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Mingot-Castellano ME, García-Candel F, Martínez-Nieto J, García-Arroba J, de la Rubia-Comos J, Gómez-Seguí I, Paciello-Coronel ML, Valcárcel-Ferreiras D, Jiménez M, Cid J, Lozano M, García-Gala JM, Angós-Vazquez S, Vara-Pampliega M, Guerra-Domínguez L, Ávila-Idrobo LF, Oliva-Hernandez A, Zalba-Marcos S, Tallón-Ruiz I, Ortega-Sánchez S, Goterris-Viciedo R, Moreno-Jiménez G, Domínguez-Acosta L, Araiz-Ramírez M, Hernández-Mateos L, Flores-Ballesteros E, Del Río-Garma J, Pascual-Izquierdo C. ADAMTS13 recovery in acute thrombotic thrombocytopenic purpura after caplacizumab therapy. Blood 2024; 143:1807-1815. [PMID: 38237147 DOI: 10.1182/blood.2023022725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 03/25/2024] Open
Abstract
ABSTRACT Caplacizumab prevents the interaction between von Willebrand factor and platelets and is used to treat immune thrombotic thrombocytopenic purpura (iTTP). Its administration has been associated with a delay in ADAMTS13 activity restoration after plasma exchange (PEX) suspension. We analyzed the outcomes of 113 iTTP episodes, 75 of which were treated with caplacizumab, in 108 patients from the Spanish Registry of Thrombotic Thrombocytopenic Purpura. Caplacizumab shortened the time to platelet count normalization and reduced PEX requirement, exacerbations, and relapses. There was no difference in the time to achieve ADAMTS13 activity ≥20% after PEX end between caplacizumab-treated and nontreated episodes (median [interquartile range], 14.5 [7.7-27.2] vs 13.0 [8.0-29.0] days, P = .653). However, considering the 36 episodes in which caplacizumab was started ≤3 days after iTTP diagnosis, the time for ADAMTS13 restoration from PEX end was higher than in those episodes in which caplacizumab was started >3 days after iTTP diagnosis (20.0 [12.0-43.0] vs 11.0 [3.5-20.0] days, P = .003) or than in non-caplacizumab-treated episodes (P = .033). This finding could be related to a significantly shorter duration of PEX in early caplacizumab-treated episodes than in late caplacizumab-treated episodes (5.5 [4.0-9.0] vs 15.0 [11.0-21.5] days, P < .001) or non-caplacizumab-treated episodes (11.0 [6.0-26.0] days, P < .001). There were no differences in time to ADAMTS-13 restoration from PEX start (28.0 [17.2-47.5], 27.0 [19.0-37.5] and 29.5 [15.2-45.0] days in early caplacizumab-treated, late caplacizumab-treated and non-caplacizumab-treated episodes). Early administered caplacizumab does not prevent the requirement for immunosuppression but has beneficial effects by shortening PEX requirement without major safety concerns.
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Affiliation(s)
- María-Eva Mingot-Castellano
- Department of Hematology, Hospital Universitario Virgen del Rocío, Seville, Spain
- Instituto de Biomedicina de Sevilla, Seville, Spain
| | | | | | - José García-Arroba
- Banc de Sang i Teixits, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Javier de la Rubia-Comos
- Department of Hematology, Hospital Universitario La Fe, Universidad Católica San Vicente Mártir, IIS La Fe, Valencia, Spain
| | - Inés Gómez-Seguí
- Department of Hematology, Hospital Universitario La Fe, Universidad Católica San Vicente Mártir, IIS La Fe, Valencia, Spain
| | | | | | - Moraima Jiménez
- Department of Hematology, Hospital Universitari Vall D'Hebron, Barcelona, Spain
| | - Joan Cid
- Department of Hemotherapy and Hemostasis, Apheresis and Cellular Therapy Unit, Clinical Institute of Hematological and Oncological Diseases, Instituto de Investigaciones Biomédicas August Pi i Sunyer, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Miquel Lozano
- Department of Hemotherapy and Hemostasis, Apheresis and Cellular Therapy Unit, Clinical Institute of Hematological and Oncological Diseases, Instituto de Investigaciones Biomédicas August Pi i Sunyer, Hospital Clínic de Barcelona, Barcelona, Spain
| | - José-María García-Gala
- Department of Hematology, Hospital Universitario Central de Asturias, Institute for Bio Health Investigation of Asturias, Oviedo, Spain
| | - Sonia Angós-Vazquez
- Department of Hematology, Hospital Universitario de Zaragoza, Zaragoza, Spain
| | | | - Luisa Guerra-Domínguez
- Department of Hematology, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | - Ana Oliva-Hernandez
- Department of Hematology, Hospital Universitario Nuestra Señora de la Candelaria, Tenerife, Spain
| | - Saioa Zalba-Marcos
- Department of Hematology, Hospital Universitario de Navarra, Pamplona, Spain
| | | | | | - Rosa Goterris-Viciedo
- Department of Hematology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Lourdes Domínguez-Acosta
- Department of Hematology, Hospital Universitario de Jerez de la Frontera, Jerez de la Frontera, Spain
| | | | - Luis Hernández-Mateos
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Elena Flores-Ballesteros
- Department of Hematology, Hospital Universitario Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Julio Del Río-Garma
- Department of Hematology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Cristina Pascual-Izquierdo
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Gregorio Marañon, Madrid, Spain
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Seguí IG, Mingot Castellano ME, Izquierdo CP, de la Rubia J. Should we consider caplacizumab as routine treatment for acute thrombotic thrombocytopenic purpura? An expert perspective on the pros and cons. Expert Rev Hematol 2024; 17:9-25. [PMID: 38353182 DOI: 10.1080/17474086.2024.2318347] [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: 11/15/2023] [Accepted: 02/09/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Immune thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening disorder. Caplacizumab has been the latest drug incorporated into the initial treatment of acute episodes, allowing for faster platelet recovery and a decrease in refractoriness, exacerbation, thromboembolic events, and mortality. However, caplacizumab is also associated with a bleeding risk and higher treatment costs, which prevent many centers from using it universally. AREAS COVERED Studies that included iTTP and/or caplacizumab to date were selected for this review using PubMed and MEDLINE platforms. We describe outcomes in the pre-caplacizumab era and after it, highlighting the benefits and risks of its use early in frontline, and also pointing out special situations that require careful management. EXPERT OPINION It is clear that the availability of caplacizumab has significantly and favorably impacted the management of iTTP patients. Whether this improvement is cost-effective still remains uncertain, and data on long-term sequelae and different healthcare systems will help to clarify this point. In addition, evidence of the bleeding/thrombotic risk of iTTP patients under this drug needs to be better addressed in future studies.
