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Trisolini SM, Laganà A, Capria S. Immune Thrombotic Thrombocytopenic Purpura: Pathophysiology, Diagnosis, Therapy and Open Issues. Mediterr J Hematol Infect Dis 2024; 16:e2024060. [PMID: 38984099 PMCID: PMC11232686 DOI: 10.4084/mjhid.2024.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 06/19/2024] [Indexed: 07/11/2024] Open
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and ischemic end-organ injury due to microvascular platelet-rich thrombi. iTTP pathophysiology is based on a severe ADAMTS13 deficiency, the specific von Willebrand factor (vWF)-cleaving protease, due to anti-ADAMTS13 autoantibodies. Early diagnosis and treatment reduce the mortality. Frontline therapy includes daily plasma exchange (PEX) with fresh frozen plasma replacement and immunosuppression with corticosteroids. Caplacizumab has recently been added to frontline therapy. Caplacizumab is a nanobody that binds to the A1 domain of vWF, blocking the interaction of ultra-large vWF multimers with the platelet and thereby preventing the formation of platelet-rich thrombi. Caplacizumab reduces mortality due to ischemic events, refractoriness, and exacerbations after PEX discontinuation. Until now, the criteria for response to treatment mainly took into account the normalization of platelet count and discontinuation of PEX; with the use of caplacizumab leading to rapid normalization of platelet count, it has been necessary to redefine the response criteria, taking into account also the underlying autoimmune disease. Monitoring of ADAMTS13 activity is important to identify cases with a low value of activity (<10IU/L), requiring the optimization of immunosuppressive therapy with the addition of Rituximab. Rituximab is effective in patients with refractory disease or relapsing disease. Currently, the use of Rituximab has expanded, both in frontline treatment and during follow-up, as a pre-emptive approach. Some patients do not achieve ADAMTS13 remission following the acute phase despite steroids and rituximab treatment, requiring an individualized immunosuppressive approach to prevent clinical relapse. In iTTP, there is an increased risk of venous thrombotic events (VTEs) as well as arterial thrombotic events, and most occur after platelet normalization. Until now, there has been no consensus on the use of pharmacological thromboprophylaxis in patients on caplacizumab because the drug is known to increase bleeding risk.
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Affiliation(s)
- Silvia Maria Trisolini
- Hematology, Department of Translational and Precision Medicine; "Sapienza" University of Rome, Italy
| | - Alessandro Laganà
- Resident Doctor at the Department of Hematology, University "Sapienza" of Rome, Rome, Italy
| | - Saveria Capria
- Hematology, Department of Translational and Precision Medicine; "Sapienza" University of Rome, Italy
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Wiegley N, Arora S, Norouzi S, Rovin B. A Comprehensive and Practical Approach to the Management of Lupus Nephritis in the Current Era. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:234-245. [PMID: 39004463 DOI: 10.1053/j.akdh.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/27/2023] [Accepted: 11/29/2023] [Indexed: 07/16/2024]
Abstract
Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus (SLE) and is one of the leading causes of morbidity and mortality in patients with SLE. It is estimated that up to 60% of individuals with SLE will develop LN, which can manifest at any stage of a patient's life; however, it commonly emerges early in the course of SLE and tends to exhibit a more aggressive phenotype in men compared to women. Black and Hispanic patients are more likely to progress to kidney failure than white patients. LN is characterized by kidney inflammation and chronic parenchymal damage, leading to impaired kidney function and potential progression to kidney failure. This article provides a comprehensive overview of the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of LN, highlighting the importance of early recognition and treatment of LN to prevent progressive, irreversible kidney damage and improve patient outcomes. Additionally, the article discusses current and emerging therapies for LN, including traditional immunosuppressive agents, biological agents, and novel therapies targeting specific pathways involved in LN pathogenesis, to provide a practical guide for clinicians in properly diagnosing LN and determining a patient-centered treatment plan.
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Affiliation(s)
- Nasim Wiegley
- Division of Nephrology, University of California, Davis School of Medicine, Sacramento, CA.
| | - Swati Arora
- Division of Nephrology, Allegheny Health Network, Pittsburgh, PA
| | - Sayna Norouzi
- Division of Nephrology, Loma Linda University Medical Center, Loma Linda, CA
| | - Brad Rovin
- Division of Nephrology, Ohio State University, Columbus, OH
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Abou-Ismail MY, Zhang C, Presson AP, Chaturvedi S, Antun AG, Farland AM, Woods R, Metjian A, Park YA, de Ridder G, Gibson B, Kasthuri RS, Liles DK, Akwaa F, Clover T, Baumann Kreuziger L, Sridharan M, Go RS, McCrae KR, Upreti HV, Gangaraju R, Kocher NK, Zheng XL, Raval JS, Masias C, Cataland SR, Johnson AD, Davis E, Evans MD, Mazepa M, Lim MY. A descriptive analysis of fatal outcomes in immune thrombotic thrombocytopenic purpura in the USTMA TTP Registry. Blood Adv 2024; 8:620-623. [PMID: 38100454 PMCID: PMC10838690 DOI: 10.1182/bloodadvances.2023010807] [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: 05/24/2023] [Revised: 10/30/2023] [Accepted: 11/08/2023] [Indexed: 12/17/2023] Open
Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Angela P. Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | | | - Ana G. Antun
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Ryan Woods
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Ara Metjian
- Department of Medicine, University of Colorado, Denver, CO
| | - Yara A. Park
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC
| | - Gustaaf de Ridder
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC
- Geisinger Medical Laboratories, Danville, PA
| | - Briana Gibson
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC
- Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA
| | - Raj S. Kasthuri
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Darla K. Liles
- Department of Medicine, East Carolina University, Greenville, NC
| | - Frank Akwaa
- Department of Medicine, University of Rochester, Rochester, NY
| | - Todd Clover
- Hematology/Oncology, St. Charles Healthcare, Bend, OR
| | - Lisa Baumann Kreuziger
- Versiti Blood Center of Wisconsin, Milwaukee, WI
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Ronald S. Go
- Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Harsh Vardhan Upreti
- Department of Medicine, Johns Hopkins University, Baltimore, MD
- University of Delhi, New Delhi, India
| | - Radhika Gangaraju
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Nicole K. Kocher
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS
- Institute of Reproductive Medicine and Developmental Sciences, University of Kansas Medical Center, Kansas City, KS
| | - Jay S. Raval
- Department of Pathology, University of New Mexico, Albuquerque, NM
| | | | | | - Andrew D. Johnson
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Elizabeth Davis
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Michael D. Evans
- Clinical & Translational Science Institute, University of Minnesota, Minneapolis, MN
| | - Marshall Mazepa
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Ming Y. Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT
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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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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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Scully M, Rayment R, Clark A, Westwood JP, Cranfield T, Gooding R, Bagot CN, Taylor A, Sankar V, Gale D, Dutt T, McIntyre J, Lester W. A British Society for Haematology Guideline: Diagnosis and management of thrombotic thrombocytopenic purpura and thrombotic microangiopathies. Br J Haematol 2023; 203:546-563. [PMID: 37586700 DOI: 10.1111/bjh.19026] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/18/2023]
Abstract
The objective of this guideline is to provide healthcare professionals with clear, up-to-date and practical guidance on the management of thrombotic thrombocytopenic purpura (TTP) and related thrombotic microangiopathies (TMAs), including complement-mediated haemolytic uraemic syndrome (CM HUS); these are defined by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and small vessel thrombosis. Within England, all TTP cases should be managed within designated regional centres as per NHSE commissioning for highly specialised services.
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Affiliation(s)
- M Scully
- Department of Haematology, UCLH and Haematology Programme, University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
| | - R Rayment
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - A Clark
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - T Cranfield
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Gooding
- Haematology Department, Belfast City Hospital, Belfast H&SC Trust, Belfast, UK
| | - C N Bagot
- Glasgow Royal Infirmary, Glasgow, UK
| | - A Taylor
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - V Sankar
- Department of Critical Care Medicine, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - D Gale
- Department of Renal Medicine, University College London, London, UK
| | - T Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - W Lester
- Department of Haematology, University Hospitals Birmingham, Birmingham, UK
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Matsumoto M, Miyakawa Y, Kokame K, Ueda Y, Wada H, Higasa S, Yagi H, Ogawa Y, Sakai K, Miyata T, Morishita E, Fujimura Y. Diagnostic and treatment guidelines for thrombotic thrombocytopenic purpura (TTP) in Japan 2023. Int J Hematol 2023; 118:529-546. [PMID: 37689812 PMCID: PMC10615956 DOI: 10.1007/s12185-023-03657-0] [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: 06/06/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/11/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) can rapidly become a life-threatening condition, and the importance of its appropriate diagnosis and treatment cannot be overstated. Until recently, TTP has mainly been diagnosed by clinical findings such as thrombocytopenia and hemolytic anemia. In addition to these clinical findings, however, reduced activity of a disintegrin-like and metalloprotease with thrombospondin type 1 motif 13 (ADAMTS13) below 10% has become internationally accepted as a diagnostic criterion for TTP. TTP is classified as immune-mediated TTP (iTTP) if the patient is positive for anti-ADAMTS13 autoantibodies, and as congenital TTP (cTTP) if ADAMTS13 gene abnormalities are detected. Fresh frozen plasma (FFP) transfusion is performed in patients with cTTP to supplement ADAMTS13. Plasma exchange therapy using FFP is conducted in patients with iTTP to supplement ADAMTS13 and to remove both anti-ADAMTS13 autoantibodies and unusually large von Willebrand factor (VWF) multimers. To suppress autoantibody production, corticosteroid therapy is administered in conjunction with plasma exchange. The monoclonal anti-CD-20 antibody rituximab is effective in patients with iTTP. In addition, caplacizumab, an anti-VWF A1 domain nanobody, has a novel mechanism of action, involving direct inhibition of platelet glycoprotein Ib-VWF binding. The recommended first-line treatments of iTTP in Japan are plasma exchange and corticosteroids, as well as caplacizumab.
