1
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Al-Samkari H. 2025 update on clinical trials in immune thrombocytopenia. Am J Hematol 2024. [PMID: 39105413 DOI: 10.1002/ajh.27448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/15/2024] [Accepted: 07/21/2024] [Indexed: 08/07/2024]
Abstract
Although the development and regulatory approval of the thrombopoietin receptor agonists revolutionized aspects of the immune thrombocytopenia (ITP) treatment landscape over the past two decades, there remain many areas of high unmet need. Therefore, a number of investigational and repurposed agents are currently undergoing clinical development in ITP. In a departure from historical trials, which largely focused on the indefinite treatment of persistent or chronic ITP, ongoing trials run the gamut of disease phases, and include novel agents being evaluated in early phases of the disease to attempt to modify the disease course. Many agents in development target disease pathophysiologic mechanisms not previously targeted by agents in current use, including platelet autoantibody recycling, B-cell maturation and differentiation, long-lived plasma cells, and the complement system, among others. These agents represent promising treatment options for patients with otherwise refractory disease or who are intolerant of currently available therapies. Additionally, with our increasing understanding of the diverse immune mechanisms at play in ITP, the expansion of the therapeutic armamentarium to include agents targeting diverse pathophysiologic mechanisms may allow a more personalized therapeutic selection in the future. This manuscript provides an up-to-date, in-depth overview of recently completed and ongoing clinical trials in ITP.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Clardy SL, Smith TL. Therapeutic Approach to Autoimmune Neurologic Disorders. Continuum (Minneap Minn) 2024; 30:1226-1258. [PMID: 39088294 DOI: 10.1212/con.0000000000001463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024]
Abstract
OBJECTIVE Autoimmune neurologic disorders encompass a broad category of diseases characterized by immune system attack of the central, peripheral, or autonomic nervous systems. This article provides information on both acute and maintenance immunotherapy used to treat autoimmune neurologic disorders as well as a review of symptomatic management and special considerations when caring for patients with these diseases. LATEST DEVELOPMENTS Over the past 20 years, more than 50 antibodies have been identified and associated with autoimmune neurologic disorders. Although advances in diagnostic testing have allowed for more rapid diagnosis, the therapeutic approach to these disorders has largely continued to rely on expert opinion, case series, and case reports. With US Food and Drug Administration (FDA) approval of biologic agents to treat neuromyelitis optica spectrum disorder (NMOSD) and myasthenia gravis as well as ongoing clinical trials for the treatment of autoimmune encephalitis, the landscape of immunotherapy options continues to expand. Consideration of the unique pathogenesis of individual autoimmune neurologic disorders as well as the mechanism of action of the diverse range of treatment options can help guide treatment decisions today while evidence from clinical trials informs new therapeutics in the future. ESSENTIAL POINTS Recognizing patients who have a clinical history and examination findings concerning for autoimmune neurologic disorders and conducting a thorough and directed imaging and laboratory evaluation aimed at ruling out mimics, identifying specific autoimmune syndromes, and screening for factors that may have an impact on immunotherapy choices early in the clinical course are essential to providing optimal care for these patients. Providers must consider immunotherapy, symptomatic treatment, and a multidisciplinary approach that addresses each patient's unique needs when treating patients with autoimmune neurologic disorders.
