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Zheng XL. Novel mechanisms of action of emerging therapies of hereditary thrombotic thrombocytopenic purpura. Expert Rev Hematol 2024; 17:341-351. [PMID: 38752747 PMCID: PMC11209763 DOI: 10.1080/17474086.2024.2356763] [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: 03/12/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Hereditary thrombotic thrombocytopenic purpura (hTTP) is caused by deficiency of plasma ADAMTS13 activity, resulting from ADAMTS13 mutations. ADAMTS13 cleaves ultra large von Willebrand factor (VWF), thus reducing its multimer sizes. Hereditary deficiency of plasma ADAMTS13 activity leads to the formation of excessive platelet-VWF aggregates in small arterioles and capillaries, resulting in hTTP. AREAS COVERED PubMed search from 1956 to 2024 using thrombotic thrombocytopenic purpura and therapy identified 3,675 articles. Only the articles relevant to the topic were selected for discussion, which focuses on pathophysiology, clinical presentations, and mechanisms of action of emerging therapeutics for hTTP. Current therapies include infusion of plasma, or coagulation factor VIII, or recombinant ADAMTS13. Emerging therapies include anti-VWF A1 aptamers or nanobody and gene therapies with adeno-associated viral vector or self-inactivated lentiviral vector or a sleeping beauty transposon system for a long-term expression of a functional ADAMTS13 enzyme. EXPERT OPINION Frequent plasma infusion remains to be the standard of care in most parts of the world, while recombinant ADAMTS13 has become the treatment of choice for hTTP in some of the Western countries. The success of gene therapies in preclinical models may hold a promise for future development of these novel approaches for a cure of hTTP.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine and Institute of Reproductive Medicine and Developmental Sciences, the University of Kansas Medical Center, Kansas City, Kansas 66160, USA
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Schimmer RR, Sutter T, Bachofner A, Ranieri E, Rodewald AK, Kremer Hovinga JA, Kimmich N, Trinchero A, Studt JD. Successful management of refractory immune-mediated thrombotic thrombocytopenic purpura during pregnancy and delivery using the anti-VWF nanobody caplacizumab. Br J Haematol 2024; 204:1994-1998. [PMID: 38168722 DOI: 10.1111/bjh.19284] [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: 10/31/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024]
Abstract
Pregnancy is a potential trigger of acute thrombotic thrombocytopenic purpura (TTP). The management of pregnancy-associated immune-mediated TTP (iTTP) can be challenging, especially when it is refractory to standard treatment. Caplacizumab, a nanobody to von Willebrand factor (VWF) blocking its A1 domain, is a valuable new therapeutic option. Its use is, however, not approved during pregnancy and breastfeeding. We describe the successful off-label administration of caplacizumab during pregnancy and delivery in a patient with refractory iTTP. The favourable outcome without significant thrombotic or haemorrhagic complications indicates that caplacizumab may be an effective and safe treatment option in refractory iTTP during pregnancy.
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Affiliation(s)
- Roman R Schimmer
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Tabea Sutter
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Adrian Bachofner
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Elisabetta Ranieri
- Department of Obstetrics, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Ann-Kathrin Rodewald
- Department of Pathology and Molecular Pathology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Haematology and Central Haematological Laboratory, Inselspital Bern, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Nina Kimmich
- Department of Obstetrics, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Alice Trinchero
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Haematology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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Frimat M, Gnemmi V, Stichelbout M, Provôt F, Fakhouri F. Pregnancy as a susceptible state for thrombotic microangiopathies. Front Med (Lausanne) 2024; 11:1343060. [PMID: 38476448 PMCID: PMC10927739 DOI: 10.3389/fmed.2024.1343060] [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: 11/22/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024] Open
Abstract
Pregnancy and the postpartum period represent phases of heightened vulnerability to thrombotic microangiopathies (TMAs), as evidenced by distinct patterns of pregnancy-specific TMAs (e.g., preeclampsia, HELLP syndrome), as well as a higher incidence of nonspecific TMAs, such as thrombotic thrombocytopenic purpura or hemolytic uremic syndrome, during pregnancy. Significant strides have been taken in understanding the underlying mechanisms of these disorders in the past 40 years. This progress has involved the identification of pivotal factors contributing to TMAs, such as the complement system, ADAMTS13, and the soluble VEGF receptor Flt1. Regardless of the specific causal factor (which is not generally unique in relation to the usual multifactorial origin of TMAs), the endothelial cell stands as a central player in the pathophysiology of TMAs. Pregnancy has a major impact on the physiology of the endothelium. Besides to the development of placenta and its vascular consequences, pregnancy modifies the characteristics of the women's microvascular endothelium and tends to render it more prone to thrombosis. This review aims to delineate the distinct features of pregnancy-related TMAs and explore the contributing mechanisms that lead to this increased susceptibility, particularly influenced by the "gravid endothelium." Furthermore, we will discuss the potential contribution of histopathological studies in facilitating the etiological diagnosis of pregnancy-related TMAs.