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Affiliation(s)
- Masanori Matsumoto
- Department of Blood Transfusion Medicine and Department of Hematology, Nara Medical University, 840 Shijyo-cho, Kashihara, Nara, 634-8521, Japan.
| | | | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasunori Ueda
- Department of Hematology/Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hideo Wada
- Department of General Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Satoshi Higasa
- Department of Hematology, Hyogo Medical University, Nishinomiya, Japan
| | - Hideo Yagi
- Department of Hematology and Oncology, Nara Prefecture General Medical Center, Nara, Japan
| | | | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Toshiyuki Miyata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Eriko Morishita
- Department of Clinical Laboratory Science, Kanazawa University, Kanazawa, Japan
| | - Yoshihiro Fujimura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
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Völker LA, Brinkkoetter PT, Cataland SR, Masias C. Five years of caplacizumab - lessons learned and remaining controversies in immune-mediated thrombotic thrombocytopenic purpura. J Thromb Haemost 2023; 21:2718-2725. [PMID: 37562668 DOI: 10.1016/j.jtha.2023.07.027] [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: 04/28/2023] [Revised: 07/24/2023] [Accepted: 07/29/2023] [Indexed: 08/12/2023]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare hematologic disease caused by autoantibodies against ADAMTS-13 that trigger microangiopathic hemolytic anemia. Therapeutic plasma exchange and glucocorticoids have been the mainstay of treatment for the past 30 years. In 2019, caplacizumab was approved as an addition to this regimen for the acute treatment of iTTP. Randomized controlled trials and real-world evidence have shown that caplacizumab reduces the time to platelet count normalization, refractoriness, and exacerbations of the disease, with an acceptable safety profile. In the past 5 years, there have been arguments against the upfront use of caplacizumab in all patients with iTTP, particularly related to the perceived lack of clinical benefit, safety concerns related to bleeding risk, and high costs. This perspective aimed to address these concerns in the context of the experience of expert centers that have used the drug for >5 years.
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Affiliation(s)
- Linus Alexander Völker
- Department II of Internal Medicine, Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany.
| | - Paul Thomas Brinkkoetter
- Department II of Internal Medicine, Center for Molecular Medicine Cologne, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany; Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany
| | - Spero R Cataland
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
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Özpolat HT, Stolla M. Rituximab in the treatment of immune-mediated thrombotic thrombocytopenic purpura. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2023; 21:369-374. [PMID: 37146296 PMCID: PMC10497387 DOI: 10.2450/bloodtransfus.503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/01/2023] [Indexed: 05/07/2023]
Affiliation(s)
| | - Moritz Stolla
- Bloodworks Northwest Research Institute, Seattle, WA, United States of America
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States of America
- Department of Medicine, Division of Hematology, University of Washington School of Medicine, Seattle, WA, United States of America
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Oliver M, Patriquin CJ, Pavenski K. Predictors of relapse and prophylactic management of immune thrombotic thrombocytopenic purpura. Transfus Apher Sci 2023; 62:103749. [PMID: 37344323 DOI: 10.1016/j.transci.2023.103749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Affiliation(s)
- Monika Oliver
- Department of Medicine, University of Alberta, Canada; Division of Hematology, University of Alberta Hospital, Canada
| | - Christopher J Patriquin
- Department of Medicine, University of Toronto, Canada; Division of Medical Oncology & Hematology, University Health Network, Toronto, Canada
| | - Katerina Pavenski
- Department of Medicine, University of Toronto, Canada; Department of Laboratory Medicine & Pathobiology, University of Toronto, Canada; Departments of Medicine and Laboratory Medicine, St. Michael's Hospital-Unity Health Toronto, Canada.
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Mansour I, Murugapandian S, Tanriover B, Thajudeen B. Contemporary Monoclonal Antibody Utilization in Glomerular Diseases. Mayo Clin Proc Innov Qual Outcomes 2023; 7:276-290. [PMID: 37448529 PMCID: PMC10338194 DOI: 10.1016/j.mayocpiqo.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023] Open
Abstract
Therapeutic monoclonal antibodies (MAbs) have been one of the fastest growing drug classes in the past 2 decades and are indicated in the treatment of cancer, autoimmune disorders, solid organ transplantation, and glomerular diseases. The Food and Drug Administration has approved 100 MAbs between 1986 and 2021, and MAbs account for 20% of Food and Drug Administration's new drug approval every year. MAbs are preferred over traditional immunosuppressive agents because of their high specificity, reduced number of drug-drug interactions, and low toxicity, which make them a prime example of personalized medicine. In this review article, we provide an overview of the taxonomy, pharmacology, and therapeutic applications of MAbs in glomerular diseases. We searched the literature through PubMed using the following search terms: monoclonal antibodies, glomerular diseases, pharmacokinetics, pharmacodynamics, immunoglobulin, murine, chimeric,humanized, and fully human, and limited our search to years 2018-2023. We selected peer-reviewed journal articles with an evidence-based approach, prioritizing randomized control trials in specific glomerular diseases, if available. Advances in the MAb field have resulted in a significant paradigm shift in targeted treatment of immune-mediated glomerular diseases, and multiple randomized control trials are currently being conducted. Increased recognition is critical to expand their use in experimental research and personalized medicine.
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Affiliation(s)
- Iyad Mansour
- Division of Nephrology, College of Medicine, The University of Arizona, Tucson
| | | | - Bekir Tanriover
- Division of Nephrology, College of Medicine, The University of Arizona, Tucson
| | - Bijin Thajudeen
- Division of Nephrology, College of Medicine, The University of Arizona, Tucson
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Butt A, Allen C, Purcell A, Ito S, Goshua G. Global Health Resource Utilization and Cost-Effectiveness of Therapeutics and Diagnostics in Immune Thrombotic Thrombocytopenic Purpura (TTP). J Clin Med 2023; 12:4887. [PMID: 37568288 PMCID: PMC10420213 DOI: 10.3390/jcm12154887] [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: 05/26/2023] [Revised: 06/28/2023] [Accepted: 07/21/2023] [Indexed: 08/13/2023] Open
Abstract
In this review, we examine the current landscape of health resource utilization and cost-effectiveness data in the care of patient populations with immune thrombotic thrombocytopenic purpura. We focus on the therapeutic (therapeutic plasma exchange, glucocorticoids, rituximab, caplacizumab) and diagnostic (ADAMTS13 assay) health technologies employed in the care of patients with this rare disease. Health resource utilization and cost-effectiveness data are limited to the high-income country context. Measurement of TTP-specific utility weights in the high-income country context and collection of health resource utilization data in the low- and middle-income country settings would enable an evaluation of country-specific quality-adjusted life expectancy and cost-effectiveness of these therapeutic and diagnostic health technologies. This quantification of value is one way to mitigate cost concerns where they exist.
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Affiliation(s)
- Ayesha Butt
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - Cecily Allen
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | | | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06510, USA
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Zheng L, Zheng XL. How should caplacizumab be used for treatment of immune thrombotic thrombocytopenic purpura? ANNALS OF BLOOD 2023; 8:11. [PMID: 37200543 PMCID: PMC10187608 DOI: 10.21037/aob-21-87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Affiliation(s)
- Lucy Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - X Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
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Underwood MI, Alwan F, Thomas MR, Scully MA, Crawley JTB. Autoantibodies enhance ADAMTS-13 clearance in patients with immune thrombotic thrombocytopenic purpura. J Thromb Haemost 2023; 21:1544-1552. [PMID: 36813118 DOI: 10.1016/j.jtha.2023.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/20/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Severe deficiency in ADAMTS-13 (<10%) and the loss of von Willebrand factor-cleaving function can precipitate microvascular thrombosis associated with thrombotic thrombocytopenic purpura (TTP). Patients with immune-mediated TTP (iTTP) have anti-ADAMTS-13 immunoglobulin G antibodies that inhibit ADAMTS-13 function and/or increase ADAMTS-13 clearance. Patients with iTTP are treated primarily by plasma exchange (PEX), often in combination with adjunct therapies that target either the von Willebrand factor-dependent microvascular thrombotic processes (caplacizumab) or the autoimmune components (steroids or rituximab) of the disease. OBJECTIVES To investigate the contributions of autoantibody-mediated ADAMTS-13 clearance and inhibition in patients with iTTP at presentation and through the course of the PEX therapy. PATIENTS/METHODS Anti-ADAMTS-13 immunoglobulin G antibodies, ADAMTS-13 antigen, and activity were measured before and after each PEX in 17 patients with iTTP and 20 acute TTP episodes. RESULTS At presentation, 14 out of 15 patients with iTTP had ADAMTS-13 antigen levels of <10%, suggesting a major contribution of ADAMTS-13 clearance to the deficiency state. After the first PEX, both ADAMTS-13 antigen and activity levels increased similarly, and the anti-ADAMTS-13 autoantibody titer decreased in all patients, revealing ADAMTS-13 inhibition to be a modest modifier of the ADAMTS-13 function in iTTP. Analysis of ADAMTS-13 antigen levels between consecutive PEX treatments revealed that the rate of ADAMTS-13 clearance in 9 out of 14 patients analyzed was 4- to 10-fold faster than the estimated normal rate of clearance. CONCLUSION These data reveal, both at presentation and during PEX treatment, that antibody-mediated clearance of ADAMTS-13 is the major pathogenic mechanism that causes ADAMTS-13 deficiency in iTTP. Understanding the kinetics of ADAMTS-13 clearance in iTTP may now enable further optimization of treatment of patients with iTTP.
