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Qarni TN, Jones FJS, Drachman B, Khella S, Pieretti J, Bustamante NS, Karam C. Treatment characteristics of patients with hereditary transthyretin amyloidosis: a cohort study. Orphanet J Rare Dis 2024; 19:191. [PMID: 38720335 PMCID: PMC11077800 DOI: 10.1186/s13023-024-03198-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND There are novel medications approved for the treatment of hereditary transthyretin amyloidosis (ATTRv), classified as transthyretin (TTR) stabilizers or gene silencers. While many patients may be on both classes of medications, there is no data available on the safety and efficacy of combination therapy. OBJECTIVES To describe ATTRv patient and TTR-targeted therapy characteristics in a US cohort, and compare outcomes with combination therapy versus monotherapy. METHODS We performed a retrospective cohort study with electronic health record data of patients with ATTRv seen at a single institution between January 2018 and December 2022. We collected data on symptomatology, gene mutation, disease severity, ATTRv treatment, hospitalizations, and mortality. RESULTS One hundred sixty-two patients with ATTRv were identified. The average age at diagnosis was 65 years. 86 patients (53%) had the V122I variant. 119 patients were symptomatic, of whom 103 were started on ATTRv-specific treatment. 41 patients (40%) had cardiomyopathy only, and 53 (51%) had a mixed phenotype of cardiomyopathy and neuropathy. 38 patients (37%) received therapy with both a gene silencer and protein stabilizer. 9 patients (15%) in the monotherapy group had two or more cardiac hospitalizations after starting treatment, compared to 3 patients (9%) on combination therapy (p=0.26). The adjusted hazard ratio of all-cause mortality for the patients on combination therapy compared to monotherapy was 0.37 (0.08-1.8, p=0.21). CONCLUSIONS While the efficacy is unproven, over one-third of patients with ATTRv are on both a stabilizer and a silencer. There were no safety issues for combination therapy. There was a trend towards improved hospitalizations and survival in patients in the combination group but this was not statistically significant. Larger studies with longer follow-up are necessary to determine benefit of combination therapy.
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Affiliation(s)
- Taha N Qarni
- Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce St, 3 Gates, Philadelphia, PA, 19104, USA.
| | - Felipe J S Jones
- Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce St, 3 Gates, Philadelphia, PA, 19104, USA
| | - Brian Drachman
- Department of Cardiology, University of Pennsylvania, Philadelphia, PA, USA
- Penn Amyloidosis Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Sami Khella
- Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce St, 3 Gates, Philadelphia, PA, 19104, USA
- Department of Cardiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Janice Pieretti
- Department of Cardiology, University of Pennsylvania, Philadelphia, PA, USA
- Penn Amyloidosis Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Nicolas Sarmiento Bustamante
- Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce St, 3 Gates, Philadelphia, PA, 19104, USA
| | - Chafic Karam
- Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Spruce St, 3 Gates, Philadelphia, PA, 19104, USA
- Penn Amyloidosis Center, University of Pennsylvania, Philadelphia, PA, USA
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González-Moreno J, Dispenzieri A, Grogan M, Coelho T, Tournev I, Waddington-Cruz M, Wixner J, Diemberger I, Garcia-Pavia P, Chapman D, Gupta P, Glass O, Amass L. Clinical and Genotype Characteristics and Symptom Migration in Patients With Mixed Phenotype Transthyretin Amyloidosis from the Transthyretin Amyloidosis Outcomes Survey. Cardiol Ther 2024; 13:117-135. [PMID: 38117424 PMCID: PMC10899146 DOI: 10.1007/s40119-023-00344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION Transthyretin amyloidosis (ATTR amyloidosis) is primarily associated with a cardiac or neurologic phenotype, but a mixed phenotype is increasingly described. METHODS This study describes the mixed phenotype cohort in the Transthyretin Amyloidosis Outcomes Survey (THAOS). THAOS is an ongoing, longitudinal, observational survey of patients with ATTR amyloidosis, including both hereditary (ATTRv) and wild-type disease, and asymptomatic carriers of pathogenic transthyretin variants. Baseline characteristics of patients with a mixed phenotype (at enrollment or reclassified during follow-up) are described (data cutoff: January 4, 2022). RESULTS Approximately one-third of symptomatic patients (n = 1185/3542; 33.5%) were classified at enrollment or follow-up as mixed phenotype (median age, 66.5 years). Of those, 344 (29.0%) were reclassified to mixed phenotype within a median 1-2 years of follow-up. Most patients with mixed phenotype had ATTRv amyloidosis (75.7%). The most frequent genotypes were V30M (38.9%) and wild type (24.3%). CONCLUSIONS These THAOS data represent the largest analysis of a real-world mixed phenotype ATTR amyloidosis population to date and suggest that a mixed phenotype may be more prevalent than previously thought. Patients may also migrate from a primarily neurologic or cardiologic presentation to a mixed phenotype over time. These data reinforce the need for multidisciplinary evaluation at initial assessment and follow-up of all patients with ATTR amyloidosis. TRIAL REGISTRATION ClinicalTrials.gov: NCT00628745.