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Affiliation(s)
- Marie Frimat
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
- Inserm, Institut Pasteur de Lille, Univ. Lille, Lille, France
| | | | | | - François Provôt
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, CHUV and University of Lausanne, Lausanne, Switzerland
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Béranger N, Coppo P, Tsatsaris V, Boisseau P, Provôt F, Delmas Y, Poullin P, Vanhoorelbeke K, Veyradier A, Joly BS. Management and follow-up of pregnancy-onset thrombotic thrombocytopenic purpura: the French experience. Blood Adv 2024; 8:183-193. [PMID: 38039511 PMCID: PMC10805644 DOI: 10.1182/bloodadvances.2023011972] [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: 10/19/2023] [Revised: 11/21/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023] Open
Abstract
ABSTRACT Pregnancy-onset thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening disease of which diagnosis and management requires experienced multidisciplinary teams. The mechanisms responsible for a deficiency in the disintegrin and metalloprotease with thrombospondin type 1 repeats, member 13 (ADAMTS13) leading to pregnancy-onset TTP may be congenital or acquired, and studying ADAMTS13 conformation could be of interest. The differential diagnosis between TTP and other pregnancy-associated thrombotic microangiopathies (TMA) is often challenging. Our retrospective multicenter study highlights the significance and the challenges associated with pregnancy-onset TTP and childbirth in terms of diagnosis, obstetric management, and follow-up aspects. Among 1174 pregnancy-onset TMA enrolled in the French Registry for TMA from 2000 to 2020, we identified 108 pregnancy-onset TTP: 52 immune-mediated TTP (iTTP, 48.1%), 27 acquired TTP of unidentified mechanism (uTTP, 25%), and 29 congenital TTP (cTTP, 26.9%). Data show that maternal outcome is good (survival rate: 95%) and fetal outcome is linked to the gestational age at the onset of the disease (survival rate: 75.5%). Three distinct entities with different natural histories emerged: pregnancy-onset iTTP appears similar to idiopathic iTTP, with an open ADAMTS13 conformation, and is marked by a relapse risk independent of subsequent pregnancies; pregnancy-onset uTTP appears to have a different pathophysiology with an unexpected open ADAMTS13 conformation and a very low relapse risk independent of subsequent pregnancies; finally, pregnancy-onset cTTP is characterized by the necessity of pregnancy as a systematic and specific trigger and a need for prophylactic plasmatherapy for subsequent pregnancies. This trial was registered at www.clinicaltrials.gov as #NCT00426686, and at the Health Authority and the French Ministry of Health (P051064/PHRC AOM05012).
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Affiliation(s)
- Nicolas Béranger
- Service d'Hématologie biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris.Nord, Université Paris Cité, Paris, France
- EA-3518, Institut de Recherche Saint-Louis, Université Paris Cité, Paris, France
| | - Paul Coppo
- Service d’Hématologie, Centre de référence des microangiopathies thrombotiques, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Université, Paris, France
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Paris, France
| | - Vassilis Tsatsaris
- Maternité Port Royal, Hôpital Cochin, FHU PREMA, Assistance Publique-Hôpitaux de Paris.Centre, Université de Paris, Paris, France
- INSERM UMR-S 1139, Physiopathologie et pharmacotoxicologie placentaire humaine, Université de Paris, Paris, France
| | | | | | - Yahsou Delmas
- Service de Néphrologie, CHU de Bordeaux, Bordeaux, France
| | - Pascale Poullin
- Service d’Hémaphérèse, Hôpital de la Conception, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Agnès Veyradier
- Service d'Hématologie biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris.Nord, Université Paris Cité, Paris, France
- EA-3518, Institut de Recherche Saint-Louis, Université Paris Cité, Paris, France
| | - Bérangère S. Joly
- Service d'Hématologie biologique, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris.Nord, Université Paris Cité, Paris, France
- EA-3518, Institut de Recherche Saint-Louis, Université Paris Cité, Paris, France
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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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Coppo P, Joly BS. Caplacizumab: A game changer also in pregnancy-associated immune-mediated thrombotic thrombocytopenic purpura? Br J Haematol 2023; 202:725-727. [PMID: 37291806 DOI: 10.1111/bjh.18915] [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: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/10/2023]
Abstract
Therapeutic options in immune-mediated thrombotic thrombocytopenic purpura (iTTP) during pregnancy are limited besides therapeutic plasma exchange (TPE) and corticosteroids. The report by Odetola et al. suggests that caplacizumab represents a reasonable option in iTTP during pregnancy, especially when the disease is not rapidly controlled with the standard TPE-corticosteroid association. Commentary on: Odetola et al. Safe and effective use of caplacizumab in pregnancy-related acquired thrombotic thrombocytopenic purpura. Br J Haematol 2023;202:879-882.
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Affiliation(s)
- Paul Coppo
- Service d'hématologie, AP-HP. 6 and Sorbonne - Université, Paris, France
- Centre National de Référence des Microangiopathies thrombotiques (CNR-MAT), AP-HP. 6 and Sorbonne - Université, Paris, France
- Centre de Recherche des Cordeliers, INSERM UMRS1138, Paris, France
| | - Bérangère S Joly
- Centre National de Référence des Microangiopathies thrombotiques (CNR-MAT), AP-HP. 6 and Sorbonne - Université, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP.Nord, Université Paris Cité, Paris, France
- EA3518, Institut de Recherche Saint-Louis, Université Paris Cité, Paris, France
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