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Affiliation(s)
- Mary I Underwood
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Ferras Alwan
- Haemophilia Centre, Imperial College Healthcare Trust, London, United Kingdom; University College Hospital, London, United Kingdom
| | | | | | - James T B Crawley
- Centre for Haematology, Imperial College London, London, United Kingdom.
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Yin J, Tian H, Kong DQ, Li Y, Gu CY, Wu DP, Yu ZQ. [A combined regimen based on bortezomib and glucocorticoids for 6 patients with recurrent/refractory immune thrombotic thrombocytopenic purpura]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:413-417. [PMID: 37550192 PMCID: PMC10440622 DOI: 10.3760/cma.j.issn.0253-2727.2023.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Indexed: 08/09/2023]
Abstract
Objective: To observe the efficacy and adverse reactions of a combination therapy regimen based on bortezomib and glucocorticoids in recurrent/refractory immune thrombocytopenic purpura (iTTP) . Methods: Six patients with recurrent/refractory TTP were included and treated with a glucocorticoid and two courses of bortezomib-based regimen. The clinical remission status of patients, changes in ADAMTS13 activity/ADAMTS13 inhibitor, and the occurrence of treatment-related adverse reactions were observed. Results: Of the 6 patients, 2 were males and 4 were females, with a median age of 21.5 (18-68) years. Refractory TTP was found in 1 case and recurrent TTP in 5 cases. Glucocorticoids were administered with reference to prednisone at 1 mg·kg(-1)·d(-1), and gradually reduced in dosage after achieving clinical remission. Bortezomib is subcutaneously administered at 1.3 mg/m(2) on days 1, 4, 8, and 11 with a 28-day treatment course consisting of 2 courses. Six patients achieved clinical remission after receiving bortezomib as the main treatment. ADMATS13 activity returned to normal in all patients with TTP after treatment, and the ADAMTS13 inhibitor turned negative. Thrombocytopenia is the most common adverse reaction after treatment, with other adverse reactions, including peripheral neuritis and abdominal pain, but ultimately all patients returned to normal. In a median follow-up of 26 (9-41) months, 5 patients maintained sustained remission, and 1 patient relapsed after 16 months of bortezomib treatment. Conclusion: Combination therapy of bortezomib and glucocorticoids has a satisfactory therapeutic effect and controllable adverse reactions for recurrent/refractory iTTP.
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Affiliation(s)
- J Yin
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - H Tian
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - D Q Kong
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - Y Li
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - C Y Gu
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - D P Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
| | - Z Q Yu
- Department of Hematology, The First Affiliated Hospital of Soochow University, National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, NHC Key Laboratory of Thrombosis and Hemostasis, Collaborative Innovation Center of Hematology, Soochow University, Suzhou 215006, China
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16
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Frontiers in pathophysiology and management of thrombotic thrombocytopenic purpura. Int J Hematol 2023; 117:331-340. [PMID: 36757521 DOI: 10.1007/s12185-023-03552-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a fatal disease in which platelet-rich microthrombi cause end-organ ischemia and damage. TTP is caused by markedly reduced ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) activity. Hereditary or congenital TTP (cTTP) is caused by ADAMTS13 gene mutations. In acquired or immune TTP (iTTP), ADAMTS13 activity is reduced by anti-ADAMTS13 autoantibodies. TTP is characterized by thrombocytopenia, hemolytic anemia, fever, renal dysfunction, and neuropsychiatric symptoms. Therapeutic plasma exchange (TPE) and immunosuppressive therapy are the mainstays of treatment. As untreated TTP has a high mortality rate, immediate initiation of TPE is recommended when TTP is suspected. Conventionally, corticosteroids have been used for immunosuppressive therapy. Current drug therapies include rituximab, an anti-CD20 antibody that is effective in newly diagnosed cases and refractory cases, as well as for relapse prevention, and caplacizumab, an anti- von Willebrand factor (VWF) nanobody that inhibits the binding of platelets to VWF and prevents microthrombi formation. Recombinant human ADAMTS13 is a promising treatment for cTTP. Although these therapeutic advances have improved the outcomes of TTP, early diagnosis and prompt initiation of appropriate therapy are necessary to achieve these outcomes.
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17
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Mutoh T, Ohashi K, Nagai T, Sugiura A, Kudo M, Fujii H. Upfront rituximab therapy for thrombotic thrombocytopenic purpura in systemic lupus erythematosus: a case-based review. Rheumatol Int 2023; 43:373-381. [PMID: 35962219 DOI: 10.1007/s00296-022-05182-5] [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: 06/22/2022] [Accepted: 08/04/2022] [Indexed: 02/07/2023]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the production of various autoantibodies and deposition of immune complexes on tissues. Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening hematological disorder that rarely develops in SLE, mainly caused by inhibitory or clearing autoantibody against ADAMTS13. Although B cells play critical roles in the pathogenesis of two diseases, the role of B-cell depletion therapy using rituximab (RTX), a chimeric monoclonal antibody targeting CD20, in the management of TTP associated with SLE remains unclear. We present a 27-year-old woman who manifested TTP and nephritis simultaneously at diagnosis of SLE. This patient successfully responded to high-dose glucocorticoids combined with plasma exchange, and early administration of RTX-induced sustained remission of TTP without relapse over 16 months. This literature review in light of our case demonstrates relationship between early intervention with RTX and better treatment response despite the degree of ADAMTS13 activity. Moreover, we discuss the clinical features in TTP associated with SLE, risk factors for the development of TTP in SLE, and possible outcomes based on RTX dose. It is important to consider upfront RTX as a promising treatment strategy for SLE-associated secondary TTP to improve short-term response and long-term prognosis.
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Affiliation(s)
- Tomoyuki Mutoh
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan.
| | - Keiichi Ohashi
- Department of Hematology, Ishinomaki Red Cross Hospital, Ishinomaki, Miyagi, Japan
| | - Taichi Nagai
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
| | - Akira Sugiura
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Masataka Kudo
- Department of Rheumatology, Osaki Citizen Hospital, 3-8-1 Furukawa Honami, Osaki, Miyagi, 989-6183, Japan
- Department of Nephrology and Endocrinology, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Hiroshi Fujii
- Department of Rheumatology, Tohoku University Hospital, Sendai, Miyagi, Japan
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18
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Chen M, Shortt J. Plasma-cell directed therapy for immune thrombotic thrombocytopenic purpura (iTTP). Transfus Med Rev 2022; 36:204-214. [DOI: 10.1016/j.tmrv.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
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19
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How I treat immune-mediated thrombotic thrombocytopenic purpura after hospital discharge. Blood 2022; 140:438-444. [PMID: 35667044 DOI: 10.1182/blood.2021014514] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/14/2022] [Indexed: 11/20/2022] Open
Abstract
Immune-mediated thrombocytopenic purpura (iTTP) is a thrombotic microangiopathy characterized by an acquired ADAMTS13 deficiency as a result of the presence of an antibody inhibitor of ADAMTS13 leading to the formation of ultralarge von Willebrand multimers. Treatment of iTTP includes plasma exchange, high-dose glucocorticoids, rituximab, and, more recently, caplacizumab, to prevent the development of exacerbations. There is the risk of both relapse and long-term complications that include neurocognitive deficits and cardiovascular events that occur in patients in remission after recovery from an acute iTTP episode. Data on the risk factors for the development of these complications, the appropriate screening, and treatment are limited due to the paucity of research. This article is a review of the current understanding on the risk factors for exacerbation, relapse, and long-term complications of iTTP and discusses an approach to observing patients with iTTP after hospital discharge and during the long-term follow-up in the outpatient setting.