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Strüßmann T, Heinz J, Wäsch R, Jung J, Engelhardt M, Duyster J, Finke J, Duque-Afonso J, Marks R. Long-term complete remissions of refractory severe idiopathic immune thrombocytopenia treated with daratumumab: A case series. Br J Haematol 2024. [PMID: 39073116 DOI: 10.1111/bjh.19660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 07/11/2024] [Indexed: 07/30/2024]
Affiliation(s)
- T Strüßmann
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - J Heinz
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - R Wäsch
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - J Jung
- Center for Personalized Medicine (ZPM), Klinikum Rechts der Isar, Technical University of Munich (TUM), Munich, Germany
| | - M Engelhardt
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - J Duyster
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - J Finke
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - J Duque-Afonso
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - R Marks
- Department of Hematology/Oncology/Stem Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
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4
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Stolz SM, Schwotzer R, Rösler W, Hofer KD, Balabanov S, Manz MG, Rieger MJ. Efficacy of thrombopoietin receptor agonists versus rituximab in non-responsive immune thrombocytopenia-A single centre retrospective analysis. Br J Haematol 2024. [PMID: 38973132 DOI: 10.1111/bjh.19629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/24/2024] [Indexed: 07/09/2024]
Abstract
Management of immune thrombocytopenia (ITP) beyond initial glucocorticoid therapy is challenging. In this retrospective single-centre cohort study, we compared all ITP patients relapsed or non-responsive to glucocorticoid therapy treated with either continuous TPO-RAs (n = 35) or rituximab induction (n = 20) between 2015 and 2022. While both groups showed high initial complete response rates (CR, 68.6 vs. 80.0%, ns), the overall rate of progression to the next therapy was higher after time-limited rituximab (75.0 vs. 42.9%), resulting in a lower relapse-free survival (median 16.6 vs. 25.8 months, log-rank; p < 0.05). We conclude that both treatments show similar initial efficacy and their ideal duration of therapy warrants further investigation.
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Affiliation(s)
- Sebastian M Stolz
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Rahel Schwotzer
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Wiebke Rösler
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Kevin D Hofer
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Stefan Balabanov
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
| | - Max J Rieger
- Department of Medical Oncology and Hematology, University Hospital of Zurich, Zurich, Switzerland
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5
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Jalink M, Jacobs CF, Khwaja J, Evers D, Bruggeman C, Fattizzo B, Michel M, Crickx E, Hill QA, Jaeger U, Kater AP, Mäkelburg ABU, Breedijk A, te Boekhorst PAW, Hoeks MPA, de Haas M, D’Sa S, Vos JMI. Daratumumab monotherapy in refractory warm autoimmune hemolytic anemia and cold agglutinin disease. Blood Adv 2024; 8:2622-2634. [PMID: 38507742 PMCID: PMC11157213 DOI: 10.1182/bloodadvances.2024012585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/07/2024] [Accepted: 02/28/2024] [Indexed: 03/22/2024] Open
Abstract
ABSTRACT Autoimmune hemolytic anemia (AIHA) is a rare autoantibody-mediated disease. For steroid and/or rituximab-refractory AIHA, there is no consensus on optimal treatment. Daratumumab, a monoclonal antibody targeting CD38, could be beneficial by suppression of CD38+ plasma cells and thus autoantibody secretion. In addition, because CD38 is also expressed by activated T cells, daratumumab may also act via immunomodulatory effects. We evaluated the efficacy and safety of daratumumab monotherapy in an international retrospective study including 19 adult patients with heavily pretreated refractory AIHA. In warm AIHA (wAIHA, n = 12), overall response was 50% with a median response duration of 5.5 months (range, 2-12), including ongoing response in 2 patients after 6 and 12 months. Of 6 nonresponders, 4 had Evans syndrome. In cold AIHA (cAIHA, n = 7) overall hemoglobin (Hb) response was 57%, with ongoing response in 3 of 7 patients. One additional patient with nonanemic cAIHA was treated for severe acrocyanosis and reached a clinical acrocyanosis response as well as a Hb increase. Of 6 patients with cAIHA with acrocyanosis, 4 had improved symptoms after daratumumab treatment. In 2 patients with wAIHA treated with daratumumab, in whom we prospectively collected blood samples, we found complete CD38+ T-cell depletion after daratumumab, as well as altered T-cell subset differentiation and a severely diminished capacity for cell activation and proliferation. Reappearance of CD38+ T cells coincided with disease relapse in 1 patient. In conclusion, our data show that daratumumab therapy may be a treatment option for refractory AIHA. The observed immunomodulatory effects that may contribute to the clinical response deserve further exploration.
