyloid fibrils that accumulate beneath the corneal epithelium consist of lactoferrin and can severely impair visual acuity. Keratoplasty and its variants are performed for visual rehabilitation.Conclusion: A routine ophthalmic follow-up is recommended for all patients with established or suspected amyloidosis, independent of the biochemical type of the amyloid. Close collaboration between the ophthalmologist and the internist will facilitate a more precise diagnosis of ocular involvement in amyloidosis and allow the multidisciplinary management of these patients.Abbreviations: CD: corneal dystrophy; CLA: corneal lattice amyloidosis; CNS: central nervous system; CT: computed tomography; FAP: familial amyloidotic polyneuropathy; GDLCD: gelatinous drop-like corneal dystrophy; GLN: gelsolin; LCD: lattice corneal dystrophy; MRI: magnetic resonance imaging; OLT: orthotopic liver transplantation; TEM: transmission electron microscopy; TGFBI: transforming growth factor β induced; TTR: transthyretin.
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Affiliation(s)
- Rosanna Dammacco
- Department of Ophthalmology and Neuroscience, University of Bari "Aldo Moro", Medical School, Bari, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Walter Lisch
- Department of Ophthalmology, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Tero T Kivelä
- Department of Ophthalmology, University of Helsinki, Helsinki, Finland.,Helsinki University Central Hospital, Helsinki, Finland
| | - Ermete Giancipoli
- Department of Biomedical Sciences, Ophthalmology Unit, University of Sassari, Sassari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Medical School, Bari, Italy
| | - Franco Dammacco
- Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Medical School, Bari, Italy
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30
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Buxbaum JN. Treatment of hereditary and acquired forms of transthyretin amyloidosis in the era of personalized medicine: the role of randomized controlled trials. Amyloid 2019; 26:55-65. [PMID: 30907141 DOI: 10.1080/13506129.2019.1575201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There have now been randomized controlled trials of four different therapeutics for hereditary amyloid polyneuropathy related to transthyretin (TTR) deposition and one for amyloidotic cardiomyopathy of both genetic and sporadic origin. It is likely that in the next few months those not already approved by either the US Food and Drug Administration (FDA) and/or the European Medicines Authority (EMA) will receive similar approvals for treatment for all or particular groups of patients. This is a far cry from circumstances less than 10 years ago when the only available therapy was gene replacement by liver transplant. The randomized controlled trials have shown that all the treatments (tafamidis, diflunisal, patisiran, and inotersen) are effective in the context of a clinical trial. However, we have very little idea of whether individual patients will respond in an equally positive way to all the drugs or whether there will be some who respond better to one or another or not respond at all, nor do we know whether combinations will be additive or synergistic. We lack validated markers of clinical response. While the small molecule TTR stabilizers increase serum TTR levels, the RNA-based drugs lower serum TTR. In the latter case, it is not clear that the reduction in serum TTR is related to the clinical response in a 1:1 fashion. Pharmaceutical companies have made substantial investments in the development of these agents and will clearly attempt to recoup those investments quickly. It is incumbent upon those of us who care for these patients to develop ways to assess the effects of therapy in the shortest possible time at the lowest possible cost. The better we are able to accomplish this the more likely it is that we will be able to treat the most patients in the most clinically efficient fashion regardless of their economic status. We now have the drugs we just have to figure out who should get them and when.
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Affiliation(s)
- Joel N Buxbaum
- a The Scripps Research Institute , San Diego , CA , USA.,b The Scintillon Institute , San Diego , CA , USA.,c Protego Biopharma , San Diego , CA , USA
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Abstract
INTRODUCTION Hereditary transthyretin-mediated amyloidosis is caused by a mutation in transthyretin (TTR) gene resulting in misfolded TTR protein accumulating as amyloid fibrils. Patisiran is a lipid nanoparticle formulation of ribonucleic acid interference (RNAi), which can reduce the production of TTR. Areas covered: In this review, the chemical property, mechanism of action, pharmacokinetics, clinical efficacy, and safety of patisiran were introduced. Expert Commentary: Patisiran offers a new treatment option for patients with hereditary transthyretin-mediated amyloidosis. Patisiran can significantly reduce the TTR level and improve patient's neuropathy and quality of life. The common adverse reactions were upper respiratory tract infections and infusion-related reactions.
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Affiliation(s)
- Junyi Yang
- a Department of Pharmaceutical , Central Hospital of Linyi City , Yishui , Shandong , China
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Simões CJV, Almeida ZL, Cardoso AL, Bezerra F, Almeida MR, Beirão J, Pinho E Melo TMVD, Saraiva MJ, Brito RMM. Lead optimization of resilient next-generation transthyretin stabilizers for multiple target-product profiles: approaching the CNS. Amyloid 2019; 26:77-78. [PMID: 31343302 DOI: 10.1080/13506129.2019.1583195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Carlos J V Simões
- a Instituto Pedro Nunes, BSIM Therapeutics , Coimbra , Portugal.,b Coimbra Chemistry Centre and Chemistry Department, University of Coimbra , Coimbra , Portugal
| | - Zaida L Almeida
- b Coimbra Chemistry Centre and Chemistry Department, University of Coimbra , Coimbra , Portugal
| | - Ana L Cardoso
- b Coimbra Chemistry Centre and Chemistry Department, University of Coimbra , Coimbra , Portugal
| | - Filipa Bezerra
- c i3S-IBMC - Instituto de Biologia Molecular e Celular Universidade do Porto , Porto , Portugal
| | - Maria R Almeida
- c i3S-IBMC - Instituto de Biologia Molecular e Celular Universidade do Porto , Porto , Portugal.,d ICBAS - Institute of Biomedical Sciences Abel Salazar University of Porto , Porto , Portugal
| | - João Beirão
- e Centro Hospitalar do Porto, Ophtalmology Service , Porto , Portugal
| | | | - Maria J Saraiva
- c i3S-IBMC - Instituto de Biologia Molecular e Celular Universidade do Porto , Porto , Portugal
| | - Rui M M Brito
- b Coimbra Chemistry Centre and Chemistry Department, University of Coimbra , Coimbra , Portugal.,f Instituto Pedro Nunes, BSIM Therapeutics , Coimbra , Portugal
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