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20
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Efficacy and safety of azathioprine during remission of immune-mediated thrombotic thrombocytopenic purpura. Blood Adv 2022; 6:5463-5466. [PMID: 35772164 PMCID: PMC9631697 DOI: 10.1182/bloodadvances.2022007632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
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21
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Mingot Castellano ME, Pascual Izquierdo C, González A, Viejo Llorente A, Valcarcel Ferreiras D, Sebastián E, García Candel F, Sarmiento Palao H, Gómez Seguí I, de la Rubia J, Cid J, Martínez Nieto J, Hernández Mateo L, Goterris Viciedo R, Fidalgo T, Salinas R, Del Rio-Garma J. Recommendations for the diagnosis and treatment of patients with thrombotic thrombocytopenic purpura. Med Clin (Barc) 2022; 158:630.e1-630.e14. [PMID: 34266669 DOI: 10.1016/j.medcli.2021.03.040] [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: 02/06/2021] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 11/09/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) characterized by the development of microangiopathic haemolytic anaemia, thrombocytopenia, and ischaemic organ dysfunction associated with ADAMTS13 levels lower than 10% in most cases. Recently there have been numerous advances in the field of PTT, new, rapid and accessible techniques capable of quantifying ADAMTS13 activity and inhibitors. The massive sequencing systems facilitate the identification of polymorphisms in the ADAMTS13 gene. In addition, new drugs such as caplacizumab have appeared and relapse prevention strategies are being proposed with the use of rituximab. The existence of TTP patient registries allow a deeper understanding of this disease but the great variability in the diagnosis and treatment makes it necessary to elaborate guidelines that homogenize terminology and clinical practice. The recommendations set out in this document were prepared following the AGREE methodology. The research questions were formulated according to the PICO format. A search of the literature published during the last 10 years was carried out. The recommendations were established by consensus among the entire group, specifying the existing strengths and limitations according to the level of evidence obtained. In conclusion, this document contains recommendations on the management, diagnosis, and treatment of TTP with the ultimate objective of developing guidelines based on the evidence published to date that allow healthcare professionals to optimize TTP treatment.
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Affiliation(s)
| | | | - Ataulfo González
- Servicio de Hematología y Hemoterapia, Hospital Universitario de San Carlos, Madrid, España
| | - Aurora Viejo Llorente
- Servicio de Hematología, Área de Hemoterapia, Hospital Universitario La Paz, Madrid, España
| | - David Valcarcel Ferreiras
- Unidad de Hematología Intensiva y Terapia Celular, Departamento de Hematología, Instituto de Oncología Vall d'Hebron (VHIO), Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Elena Sebastián
- Servicio de Hematología y Hemoterapia, Hospital Infantil Universitario Niño Jesús, Madrid, España
| | - Faustino García Candel
- Sección de Hemostasia y Trombosis, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | | | - Inés Gómez Seguí
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Javier de la Rubia
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Joan Cid
- Unidad de Aféresis y Terapia Celular, Servicio de Hemoterapia y Hemostasia, Institut Clínic de Malalties Hematològiques i Oncològiques (ICMHO). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Hospital Clínic i Provincial de Barcelona, Barcelona, España
| | - Jorge Martínez Nieto
- Servicio de Hematología y Hemostasia, Hospital Universitario Clínico San Carlos. Instituto de Investigación Sanitaria San Carlos (IdissC), Madrid, España
| | - Luis Hernández Mateo
- Servicio de Hematología y Hemoterapia, Hospital General de Alicante, Valencia, España
| | - Rosa Goterris Viciedo
- Servicio de Hematología y Hemoterapia, Hospital Clínico Valencia. INCLIVA, Valencia, España
| | - Teresa Fidalgo
- Departamento de Hematología Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ramon Salinas
- Banc de Sang i Teixits de Catalunya, Barcelona, España
| | - Julio Del Rio-Garma
- Servicio de Transfusión. Servicio de Hematología. Complexo Hospitalario Universitario de Ourense, Galicia, España.
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22
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Alterations in B- and circulating T-follicular helper cell subsets in immune thrombotic thrombocytopenic purpura. Blood Adv 2022; 6:3792-3802. [PMID: 35507753 PMCID: PMC9631570 DOI: 10.1182/bloodadvances.2022007025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/19/2022] [Indexed: 11/20/2022] Open
Abstract
Abnormal B-cell phenotype in acute iTTP with decreased transitional and post–germinal center memory cells and increased plasmablasts. Decreased total and PD1+ circulating T-follicular helper cells and changes in B-cell CD80 expression suggest altered B- and T-cell interactions.
T follicular helper (Tfh) cells regulate development of antigen-specific B-cell immunity. We prospectively investigated B-cell and circulating Tfh (cTfh) cell subsets in 45 patients with immune thrombotic thrombocytopenic purpura (iTTP) at presentation and longitudinally after rituximab (RTX). B-cell phenotype was altered at acute iTTP presentation with decreased transitional cells and post–germinal center (post-GC) memory B cells and increased plasmablasts compared with healthy controls. A higher percentage of plasmablasts was associated with higher anti-ADAMTS13 IgG and lower ADAMTS13 antigen levels. In asymptomatic patients with ADAMTS13 relapse, there were increased naïve B cells and a global decrease in memory subsets, with a trend to increased plasmablasts. Total circulating Tfh (CD4+CXCR5+) and PD1+ Tfh cells were decreased at iTTP presentation. CD80 expression was decreased on IgD+ memory cells and double-negative memory cells in acute iTTP. At repopulation after B-cell depletion in de novo iTTP, post-GC and double-negative memory B cells were reduced compared with pre-RTX. RTX did not cause alteration in cTfh cell frequency. The subsequent kinetics of naïve, transitional, memory B cells and plasmablasts did not differ significantly between patients who went on to relapse vs those who remained in remission. In summary, acute iTTP is characterized by dysregulation of B- and cTfh cell homeostasis with depletion of post-GC memory cells and cTfh cells and increased plasmablasts. Changes in CD80 expression on B cells further suggest altered interactions with T cells.
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23
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Doyle AJ, Stubbs MJ, Lester W, Thomas W, Westwood J, Thomas M, Percy C, Prasannan N, Scully M. The use of obinutuzumab and ofatumumab in the treatment of immune thrombotic thrombocytopenic purpura. Br J Haematol 2022; 198:391-396. [DOI: 10.1111/bjh.18192] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/21/2022] [Accepted: 03/25/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Andrew J. Doyle
- Department of Haematology University College Hospitals London NHS Foundation Trust London UK
| | - Matthew J. Stubbs
- Department of Haematology University College Hospitals London NHS Foundation Trust London UK
- Cardiometabolic Programme University College London Hospitals Biomedical Research Centre, National Institute for Health Research London UK
| | - Will Lester
- Department of Haematology University Hospitals Birmingham Birmingham UK
| | - Will Thomas
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - John‐Paul Westwood
- Department of Haematology University College Hospitals London NHS Foundation Trust London UK
| | - Mari Thomas
- Department of Haematology University College Hospitals London NHS Foundation Trust London UK
- Cardiometabolic Programme University College London Hospitals Biomedical Research Centre, National Institute for Health Research London UK
| | - Charles Percy
- Department of Haematology University Hospitals Birmingham Birmingham UK
| | - Nithya Prasannan
- Department of Haematology University College Hospitals London NHS Foundation Trust London UK
| | - Marie Scully
- Department of Haematology University College Hospitals London NHS Foundation Trust London UK
- Cardiometabolic Programme University College London Hospitals Biomedical Research Centre, National Institute for Health Research London UK
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24
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Koneczny I, Tzartos J, Mané-Damas M, Yilmaz V, Huijbers MG, Lazaridis K, Höftberger R, Tüzün E, Martinez-Martinez P, Tzartos S, Leypoldt F. IgG4 Autoantibodies in Organ-Specific Autoimmunopathies: Reviewing Class Switching, Antibody-Producing Cells, and Specific Immunotherapies. Front Immunol 2022; 13:834342. [PMID: 35401530 PMCID: PMC8986991 DOI: 10.3389/fimmu.2022.834342] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/28/2022] [Indexed: 12/24/2022] Open
Abstract
Organ-specific autoimmunity is often characterized by autoantibodies targeting proteins expressed in the affected tissue. A subgroup of autoimmunopathies has recently emerged that is characterized by predominant autoantibodies of the IgG4 subclass (IgG4-autoimmune diseases; IgG4-AID). This group includes pemphigus vulgaris, thrombotic thrombocytopenic purpura, subtypes of autoimmune encephalitis, inflammatory neuropathies, myasthenia gravis and membranous nephropathy. Although the associated autoantibodies target specific antigens in different organs and thus cause diverse syndromes and diseases, they share surprising similarities in genetic predisposition, disease mechanisms, clinical course and response to therapies. IgG4-AID appear to be distinct from another group of rare immune diseases associated with IgG4, which are the IgG4-related diseases (IgG4-RLD), such as IgG4-related which have distinct clinical and serological properties and are not characterized by antigen-specific IgG4. Importantly, IgG4-AID differ significantly from diseases associated with IgG1 autoantibodies targeting the same organ. This may be due to the unique functional characteristics of IgG4 autoantibodies (e.g. anti-inflammatory and functionally monovalent) that affect how the antibodies cause disease, and the differential response to immunotherapies of the IgG4 producing B cells/plasmablasts. These clinical and pathophysiological clues give important insight in the immunopathogenesis of IgG4-AID. Understanding IgG4 immunobiology is a key step towards the development of novel, IgG4 specific treatments. In this review we therefore summarize current knowledge on IgG4 regulation, the relevance of class switching in the context of health and disease, describe the cellular mechanisms involved in IgG4 production and provide an overview of treatment responses in IgG4-AID.