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Affiliation(s)
- Marit Jalink
- Center for Clinical Transfusion Research, Sanquin Research, Amsterdam, The Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Chaja F. Jacobs
- Experimental Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Cancer Immunology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Immunology, Amsterdam, The Netherlands
| | - Jahanzaib Khwaja
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Dorothea Evers
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Coty Bruggeman
- Department of Hematology, Martini Ziekenhuis, Groningen, The Netherlands
| | - Bruno Fattizzo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Marc Michel
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Etienne Crickx
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Quentin A. Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Ulrich Jaeger
- Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Arnon P. Kater
- Experimental Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Cancer Immunology, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Immunology, Amsterdam, The Netherlands
| | - Anja B. U. Mäkelburg
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - Anouk Breedijk
- Department of Internal Medicine, Deventer Ziekenhuis, Deventer, The Netherlands
| | - Peter A. W. te Boekhorst
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marlijn P. A. Hoeks
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Masja de Haas
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Immunohematology Diagnostics, Sanquin, Amsterdam, The Netherlands
| | - Shirley D’Sa
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Josephine M. I. Vos
- Department of Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Cancer Immunology, Amsterdam, The Netherlands
- Department of Immunohematology Diagnostics, Sanquin, Amsterdam, The Netherlands
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6
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Kunvarjee B, Contreras Yametti GP, Blouin AG, Linder GE, Borge PD, Maryamchik E, Budhai A, Gupta GK, Scaradavou A, Spitzer BG, Curran KJ, Oved JH, Harris AC, Sharma A, Boelens JJ, Cancio MI. Donor-specific antibody desensitization with daratumumab prior to haematopoietic cell transplant for sickle cell disease: A case report. Br J Haematol 2024; 204:1540-1544. [PMID: 38212144 DOI: 10.1111/bjh.19289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Affiliation(s)
- Binni Kunvarjee
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gloria Paz Contreras Yametti
- Pediatric Bone Marrow Transplant and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amanda G Blouin
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Grace E Linder
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - P Dayand Borge
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elena Maryamchik
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexandra Budhai
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gaurav K Gupta
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andromachi Scaradavou
- Pediatric Bone Marrow Transplant and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Barbara G Spitzer
- Pediatric Bone Marrow Transplant and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kevin J Curran
- Pediatric Bone Marrow Transplant and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph H Oved
- Pediatric Bone Marrow Transplant and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew C Harris
- Pediatric Bone Marrow Transplant and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jaap Jan Boelens
- Pediatric Bone Marrow Transplant and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria I Cancio
- Pediatric Bone Marrow Transplant and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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7
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Noel JC, Lagassé D, Golding B, Sauna ZE. Emerging approaches to induce immune tolerance to therapeutic proteins. Trends Pharmacol Sci 2023; 44:1028-1042. [PMID: 37903706 DOI: 10.1016/j.tips.2023.10.002] [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: 09/25/2023] [Revised: 10/04/2023] [Accepted: 10/08/2023] [Indexed: 11/01/2023]
Abstract
Immunogenicity affects the safety and efficacy of therapeutic proteins. This review is focused on approaches for inducing immunological tolerance to circumvent the immunogenicity of therapeutic proteins in the clinic. The few immune tolerance strategies that are used in the clinic tend to be inefficient and expensive and typically involve global immunosuppression, putting patients at risk of infections. The hallmark of a desirable immune tolerance regimen is the specific alleviation of immune responses to the therapeutic protein. In the past decade, proof-of-principle studies have demonstrated that emerging technologies, including nanoparticle-based delivery of immunomodulators, cellular targeting and depletion, cellular engineering, gene therapy, and gene editing, can be leveraged to promote tolerance to therapeutic proteins. We discuss the potential of these novel approaches and the barriers that need to be overcome for translation into the clinic.