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Affiliation(s)
- Juan González-Moreno
- Servicio de Medicina Interna, Hospital Universitario Son Llatzer, Instituto de Investigación Sanitaria Illes Balears, Palma, Spain.
| | | | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Teresa Coelho
- Unidade Corino Andrade, Hospital Santo António, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ivailo Tournev
- Department of Neurology, Clinic of Nervous Diseases, UMBAL Aleksandrovska, Medical University, Sofia, Bulgaria
- Department of Cognitive Science, New Bulgarian University, Sofia, Bulgaria
| | - Márcia Waddington-Cruz
- National Amyloidosis Referral Center, CEPARM, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jonas Wixner
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Igor Diemberger
- Department of Medical and Surgical Sciences, DIMEC, University of Bologna, Bologna, Italy
- UOC di Cardiologia, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Dipartimento Cardiotoraco-vascolare, via Massarenti 9, 40138, Bologna, Italy
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | | | - Pritam Gupta
- Pfizer Healthcare India Pvt. Ltd, Chennai, India
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Pinton S, Vacchi E, Chiaro G, Raimondi A, Tzankov A, Gerber B, Gobbi C, Kaelin-Lang A, Melli G. Amyloid detection and typing yield of skin biopsy in systemic amyloidosis and polyneuropathy. Ann Clin Transl Neurol 2023; 10:2347-2359. [PMID: 37849451 PMCID: PMC10723241 DOI: 10.1002/acn3.51924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE Disease-modifying therapies are available for amyloidosis but are ineffective if end-organ damage is severe. As small fiber neuropathy is an early and common feature of amyloidosis, we assessed detection and typing yield of skin biopsy for amyloid in patients with confirmed systemic amyloidosis and neuropathic symptoms. METHODS In this case-control study, patients with transthyretin and light chain amyloidosis (ATTRv, ATTRwt, and AL) were consecutively recruited. They were sex and age-matched to three control groups (1) non-neuropathic controls (NNC), (2) monoclonal gammopathy of undetermined significance (MGUS), and (3) other neuropathic disease controls (ONC). Patients underwent a double 3 mm skin biopsy in proximal and distal leg. Amyloid index and burden, protein typing by immuno-electron microscopy, intraepidermal nerve fiber density, electroneuromyography, and clinical characteristics were analyzed. RESULTS We studied 15 subjects with confirmed systemic amyloidosis, 20 NNC, 18 MGUS, and 20 ONC. Amyloid was detected in 100% of patients with amyloidosis (87% in ankle and 73% in thigh). It was not detected in any of the control groups. A small fiber neuropathy was encountered in 100% of amyloidosis patients, in 80% of MGUS, and in 78% of ONC. Amyloid burden was higher in ATTRv, followed by AL and ATTRwt. The ultrastructural examination allowed the identification of the precursor protein by immunotyping in most of the cases. INTERPRETATION Skin biopsy is a minimally invasive test with optimal sensitivity for amyloid. It allows amyloid typing by electron microscope to identify the precursor protein. The diagnostic work up of systemic amyloidosis should include a skin biopsy.