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Affiliation(s)
- Inga Koneczny
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
- *Correspondence: Inga Koneczny,
| | - John Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- 2nd Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Marina Mané-Damas
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Vuslat Yilmaz
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Maartje G. Huijbers
- Department of Human Genetics, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | - Konstantinos Lazaridis
- Department of Immunology, Laboratory of Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Romana Höftberger
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Erdem Tüzün
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Pilar Martinez-Martinez
- Research Group Neuroinflammation and Autoimmunity, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Socrates Tzartos
- Neuroimmunology, Tzartos NeuroDiagnostics, Athens, Greece
- Department of Neurobiology, Hellenic Pasteur Institute, Athens, Greece
| | - Frank Leypoldt
- Neuroimmunology, Institute of Clinical Chemistry and Department of Neurology, UKSH Kiel/Lübeck, Kiel University, Kiel, Germany
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25
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Subhan M, Scully M. Advances in the management of TTP. Blood Rev 2022; 55:100945. [DOI: 10.1016/j.blre.2022.100945] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 12/16/2022]
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26
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Eller K, Knoebl P, Bakkaloglu SA, Menne JJ, Brinkkoetter PT, Grandt L, Thiem U, Coppo P, Scully M, Haller MC. OUP accepted manuscript. Nephrol Dial Transplant 2022; 37:1229-1234. [PMID: 35195251 PMCID: PMC9217651 DOI: 10.1093/ndt/gfac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Paul Knoebl
- Division of Haematology and Haemostasis, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sevcan A Bakkaloglu
- Department of Paediatric Nephrology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Jan J Menne
- KRH Klinikum Mitte – Location Siloah, Hannover, Germany
| | - Paul T Brinkkoetter
- Department II of Internal Medicine and Centre for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Leonie Grandt
- Department of Medicine III - Nephrology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Ursula Thiem
- Department of Medicine III - Nephrology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Paul Coppo
- Department of Haematology, Reference Centre for Thrombotic Microangiopathies, Saint-Antoine University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie Scully
- Department of Haematology, University College London Hospitals, London, UK
| | - Maria C Haller
- Department of Medicine III - Nephrology, Ordensklinikum Linz Elisabethinen, Linz, Austria
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27
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Westwood JP, Scully M. Management of acquired, immune thrombocytopenic purpura (iTTP): beyond the acute phase. Ther Adv Hematol 2022; 13:20406207221112217. [PMID: 35923772 PMCID: PMC9340390 DOI: 10.1177/20406207221112217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022] Open
Abstract
Modern therapy for acute TTP has resulted in a dramatic improvement in
outcomes, with the combination of plasma exchange, immunosuppression,
and caplacizumab being associated with >90% survival rates
following an acute episode. TTP is no longer associated with just the
acute episode, but requires long-term follow-up. There remains
significant morbidity associated with acute TTP, and many patients
suffer marked neuropsychological sequelae, including impairment in
cognitive functioning, affective disorders, and reduction in
health-related quality of life measures. The focus of management
beyond the acute phase centres on relapse prevention,
via careful monitoring of patients and the use
of either ad hoc or regular immunosuppressive therapies. The main
therapy used is rituximab, but despite more limited evidence, other
immunosuppressive therapies may be required to aim for normalisation
of ADAMTS 13 activity. Follow-up with a reduction in ADAMTS 13
activity levels (ADAMTS 13 relapse), rituximab is central to
normalisation of activity levels and prevention of a clinical relapse.
Fundamental to elective therapy is the role of ADAMTS 13 activity
monitoring, and impact of reduced ADAMTS13 activity on end organ
damage. This review discusses monitoring and treatment strategy for
long-term management of TTP, including the variety of therapies
available to maintain remission, prevent relapse and a summary of a
long-term treatment pathway.
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Affiliation(s)
| | - Marie Scully
- Department of Haematology, UCLH, London, UK
- National Institute for Health Research Cardiometabolic Programme, UCLH/UCL Cardiovascular BRC, 250 Euston Road, NW1 2PG London, UK
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28
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Pavenski K, Huang SHS, Patriquin CJ. Predictors of relapse and preventative strategies in immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:1027-1040. [PMID: 34747320 DOI: 10.1080/17474086.2021.2003703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare autoimmune blood disorder, which presents with microangiopathic hemolytic anemia, thrombocytopenia, and microvascular thrombosis and is caused by severe deficiency of ADAMTS13. iTTP may result in both acute and chronic complications and is rapidly fatal without expedient treatment. Life-time risk of relapse is approximately 40%. AREAS COVERED A number of predictors of relapse has been described in the literature. The most well-studied predictor of relapse is persistent ADAMTS13 deficiency; however, it is not a perfect marker. Relapse can be prevented by treatment with immunosuppressive medications, with rituximab being the most studied. EXPERT OPINION Patients who recover from iTTP should be regularly assessed, including with ADAMTS13 activity testing. The optimal frequency of assessments has not been established, but every 3 months is recommended. Considering the potential for significant organ damage and mortality associated with iTTP relapse, patients in remission and with persistent ADAMTS13 activity of 10-20% should be prophylactically treated with immunosuppression. Additional markers to precisely identify patients at higher risk of relapse are needed.
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Affiliation(s)
- Katerina Pavenski
- Departments of Medicine and Laboratory Medicine, St. Michael's Hospital, Toronto, Canada.,Departments of Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Shih-Han Susan Huang
- Department of Medicine, Division of Nephrology, Western University, London, Canada
| | - Christopher J Patriquin
- Department of Medicine, Division of Medical Oncology & Hematology, University Health Network, Toronto, Canada
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 711] [Impact Index Per Article: 237.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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[Treatment of immune-mediated thrombotic thrombocytopenic purpura: A decisive turning point]. Transfus Clin Biol 2021; 28:380-385. [PMID: 34464709 DOI: 10.1016/j.tracli.2021.08.347] [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: 08/20/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022]
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a rare and life-threatening thrombotic microangiopathy characterized by severe deficiency of ADAMTS13, the enzyme that cleaves von Willebrand factor multimers. Recent insights into iTTP pathophysiology have led to the development of new therapies targeting ADAMTS13 replacement, anti-ADAMTS13 antibodies, and von Willebrand factor-platelet interactions. New maximalist therapeutic strategies are emerging based on triple therapy. While plasma exchange remains the cornerstone therapy of the acute phase, the introduction of front-line immunosuppressive treatments, corticosteroids and rituximab, has led to a reduction in exacerbations and relapses but without any significant improvement in survival. Caplacizumab, a bivalent humanized anti-von Willebrand factor nanobody, is poised to revolutionize the treatment of the acute phase. By inhibiting the interaction between von Willebrand factor multimers and platelets, caplacizumab prevents platelets adhesion, prevents the formation of new microthrombi and protects organs from ischemia. Its early combination with plasma exchange and immunosuppressive therapy prevents unfavorable outcomes and reduces the burden of care. Supported by repeated ADAMTS13 assays, rituximab prevents relapse in patients with persistent or recurrent ADAMTS13 deficiency in clinical remission. This review examines how advances in diagnostics and targeted therapies are changing the current treatment paradigm in both the acute and remission phases and are contributing to dramatically improve the iTTP prognosis.
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Gómez-Seguí I, Pascual Izquierdo C, de la Rubia Comos J. Best practices and recommendations for drug regimens and plasma exchange for immune thrombotic thrombocytopenic purpura. Expert Rev Hematol 2021; 14:707-719. [PMID: 34275393 DOI: 10.1080/17474086.2021.1956898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ injury. TTP pathophysiology is based on a severe ADAMTS13 deficiency, and is a medical emergency with fatal outcome if appropriate treatment is not initiated promptly. AREAS COVERED Authors will review the best options currently available to minimize mortality, prevent relapses, and obtain the best clinical response in patients with immune TTP (iTTP). Available bibliography about iTTP treatment has been searched in Library's MEDLINE/PubMed database from January 1990 until April 2021. EXPERT OPINION The generalized use of plasma exchange marked a paradigm in the management of iTTP. In recent years, strenuous efforts have been done for a better understanding of the pathophysiology of this disease, improve diagnosis, optimize treatment, reduce mortality, and prevent recurrences. The administration of front-line rituximab and, more recently, the availability of caplacizumab, the first targeted therapy for iTTP, have been steps toward a further reduction in early mortality and for the prevention of relapses.
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Affiliation(s)
- Inés Gómez-Seguí
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio De Hematología Y Hemoterapia, Hospital General , Universitario Gregorio Marañón. Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Javier de la Rubia Comos
- Servicio De Hematología Y Hemoterapia, Hospital Universitari I Politècnic La Fe, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
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33
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Cost effectiveness of caplacizumab in acquired thrombotic thrombocytopenic purpura. Blood 2021; 137:969-976. [PMID: 33280030 DOI: 10.1182/blood.2020006052] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 09/14/2020] [Indexed: 12/22/2022] Open
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) is a life-threatening disease characterized by thrombotic microangiopathy leading to end-organ damage. The standard of care (SOC) treatment is therapeutic plasma exchange (TPE) alongside immunomodulation with steroids, with increasing use of rituximab ± other immunomodulatory agents. The addition of caplacizumab, a nanobody targeting von Willebrand factor, was shown to accelerate platelet count recovery and reduce TPE treatments and hospital length of stay in TTP patients treated in 2 major randomized clinical trials. The addition of caplacizumab to SOC also led to increased bleeding from transient reductions in von Willebrand factor and increased relapse rates. Using data from the 2 clinical trials of caplacizumab, we performed the first-ever cost-effectiveness analysis in TTP. Over a 5-year period, the projected incremental cost-effectiveness ratio (ICER) in our Markov model was $1 482 260, significantly above the accepted 2019 US willingness-to-pay threshold of $195 300. One-way sensitivity analyses showed the utility of the well state and the cost of caplacizumab to have the largest effects on ICER, with a reduction in caplacizumab cost demonstrating the single greatest impact on lowering the ICER. In a probabilistic sensitivity analysis, SOC was favored over caplacizumab in 100% of 10 000 iterations. Our data indicate that the addition of caplacizumab to SOC in treatment of acquired TTP is not cost effective because of the high cost of the medication and its failure to improve relapse rates. The potential impact of caplacizumab on health system cost using longer term follow-up data merits further study.