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Affiliation(s)
- Justine C Noel
- Division of Hemostasis, Office of Plasma Protein Therapeutics, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Daniel Lagassé
- Division of Hemostasis, Office of Plasma Protein Therapeutics, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Basil Golding
- Division of Plasma Derivatives, Office of Plasma Protein Therapeutics, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Zuben E Sauna
- Division of Hemostasis, Office of Plasma Protein Therapeutics, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.
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8
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Al-Samkari H, Neufeld EJ. Novel therapeutics and future directions for refractory immune thrombocytopenia. Br J Haematol 2023; 203:65-78. [PMID: 37735554 PMCID: PMC11101754 DOI: 10.1111/bjh.19078] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder affecting approximately 1 in 20 000 people. While most patients with ITP are successfully managed with the current set of standard and approved therapeutics, patients who cannot be adequately managed with these therapies, considered to have refractory ITP, are not uncommon. Therefore, there remains an ongoing need for novel therapeutics and drug development in ITP. Several agents exploiting novel targets and mechanisms in ITP are presently under clinical development, with trials primarily recruiting heavily pretreated patients and those with otherwise refractory disease. Such agents include the neonatal Fc receptor antagonist efgartigimod, the Bruton tyrosine kinase inhibitor rilzabrutinib, the complement inhibitors sutimlimab and iptacopan and anti-CD38 monoclonal antibodies such as daratumumab and mezagitamab, among others. Each of these agents exploits therapeutic targets or other aspects of ITP pathophysiology currently not targeted by the existing approved agents (thrombopoietin receptor agonists and fostamatinib). This manuscript offers an in-depth review of the current available data for novel therapeutics in ITP presently undergoing phase 2 or 3 studies in patients with heavily pretreated or refractory ITP. It additionally highlights the future directions for drug development in refractory ITP, including discussion of innovative clinical trial designs, health-related quality of life as an indispensable clinical trial end-point and balancing potential toxicities of drugs with their potential benefits in a bleeding disorder in which few patients suffer life-threatening bleeding.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ellis J. Neufeld
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
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9
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Cvetković Z, Pantić N, Cvetković M, Virijević M, Sabljić N, Marinković G, Milosavljević V, Pravdić Z, Suvajdžić-Vuković N, Mitrović M. The Role of the Spleen and the Place of Splenectomy in Autoimmune Hemolytic Anemia-A Review of Current Knowledge. Diagnostics (Basel) 2023; 13:2891. [PMID: 37761258 PMCID: PMC10527817 DOI: 10.3390/diagnostics13182891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare, very heterogeneous, and sometimes life-threatening acquired hematologic disease characterized by increased red blood cell (RBC) destruction by autoantibodies (autoAbs), either with or without complement involvement. Recent studies have shown that the involvement of T- and B-cell dysregulation and an imbalance of T-helper 2 (Th2) and Th17 phenotypes play major roles in the pathogenesis of AIHA. AIHA can be primary (idiopathic) but is more often secondary, triggered by infections or drug use or as a part of other diseases. As the location of origin of autoAbs and the location of autoAb-mediated RBC clearance, as well as the location of extramedullary hematopoiesis, the spleen is crucially involved in all the steps of AIHA pathobiology. Splenectomy, which was the established second-line therapeutic option in corticosteroid-resistant AIHA patients for decades, has become less common due to increasing knowledge of immunopathogenesis and the introduction of targeted therapy. This article provides a comprehensive overview of current knowledge regarding the place of the spleen in the immunological background of AIHA and the rapidly growing spectrum of novel therapeutic approaches. Furthermore, this review emphasizes the still-existing expediency of laparoscopic splenectomy with appropriate perioperative thromboprophylaxis and the prevention of infection as a safe and reliable therapeutic option in the context of the limited availability of rituximab and other novel therapies.