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Affiliation(s)
- Inés Gómez Seguí
- Hematology Department institution, H. Universitario y Politécnico La Fe, Valencia, Valencia, Spain
| | | | | | - Javier de la Rubia
- Hematology Department institution, H. Universitario y Politécnico La Fe, Valencia, Valencia, Spain
- Internal Medicine, Universidad Católica "San Vicente Mártir", Valencia, Spain
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Zhou Y, Jiang H, Wei H, Xiao X, Liu L, Ji X, Zhou C. Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers. CNS Neurosci Ther 2023; 29:2760-2774. [PMID: 37365966 PMCID: PMC10493677 DOI: 10.1111/cns.14321] [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: 03/12/2023] [Revised: 05/24/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19. AIMS This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19. CONCLUSION A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.
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Affiliation(s)
- Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Xuechun Xiao
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Lu Liu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chen Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
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Joffre J, Raia L, Urbina T, Bonny V, Gabarre P, Missri L, Baudel JL, Coppo P, Guidet B, Maury E, Ait-Oufella H. Reversible skin microvascular hyporeactivity in patients with immune-mediated thrombocytopenic thrombotic purpura. Crit Care 2023; 27:116. [PMID: 36944989 PMCID: PMC10028781 DOI: 10.1186/s13054-023-04405-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/15/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare disease characterized by arteriolar and capillary microthrombosis precipitating organ failure. However, the contribution of endothelial dysfunction on impaired microvascular blood flow in iTTP patients has been poorly explored. This pilot observational study aimed to explore endothelial-mediated vasoreactivity in iTTP patients at admission and its changes after plasma exchange therapy (PE). METHODS We conducted a prospective observational study in patients (> 18-year old) admitted in ICU for iTTP. Using laser Doppler flowmetry and acetylcholine (Ach) iontophoresis in the forearm, we recorded the skin microvascular blood flow and the endothelium-mediated vasoreactivity at admission and after PE. Demographics, biological, clinical courses, and outcomes were also collected. As a control group, we used a previously published cohort of young diabetic patients after correction of ketoacidosis. RESULTS Eighteen confirmed iTTP patients and 34 controls were included in the study, mainly female (72%) aged 43 ± 16-year-old. At admission, 55% had neurological abnormalities, 50% cardiac issues and 27.8% an acute kidney injury. Median platelet count was 19 G/mL [10-37]. Baseline microvascular blood flow was decreased in iTTP patients when compared to controls (5.97 ± 4.5 vs. 10.1 ± 6.3 PU, P = 0.03), associated with markedly impaired endothelial-mediated skin microvascular reactivity (AUC: 9627 ± 8122 vs. 16,475 ± 11,738, P = 0.03). Microvascular reactivity improved after the first PE session (AUC: 9627 ± 8122 vs 16,558 ± 10,699, P = 0.007, respectively, baseline and post-PE1) and much more after the second session (26,431 ± 23,181, P = 0.04 post-PE1 vs post-PE2). Hemolysis biomarkers (LDH and bilirubin) negatively correlated with skin microvascular flow and vasoreactivity. CONCLUSION We highlighted a marked yet reversible skin endothelium-mediated microvascular hyporeactivity in iTTP patients that could participate in organ injury pathophysiology.
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Affiliation(s)
- Jérémie Joffre
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- Centre de Recherche Saint-Antoine Inserm UMR-S 938, Sorbonne University, 75012, Paris, France
| | - Lisa Raia
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Tomas Urbina
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Vincent Bonny
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Paul Gabarre
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Louai Missri
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Jean-Luc Baudel
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Paul Coppo
- Hematology Department, AP-HP, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- French Reference Center for Thrombotic Microangiopathies (CNR-MAT), Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Bertrand Guidet
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Eric Maury
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Hafid Ait-Oufella
- Intensive Care Unit, Saint-Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.
- Paris Cardiovascular Research Center, Inserm U970, University Paris Cité, Paris, France.
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