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:736-745. [PMID: 36286842 DOI: 10.26442/00403660.2021.06.200894] [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: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of acquired thrombotic thrombocytopenic purpuгa (aTTP). In patients with aTTP plasma exchanges, glucocorticosteroids allow to stop an acute attack of TTP, and use of rituximab allows to achieve remission. In recent years, caplacizumab has been used. Treatment options such as cyclosporin A, bortezomib, splenectomy, N-acetylcysteine, recombinant ADAMTS13 are also described. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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Cost savings to hospital of rituximab use in severe autoimmune acquired thrombotic thrombocytopenic purpura. Blood Adv 2021; 4:539-545. [PMID: 32045473 DOI: 10.1182/bloodadvances.2019000827] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/25/2019] [Indexed: 11/20/2022] Open
Abstract
Patients with severe autoimmune thrombotic thrombocytopenic purpura (TTP) experience acute hematologic emergencies during disease flares and a lifelong threat for relapse. Rituximab, in addition to steroids and therapeutic plasma exchange (TPE), has been shown to mitigate relapse risk. A barrier to care in initiating rituximab in the inpatient setting has been the presumed excessive cost of medication to the hospital. Retrospectively reviewing TTP admissions from 2004 to 2018 at our academic center, we calculated the actual inpatient cost of care. We then calculated the theoretical cost to the hospital of initiating rituximab in the inpatient setting for both initial TTP and relapse TTP cohorts, with the hypothesis that preventing sufficient future TTP admissions offsets the cost of initiating rituximab in all patients with TTP. At a median follow-up of 55 months in the initial TTP cohort, rituximab use produced a projected cost savings of $905 906 and would have prevented 185 inpatient admission days and saved 137 TPE procedures. In the relapse TTP setting, rituximab use produced a projected cost savings of $425 736 and would have prevented 86 inpatient admission days and saved 64 TPE procedures. From a hospital cost standpoint, cost of rituximab should no longer be a barrier to initiating inpatient rituximab in both initial and relapse TTP settings.
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Redefining outcomes in immune TTP: an international working group consensus report. Blood 2021; 137:1855-1861. [PMID: 33529333 DOI: 10.1182/blood.2020009150] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/19/2021] [Indexed: 12/17/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a potentially fatal thrombotic microangiopathy caused by autoantibody-mediated severe deficiency of ADAMTS13. Standardized definitions of response, exacerbation, remission, and relapse were initially proposed in 2003 and modified by the International Working Group for TTP in 2017. These definitions, which have been widely used in clinical practice and research, are based primarily on the platelet count and are benchmarked against the timing of discontinuation of therapeutic plasma exchange (TPE). They do not incorporate ADAMTS13 activity or the temporizing effects on the platelet count of caplacizumab, a novel anti-von Willebrand factor (VWF) nanobody. In light of these limitations, the IWG aimed to develop revised consensus outcome definitions that incorporate ADAMTS13 activity and the effects of anti-VWF therapy, by using an estimate-talk-estimate approach. The updated definitions distinguish clinical remission and clinical relapse (defined primarily by platelet count) from ADAMTS13 remission and ADAMTS13 relapse (defined by ADAMTS13 activity). The revised definitions of exacerbation and remission are benchmarked against not only the timing of discontinuation of TPE but also that of anti-VWF therapy. Retrospective validation of the revised definitions is described, although they have yet to be prospectively validated. Clinical implications of the updated outcome definitions are also discussed and an example of their application to clinical practice is provided to highlight their clinical relevance.
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Bécel G, Faict S, Picod A, Bouzid R, Veyradier A, Coppo P. Thrombotic Thrombocytopenic Purpura: When Basic Science Meets Clinical Research. Hamostaseologie 2021; 41:283-293. [PMID: 33607665 DOI: 10.1055/a-1332-3066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The therapeutic landscape of thrombotic thrombocytopenic purpura (TTP) is rapidly changing with the recent availability of new targeted therapies. This progressive shift from empiricism to pathophysiology-based treatments reflects an intensive interaction between the continuous findings in the field of basic science and an efficient collaborative clinical research and represents a convincing example of the strength of translational medicine. Despite the rarity of TTP, national and international efforts could circumvent this limitation and shed light on the epidemiology, clinical presentation, prognosis, and long-term outcome of this disease. Importantly, they also provided high-quality results and practice changing studies for the benefit of patients. We report here the most recent therapeutic findings that allowed progressively improving the prognostic of TTP, both at the acute phase and through long-term outcome.
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Affiliation(s)
- Gaëlle Bécel
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France
| | - Sylvia Faict
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France
| | - Adrien Picod
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France
| | - Raïda Bouzid
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France
| | - Agnès Veyradier
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'Hématologie Biologique, Groupe Hospitalier Saint-Louis-Lariboisière, AP-HP, Paris, France.,Université Paris-Diderot, Paris, France
| | - Paul Coppo
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, Hôpital Saint-Antoine, AP-HP - Sorbonne Université, Paris, France.,Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Paris, France
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38
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Memon R, Sui J, Lin C, Zheng XL. Cerebral Infarction in Immune Thrombotic Thrombocytopenic Purpura Is Associated with Old Age, Hypertension, Smoking, and Anti-ADAMTS13 Ig, But Not with Mortality. TH OPEN 2021; 5:e1-e7. [PMID: 33458563 PMCID: PMC7806360 DOI: 10.1055/s-0040-1722610] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/30/2020] [Indexed: 01/20/2023] Open
Abstract
Background Neurological involvement is common in patients with immune thrombotic thrombocytopenic purpura (iTTP), but the frequency, risk factors, and outcomes of these with imaging-confirmed stroke in iTTP are not known. Methods We selected 66 out of 109 iTTP patients with neurological signs and symptoms and reviewed their CT/MRI (computed tomography/magnetic resonance imaging) findings for the evidence of stroke and other clinical information in Alabama TTP Registry. Results Of these, 52 (78.8%) had their CT/MRI done on admission in whom 22 (42.3%) were positive for multiple acute or chronic infarcts. The patients with image-confirmed ischemic stroke were older, and appeared to be associated with a history of hypertension and smoking. Additionally, patients with imaging-confirmed stroke showed higher plasma concentrations of anti-ADAMTS13 IgG than those without stroke. More interestingly, there was no statistically significant difference in the rate of exacerbation and 60-day mortality between those with and without stroke. Conclusion Ischemic cerebral infarcts are common findings in brain imaging studies of patients with acute iTTP; old age, chronic hypertension, and smoking, as well as high plasma concentrations of anti-ADAMTS13 IgG may be the potential risk factors for cerebral infarction in these patients. The presence of image-confirmed ischemic stroke, however, does not predict exacerbation and 60-day mortality, although the long-term effect of such ischemic brain damage on cognitive function and quality of life remains to be determined.