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Affiliation(s)
- Zorica Cvetković
- Department of Hematology, University Hospital Medical Center Zemun, 11080 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Nikola Pantić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mirjana Cvetković
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marijana Virijević
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nikica Sabljić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Gligorije Marinković
- Department of Hematology, University Hospital Medical Center Zemun, 11080 Belgrade, Serbia
| | - Vladimir Milosavljević
- Department for HPB Surgery, University Hospital Medical Center Bežanijska Kosa, 11070 Belgrade, Serbia
| | - Zlatko Pravdić
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nada Suvajdžić-Vuković
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mirjana Mitrović
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Clinic for Hematology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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10
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Cavallaro F, Barcellini W, Fattizzo B. Antibody based therapeutics for autoimmune hemolytic anemia. Expert Opin Biol Ther 2023; 23:1227-1237. [PMID: 37874225 DOI: 10.1080/14712598.2023.2274912] [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: 07/11/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Autoimmune hemolytic anemia (AIHA) treatment has been revolutionized by the introduction of target therapies, mainly monoclonal antibodies (MoAbs). AREAS COVERED The anti-CD20 rituximab, which targets Ab production by B-cells, induces 80% of response in warm-type AIHA (wAIHA) and 50-60% in cold agglutinin disease (CAD). Other B-cell targeting MoAbs including ianalumab, povetacicept, and obexelimab are under active study. The anti-CD38 MoAb daratumumab has been used in several reports to target long-lived plasma-cells responsible for AIHA relapse, being effective even in multi-refractory cases. Anti-complement MoAbs will soon change the treatment paradigm in CAD; the anti-C1s sutimlimab rapidly increased Hb in more than 80% of the cases. Finally, MoAbs inhibiting the neonatal Fc receptor (FcRn), such as nipocalimab, can reduce the half-life of the pathogenic autoAbs, representing a promising treatment for wAIHA. EXPERT OPINION MoAbs offer the potential to improve efficacy by reducing toxicity. However, there is a huge need for clinical trials exploring response duration rather than short-term efficacy. Complement inhibitors and anti-FcRns do not abrogate autoAb production and are being developed as long-term therapies. Thus, the combination of B-cell/plasma cell targeting drugs deserves to be explored. On the other hand, their rapid efficacy should be exploited for the acute AIHA phase.
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Affiliation(s)
- Francesca Cavallaro
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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11
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Argüello Marina M, López Rubio M, Castilla García L. [Autoimmune haemolytic anaemia]. Med Clin (Barc) 2023; 160:30-38. [PMID: 36334945 DOI: 10.1016/j.medcli.2022.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/29/2022]
Abstract
Autoimmune haemolytic anaemias (AIHA) are acquired haematological disorders caused by increased peripheral erythrocyte destruction mediated by autoantibodies against erythrocyte antigens. They classified according to aetiology into primary and secondary, and according to the type of antibody and reaction temperature into AIHA due to warm antibodies (w-AIHA) and AIHA due to cold antibodies (c-AIHA). The mainstay of management in w-AIHA remains glucocorticoid therapy, and the early addition of rituximab has shown good results in recent studies. Primary c-AIHA is mainly treated with rituximab, alone or in combination with chemotherapy. New drugs such as Syk inhibitors, anti-FcRn Ig and complement inhibitors are in advanced development and will expand the therapeutic arsenal, especially in refractory or relapsed cases.
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Affiliation(s)
- María Argüello Marina
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España.