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Affiliation(s)
- Sandra Pinton
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Elena Vacchi
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Giacomo Chiaro
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Andrea Raimondi
- Institute for Research in Biomedicine, Università della Svizzera italiana, Bellinzona, Switzerland
- Experimental Imaging Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alexandar Tzankov
- Histopathology, Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- University of Zurich, Zurich, Switzerland
| | - Claudio Gobbi
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Alain Kaelin-Lang
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Giorgia Melli
- Neurology Department, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Neurodegenerative disorders lab, Laboratories for Translational Research, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Pernice HF, Hahn K. [Neurological manifestations of ATTR amyloidosis]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:848-854. [PMID: 37555967 DOI: 10.1007/s00108-023-01570-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/10/2023]
Abstract
Transthyretin amyloidosis (ATTR) is a rare disease in which the protein transthyretin (TTR) is deposited in the form of amyloid fibrils in various tissues and organs and secondarily leads to functional impairment, especially in peripheral nerves and the heart. A differentiation is made between hereditary and sporadic forms. The hereditary variant is inherited in an autosomal dominant manner and usually occurs in the younger to middle-aged, while the sporadic form occurs in older age and has no known genetic cause. Typical signs of hereditary ATTR amyloidosis (ATTRv, v for variant) include a rapidly progressing sensorimotor and autonomic polyneuropathy (PNP), cardiac dysfunction as well as ocular and gastrointestinal symptoms. A carpal tunnel syndrome often precedes the manifestation. Various options (tafamidis, patisiran, inotersen or vutrisiran) are available for the treatment of patients with ATTRv with PNP in Germany, depending on the severity. In the sporadic variant of wild-type ATTR amyloidosis (ATTRwt), symptoms of progressive cardiomyopathy are usually prominent; however, neurological assessment of these patients often also reveals a concomitant sensory ataxic PNP. The tetramer stabilizer tafamidis can be used for treatment. Because of this complex presentation, the management of patients with ATTR amyloidosis should be performed in interdisciplinary centers specialized in amyloidosis.
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Affiliation(s)
- Helena F Pernice
- Amyloidosis Center Charité Berlin (ACCB), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Katrin Hahn
- Amyloidosis Center Charité Berlin (ACCB), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland.
- Berlin Institute of Health at Charité (BIH), Universitätsmedizin Berlin, Berlin, Deutschland.
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Monfort A, Thevenet E, Enette L, Fagour C, Inamo J, Neviere R. The ventilatory component of the muscle metaboreflex is overstimulated in transthyretin cardiac amyloidosis patients with poor aerobic capacity. Front Physiol 2023; 14:1174645. [PMID: 37256072 PMCID: PMC10225564 DOI: 10.3389/fphys.2023.1174645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/02/2023] [Indexed: 06/01/2023] Open
Abstract
Background: The exercise pressor reflex, i.e., metabo- and mechano-reflex, partially regulates the control of ventilation and cardiovascular function during exercise. Abnormal exercise pressor reflex response has been associated with exaggerated ventilatory drive, sympathovagal imbalance and exercise limitation in chronic heart failure patients. Whether metaboreflex is over-activated and participate to poor aerobic capacity in patients with hereditary transthyretin cardiac amyloidosis (CA-TTR) is unknown. Methods: Twenty-two CA-TTR patients (aged 76 ± 7, 68% male) with the V122I (p.Val142Ile) transthyretin underwent a thorough evaluation including heart rate variability metrics, electrochemical skin conductance (ESC), physical function cardiopulmonary exercise testing, and muscle metaboreflex assessment. Eleven control subjects were chosen for muscle metaboreflex assessment. Results: Age-matched controls (n = 11) and CA-TTR patients (n = 22) had similar metaboreflex sensitivity for heart rate, stroke volume, cardiac index and mean systemic arterial pressure. Compared with age-matched controls, metaboreflex sensitivity for systemic vascular resistance (-18.64% ± 6.91% vs 3.14% ± 23.35%) and minute-ventilation responses (-9.65% ± 14.83% vs 11.84% ± 23.1%) was markedly increased in CA-TTR patients. Values of ESC displayed positive correlations with stroke volume (r = 0.53, p = 0.011) and cardiac index (r = 0.51, p = 0.015) components of metaboreflex sensitivity, an inverse correlation with systemic vascular resistance (r = -0.55, p = 0.008) and a trend with mean arterial (r = -0.42, p = 0.052) components of metaboreflex sensitivity. Peak aerobic capacity (peak VO2%) displayed an inverse correlation with the ventilation component of metaboreflex sensitivity (r = -0.62, p = 0.015). Conclusion: Consistent with the "muscle hypothesis" in heart failure, it is proposed that deterioration of skeletal muscle function in hereditary CA-TTR patients may activate muscle metaboreflex, leading to an increase in ventilation and sensation of breathlessness, the perception of fatigue, and overall sympathetic activation.
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Affiliation(s)
- Astrid Monfort
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
- Cardiovascular Research Team EA7525, Université des Antilles, Fort de France, France
| | - Eugenie Thevenet
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Lievyn Enette
- Department of Endocrinology, CHU Martinique (University Hospital of Martinique), Fort de France, France
- Department of Clinical Physiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Cedric Fagour
- Department of Endocrinology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Jocelyn Inamo
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
- Cardiovascular Research Team EA7525, Université des Antilles, Fort de France, France
| | - Remi Neviere
- Cardiovascular Research Team EA7525, Université des Antilles, Fort de France, France
- Department of Clinical Physiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
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