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Affiliation(s)
- Raima Memon
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Jingrui Sui
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Chen Lin
- Department of Neurology, The University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - X. Long Zheng
- Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama, United States
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
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Delrue M, Baylatry MT, Joly A, Corre E, Marjanovic Z, El‐Khoury‐Hanna N, Féger F, Suner L, Veyradier A, Stépanian A, Coppo P. Efficacy of subcutaneous preemptive rituximab in immune-mediated thrombotic thrombocytopenic purpura: Experience from the first 12 cases. Am J Hematol 2021; 96:E26-E29. [PMID: 33068040 DOI: 10.1002/ajh.26022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Maxime Delrue
- Hôpital Lariboisière, Service d'hématologie biologique AP‐HP. Nord ‐ Université de Paris Paris France
- Institut de Recherche Saint Louis Paris France
| | - Minh Tam Baylatry
- Hôpital Saint‐Antoine, Pharmacie AP‐HP. Sorbonne Université Paris France
| | | | - Elise Corre
- Hôpital Saint‐Antoine, Service d'Hématologie AP‐HP. Sorbonne Université Paris France
- Centre de Référence des Microangiopathies thrombotiques Paris France
| | - Zora Marjanovic
- Hôpital Saint‐Antoine, Service d'Hématologie AP‐HP. Sorbonne Université Paris France
| | | | - Frédéric Féger
- Hôpital Saint‐Antoine, Service d'Hématologie biologique AP‐HP. Sorbonne Université Paris France
| | - Ludovic Suner
- Hôpital Saint‐Antoine, Service d'Hématologie biologique AP‐HP. Sorbonne Université Paris France
- Sorbonne Université, INSERM, Centre de Recherche Saint‐Antoine, CRSA Paris France
| | - Agnès Veyradier
- Hôpital Lariboisière, Service d'hématologie biologique AP‐HP. Nord ‐ Université de Paris Paris France
- Institut de Recherche Saint Louis Paris France
- Centre de Référence des Microangiopathies thrombotiques Paris France
| | - Alain Stépanian
- Hôpital Lariboisière, Service d'hématologie biologique AP‐HP. Nord ‐ Université de Paris Paris France
- Institut de Recherche Saint Louis Paris France
- Centre de Référence des Microangiopathies thrombotiques Paris France
| | - Paul Coppo
- Hôpital Saint‐Antoine, Service d'Hématologie AP‐HP. Sorbonne Université Paris France
- Centre de Référence des Microangiopathies thrombotiques Paris France
- INSERM UMRS 1138, Centre de Recherche des Cordeliers Paris France
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Abstract
The a disintegrin-like and metalloproteinase with thrombospondin motif (ADAMTS) family comprises 19 proteases that regulate the structure and function of extracellular proteins in the extracellular matrix and blood. The best characterized cardiovascular role is that of ADAMTS-13 in blood. Moderately low ADAMTS-13 levels increase the risk of ischeamic stroke and very low levels (less than 10%) can cause thrombotic thrombocytopenic purpura (TTP). Recombinant ADAMTS-13 is currently in clinical trials for treatment of TTP. Recently, new cardiovascular roles for ADAMTS proteases have been discovered. Several ADAMTS family members are important in the development of blood vessels and the heart, especially the valves. A number of studies have also investigated the potential role of ADAMTS-1, -4 and -5 in cardiovascular disease. They cleave proteoglycans such as versican, which represent major structural components of the arteries. ADAMTS-7 and -8 are attracting considerable interest owing to their implication in atherosclerosis and pulmonary arterial hypertension, respectively. Mutations in the ADAMTS19 gene cause progressive heart valve disease and missense variants in ADAMTS6 are associated with cardiac conduction. In this review, we discuss in detail the evidence for these and other cardiovascular roles of ADAMTS family members, their proteolytic substrates and the potential molecular mechanisms involved.
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Affiliation(s)
- Salvatore Santamaria
- Centre for Haematology, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - Rens de Groot
- Centre for Haematology, Imperial College London, Du Cane Road, London W12 0NN, UK.,Institute of Cardiovascular Science, University College London, 51 Chenies Mews, London WC1E 6HX, UK
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Li A, Kremer Hovinga JA. Laboratory surveillance of immune-mediated thrombotic thrombocytopenic purpura. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:82-84. [PMID: 33275690 PMCID: PMC7727562 DOI: 10.1182/hematology.2020000164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Ang Li
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX
| | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland; and
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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Loscocco GG, Malandrino D, Vannini F, Vinci MC, Di Marzio G, Fallai L, Scappini B. Successful use of caplacizumab in a case of refractory acquired thrombotic thrombocytopenic purpura following subacute thyroiditis. Transfus Apher Sci 2020; 60:103010. [PMID: 33223471 DOI: 10.1016/j.transci.2020.103010] [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: 09/10/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 11/29/2022]
Abstract
Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare condition mainly characterized by microangiopathic hemolytic anemia, thrombocytopenia, reported in approximately three cases per one million adults per year. Some reports describing co-occurrence of aTTP and other autoimmune disorders, as Graves' thyroiditis, are reported. To the best of our knowledge this is the first report describing co-occurrence of subacute thyroiditis and aTTP. The patient was refractory to conventional therapy with plasma exchange, steroids and rituximab but was successfully treated with the addition of caplacizumab, an anti-VWF bivalent variable-domain-only immunoglobulin fragment that inhibits interaction between VWF multimers and platelets.
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Affiliation(s)
- Giuseppe G Loscocco
- Hematology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Danilo Malandrino
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Francesco Vannini
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Costanza Vinci
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giulia Di Marzio
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Linda Fallai
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Barbara Scappini
- Hematology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Barba C, Peyre M, Galicier L, Cathebras P, Ranta D, Malot S, Veyradier A, Coppo P. Intensive rituximab regimen in immune-mediated thrombotic thrombocytopenic purpura can circumvent unresponsiveness to standard rituximab treatment. Br J Haematol 2020; 192:e21-e25. [PMID: 33216951 DOI: 10.1111/bjh.17170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/14/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Christophe Barba
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, AP-HP. Sorbonne-Université, Paris, France
| | - Marion Peyre
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, AP-HP. Sorbonne-Université, Paris, France
| | - Lionel Galicier
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'Immunopathologie, Hôpital Saint-Louis, AP-HP, Paris, France
| | - Pascal Cathebras
- Service de Médecine Interne, Centre Hospitalier Universitaire de St Etienne, Paris, France
| | - Dana Ranta
- Service d'Hématologie, Centre Hospitalier Universitaire de Nancy, Paris, France
| | - Sandrine Malot
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France
| | - Agnès Veyradier
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'Hématologie Biologique - Hémostase, Hôpital Lariboisière, Paris, AP-HP, France
| | - Paul Coppo
- Centre de Référence des MicroAngiopathies Thrombotiques, Paris, France.,Service d'hématologie, AP-HP. Sorbonne-Université, Paris, France.,INSERM UMRS 1138, Paris, France
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Abou-Ismail MY, Arafah Y, Fu P, Cao S, Schmaier AH, Nayak L. Outcomes of Immune Thrombotic Thrombocytopenic Purpura (iTTP) With Upfront Cyclophosphamide vs. Rituximab. Front Med (Lausanne) 2020; 7:588526. [PMID: 33195351 PMCID: PMC7657267 DOI: 10.3389/fmed.2020.588526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Immune thrombotic thrombocytopenic purpura (iTTP) is a rare, life-threatening disorder managed with plasma exchange (PLEX) and steroids. Addition of rituximab (RTX) to initial disease treatment has been shown to lower future relapse rates. Information as to whether upfront cyclophosphamide (CTX) treatment is helpful in reducing relapse is not known. Methods: In a retrospective cohort study, we identified all patients at our institution diagnosed with iTTP between 2010 and 2019. We analyzed outcomes of cumulative incidence of relapse (CIR) and duration of remission. Results: Thirty Nine patients were studied. Group A (n = 10) included patients who received upfront PLEX and steroids alone, and Group B (n = 28) included those who received either upfront RTX (n = 23) or CTX (n = 5) in addition to PLEX and steroids. The 2-year CIR was 50% in Group A and 27.7% in Group B, with a median duration of remission of 43.6 months vs. 108.3 months, respectively (p = 0.04). Group A was associated with a HR=8.7 (95% CI: 1.27, 59.45), p = 0.027 for duration of remission. There was no significant difference between CTX and RTX in both outcomes of CIR and duration of remission. We observed a potential impact on remission duration based on the presenting absolute neutrophil count (HR = 0.74, 95% CI: 0.58, 0.96) and serum creatinine (HR = 1.42, 95% CI: 1.03, 1.94). Conclusion: There was no significant difference in iTTP relapse outcomes between upfront RTX and CTX. Absolute neutrophil count and serum creatinine may have a role in predicting relapse. Larger, prospective studies are needed to evaluate these findings.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Yasmin Arafah
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Pingfu Fu
- Case Western Reserve University, Cleveland, OH, United States
| | - Shufen Cao
- Case Western Reserve University, Cleveland, OH, United States
| | - Alvin H Schmaier
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Lalitha Nayak
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
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45
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Scully M. Transforming the major autoantibody site on ADAMTS13: spacer domain variants retaining von Willebrand factor cleavage activity. Haematologica 2020; 105:2510-2512. [PMID: 33131242 PMCID: PMC7604561 DOI: 10.3324/haematol.2020.262154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Marie Scully
- Department of Haematology and National Institute for Health Research Cardiometabolic Programme, UCLH/UCL BRC, London, UK.
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46
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Gómez-Seguí I, Fernández-Zarzoso M, de la Rubia J. A critical evaluation of caplacizumab for the treatment of acquired thrombotic thrombocytopenic purpura. Expert Rev Hematol 2020; 13:1153-1164. [PMID: 32876503 DOI: 10.1080/17474086.2020.1819230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Acquired thrombotic thrombocytopenic purpura (aTTP) is a thrombotic microangiopathy caused by inhibitory autoantibodies against ADAMTS13 protein. Until recently, the combination of plasma exchange (PEX) and immunosuppression has been the standard front-line treatment in this disorder. However, aTTP-related mortality, refractoriness, and relapse are still a matter of concern. Areas covered: The better understanding of the pathophysiological mechanisms of aTTP has allowed substantial improvements in the diagnosis and treatment of this disease. Recently, the novel anti-VWF nanobody caplacizumab has been approved for acute episodes of aTTP. Caplacizumab is capable to block the adhesion of platelets to VWF, therefore inhibiting microthrombi formation in the ADAMTS13-deficient circulation. In this review, the characteristics of caplacizumab together with the available data of its efficacy and safety in the clinical setting will be analyzed. Besides, the current scenario of aTTP treatment will be provided, including the role of other innovative drugs. Expert opinion: With no doubt, caplacizumab is going to change the way we treat aTTP. In combination with standard treatment, caplacizumab can help to significantly reduce aTTP-related mortality and morbidity and could spare potential long-term consequences by minimizing the risk of exacerbation.