| | - Montserrat López Rubio
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
| | - Lucía Castilla García
- Servicio de Hematología y Hemoterapia, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, España
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12
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Strüßmann T, Jung J, Heinz J, Duque Afonso J, Wäsch R, Engelhardt M, Duyster J, Finke J, Marks R. Long-term complete remission of refractory severe idiopathic immune thrombocytopenia (ITP) treated with daratumumab. Ann Hematol 2023; 102:245-247. [PMID: 36394581 PMCID: PMC9807464 DOI: 10.1007/s00277-022-05035-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/04/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Tim Strüßmann
- grid.5963.9Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Johannes Jung
- grid.5963.9Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Jürgen Heinz
- grid.5963.9Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Jesus Duque Afonso
- grid.5963.9Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Ralph Wäsch
- grid.5963.9Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Monika Engelhardt
- grid.5963.9Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Justus Duyster
- grid.5963.9Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Jürgen Finke
- grid.5963.9Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Reinhard Marks
- grid.5963.9Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
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13
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Pacillo L, Giardino G, Amodio D, Giancotta C, Rivalta B, Rotulo GA, Manno EC, Cifaldi C, Palumbo G, Pignata C, Palma P, Rossi P, Finocchi A, Cancrini C. Targeted treatment of autoimmune cytopenias in primary immunodeficiencies. Front Immunol 2022; 13:911385. [PMID: 36052091 PMCID: PMC9426461 DOI: 10.3389/fimmu.2022.911385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/15/2022] [Indexed: 11/14/2022] Open
Abstract
Primary Immunodeficiencies (PID) are a group of rare congenital disorders of the immune system. Autoimmune cytopenia (AIC) represents the most common autoimmune manifestation in PID patients. Treatment of AIC in PID patients can be really challenging, since they are often chronic, relapsing and refractory to first line therapies, thus requiring a broad variety of alternative therapeutic options. Moreover, immunosuppression should be fine balanced considering the increased susceptibility to infections in these patients. Specific therapeutic guidelines for AIC in PID patients are lacking. Treatment choice should be guided by the underlying disease. The study of the pathogenic mechanisms involved in the genesis of AIC in PID and our growing ability to define the molecular underpinnings of immune dysregulation has paved the way for the development of novel targeted treatments. Ideally, targeted therapy is directed against an overexpressed or overactive gene product or substitutes a defective protein, restoring the impaired pathway. Actually, the molecular diagnosis or a specific drug is not always available. However, defining the category of PID or the immunological phenotype can help to choose a semi-targeted therapy directed towards the suspected pathogenic mechanism. In this review we overview all the therapeutic interventions available for AIC in PID patients, according to different immunologic targets. In particular, we focus on T and/or B cells targeting therapies. To support decision making in the future, prospective studies to define treatment response and predicting/stratifying biomarkers for patients with AIC and PID are needed.
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Affiliation(s)
- Lucia Pacillo
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Giuliana Giardino
- Pediatric Section, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Donato Amodio
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Carmela Giancotta
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Beatrice Rivalta
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Gioacchino Andrea Rotulo
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Emma Concetta Manno
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Cristina Cifaldi
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Giuseppe Palumbo
- Department of Onco Hematology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Claudio Pignata
- Pediatric Section, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Paolo Palma
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Paolo Rossi
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
- Academic Department of Pediatrics (DPUO), Research Unit of Clinical Immunology and Vaccinology, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
| | - Andrea Finocchi
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Caterina Cancrini
- Academic Department of Pediatrics (DPUO), Immune and Infectious Diseases Division, Research Unit of Primary Immunodeficiencies, IRCCS Bambino Gesù Children’s Hospital, Rome, Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
- *Correspondence: Caterina Cancrini,
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14
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Development of New Drugs for Autoimmune Hemolytic Anemia. Pharmaceutics 2022; 14:pharmaceutics14051035. [PMID: 35631621 PMCID: PMC9147507 DOI: 10.3390/pharmaceutics14051035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/27/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a rare disorder characterized by the autoantibody-mediated destruction of red blood cells, and treatments for it still remain challenging. Traditional first-line immunosuppressive therapy, which includes corticosteroids and rituximab, is associated with adverse effects as well as treatment failures, and relapses are common. Subsequent lines of therapy are associated with higher rates of toxicity, and some patients remain refractory to currently available treatments. Novel therapies have become promising for this vulnerable population. In this review, we will discuss the mechanism of action, existing data, and ongoing clinical trials of current novel therapies for AIHA, including B-cell-directed therapy, phagocytosis inhibition, plasma cell-directed therapy, and complement inhibition.
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