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Affiliation(s)
| | | | - Javier de la Rubia
- Hematology Service, University Hospital Doctor Peset , Valencia, Spain.,Internal Medicine, School of Medicine and Dentistry, Catholic University of Valencia , Valencia, Spain
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Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, Matsumoto M, Mustafa RA, Pai M, Rock G, Russell L, Tarawneh R, Valdes J, Peyvandi F. Good practice statements (GPS) for the clinical care of patients with thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2503-2512. [PMID: 32914535 PMCID: PMC7880820 DOI: 10.1111/jth.15009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Despite advances in treatment options for thrombotic thrombocytopenic purpura (TTP), there are still limited high quality data to inform clinicians regarding its management. METHODS In June 2018, the ISTH formed a multidisciplinary guideline panel to issue recommendations about treatment of TTP. The panel discussed 12 treatment questions related to both immune-mediated TTP (iTTP) and hereditary/congenital TTP (cTTP). The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence and formulate recommendations. RESULTS The panel agreed on eleven recommendations based on evidence ranging from very low to moderate certainty. For first episode and relapses of acute iTTP, the panel made a strong recommendation for the addition of corticosteroids to therapeutic plasma exchange (TPE), and a conditional recommendation for addition of rituximab and caplacizumab. For asymptomatic iTTP with low ADAMTS13, the panel made a conditional recommendation for rituximab outside of pregnancy, and for prophylactic TPE during pregnancy. For asymptomatic cTTP, the panel made a strong recommendation for prophylactic plasma infusion during pregnancy, but a conditional recommendation for plasma infusion or a wait and watch approach outside of pregnancy. CONCLUSIONS The panel's recommendations are based on all the available evidence for the treatment effects of various approaches including suppressing inflammation, blocking platelet clumping, replacing the missing and/or inhibited ADAMTS13, and suppressing ADAMTS13 antibody production. There was insufficient evidence for further comparison of different treatment approaches, for which future high-quality studies in iTTP (e.g., rituximab, corticosteroids, recombinant ADAMTS13, and caplacizumab) and in cTTP (eg, recombinant ADAMTS13) are needed.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sara K. Vesely
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d’Hématologie, Hôpital Saint-Antoine, Sorbonne Université, Assistance Publique, Hôpitaux de Paris, Paris, France
| | | | - Alfonso Iorio
- Department of Health Research Methods, Research, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Reem A. Mustafa
- Department of Medicine, The University of Kansas Mediccal Center, Kansas City, KS, USA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gail Rock
- University of Ottawa, Ottawa, ON, Canada
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rawan Tarawneh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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48
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Zheng XL, Vesely SK, Cataland SR, Coppo P, Geldziler B, Iorio A, Matsumoto M, Mustafa RA, Pai M, Rock G, Russell L, Tarawneh R, Valdes J, Peyvandi F. ISTH guidelines for treatment of thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2496-2502. [PMID: 32914526 PMCID: PMC8091490 DOI: 10.1111/jth.15010] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite advances in treatment options for thrombotic thrombocytopenic purpura (TTP), there are still limited high quality data to inform clinicians regarding its appropriate treatment. METHODS In June 2018, the ISTH formed a multidisciplinary guideline panel to issue recommendations about treatment of TTP. The panel discussed 12 treatment questions related to immune-mediated TTP (iTTP) and hereditary or congenital TTP (cTTP). The panel used the Grading of Recommendations Assessment, Development, and Evaluation approach, including evidence-to-decision frameworks, to appraise evidence and formulate recommendations. RESULTS The panel agreed on 11 recommendations based on evidence ranging from very low to moderate certainty. For first acute episode and relapses of iTTP, the panel made a strong recommendation for adding corticosteroids to therapeutic plasma exchange (TPE) and a conditional recommendation for adding rituximab and caplacizumab. For asymptomatic iTTP with low plasma ADAMTS13 activity, the panel made a conditional recommendation for the use of rituximab outside of pregnancy, but prophylactic TPE during pregnancy. For asymptomatic cTTP, the panel made a strong recommendation for prophylactic plasma infusion during pregnancy, and a conditional recommendation for plasma infusion or a wait and watch approach outside of pregnancy. CONCLUSIONS The panel's recommendations are based on all the available evidence for the effects of an individual component of various treatment approaches, including suppressing inflammation, blocking platelet clumping, replacing the missing and/or inhibited ADAMTS13, and suppressing the formation of ADAMTS13 autoantibody. There was insufficient evidence for further comparing different treatment approaches (eg, TPE, corticosteroids, rituximab, and caplacizumab, etc.), for which high quality studies are needed.
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Affiliation(s)
- X. Long Zheng
- Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sara K. Vesely
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, Service d’Hématologie, Hôpital Saint-Antoine, Sorbonne Université, Assistance Publique, Hôpitaux de Paris, Paris, France
| | | | - Alfonso Iorio
- Department of Health Research Methods, Research, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Reem A. Mustafa
- Department of Medicine, University of Kansas Mediccal Center, Kansas City, KS, USA
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gail Rock
- University of Ottawa, Ottawa, ON, Canada
| | - Lene Russell
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Rawan Tarawneh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Kucukyurt S, Eskazan AE. Assessment and Monitoring of Patients with Immune-Mediated Thrombotic Thrombocytopenic Purpura (iTTP): Strategies to Improve Outcomes. J Blood Med 2020; 11:319-326. [PMID: 33061729 PMCID: PMC7532071 DOI: 10.2147/jbm.s205630] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 09/11/2020] [Indexed: 12/15/2022] Open
Abstract
Background Acquired or immune-mediated TTP (iTTP) is a life-threatening thrombotic microangiopathy, characterized by the presence of microangiopathic hemolytic anemia and severe thrombocytopenia, and a variable degree of ischemic organ damage, related to a severe deficiency of ADAMTS13, which is a serine metalloprotease necessary for cleavage of large vWF multimers. There has been a dramatic decrease in mortality rates with the recognition of the pathophysiology of iTTP over the years. Although therapeutic plasma exchange (TPE) together with corticosteroids are the backbone of the upfront treatment of patients with iTTP with successful outcomes, patients may remain refractory and/or relapse following an initial response to this treatment. Methods We performed a review regarding the pathogenesis, diagnosis, treatment strategies, monitoring, and prognosis of iTTP. Results There are several new treatment strategies, which can be used among these patients, helping in improving outcomes of iTTP. Rituximab has been shown to be a safe and effective adjunct to TPE, especially in patients with refractory and/or relapse as well as it is increasingly used preemptively to prevent exacerbation or recurrence. Recently, caplacizumab, a nanobody targeting vWF, was approved as an addition to the current regimen of TPE and immunomodulation for patients of iTTP. Conclusion Specific predictors of relapse in patients in remission can be relevant for an optimal patient management. Different models including ADAMTS13 biomarkers can provide a new screening strategy to identify patients who may predict outcomes and the risk of relapse, benefit from preemptive therapy prior to relapse.
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Affiliation(s)
- Selin Kucukyurt
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ahmet Emre Eskazan
- Division of Hematology, Department of Internal Medicine, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
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50
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Ma W, Bai W, Wu X, Zhao J, Li M, Zeng X. Successful treatment of refractory thrombotic thrombocytopenic purpura associated with systemic lupus erythematosus with combination of plasma exchange and low-dose rituximab. Lupus 2020; 29:1961-1967. [PMID: 32838618 DOI: 10.1177/0961203320953473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Thrombotic thrombocytopenia purpura (TTP) associated with systemic lupus erythematous (SLE) (i.e., SLE-TTP) is a rare life-threatening disease often requiring intensive immunosuppressive agents, in addition to high-dose corticosteroids and plasma exchange (PEX). The optimal therapy of rituximab is unclear, but 375 mg/m2 weekly for 4 weeks is the usual practice, adopted from regimens for non-Hodgkin's lymphoma. We reported two cases of refractory SLE-TTP that showed good efficacy and prognosis with combination of methylprednisolone (MP) pulse, plasma exchange and low-dose rituximab (100 mg weekly for 4 weeks) treatment. METHODS Clinical data and treatment outcomes were reviewed of two patients diagnosed with refractory SLE-TTP at Peking Union Medical College Hospital between July 2017 and July 2018. RESULTS Both patients had SLE and presented with microangiopathic anemia and thrombocytopenia. Laboratory assays revealed high anti-nuclear antibody titers, reduced complement 3 and 4 levels, proteinuria, significantly elevated lactate dehydrogenase, schistocytes on peripheral blood smear, low ADAMTS13 activity, and the presence of ADAMTS13 inhibitor. In both patients, platelet counts remained below 50 × 109/L after MP pulse and 6 PEXs, confirming the diagnosis of refractory SLE-TTP. Low-dose rituximab (100 mg weekly for 4 weeks) was administered in both cases, resulting in normalization of platelet counts and significant reductions in B-lymphocyte counts. No TTP relapse or SLE flare occurred during 24 months of follow-up. CONCLUSIONS Our cases confirmed the efficacy and good follow-up outcomes of low-dose rituximab treatment (100 mg weekly for 4 weeks) for refractory SLE-TTP.
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Affiliation(s)
- Wanlu Ma
- Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Bai
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Xueyan Wu
- Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
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