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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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2
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Peng JY, Wang SY, Chen MQ, Liu CX, Zhao YT, Xu TS, Wu QL. Efficacy and relative safety of caplacizumab in immune-mediated thrombotic thrombocytopenic purpura: a systematic review and meta-analysis. Blood Coagul Fibrinolysis 2024; 35:271-278. [PMID: 38874905 DOI: 10.1097/mbc.0000000000001313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Immune-mediated thrombotic thrombocytopenia purpura (iTTP) is a rare microvascular disease characterized by severe disseminated microvascular thrombose-bleeding syndrome. Caplacizumab has been approved for the treatment of iTTP in combination with Plasma Exchange (PE) and immunosuppressive therapy, but its role in iTTP therapy remains uncertain. Therefore, we conducted a meta-analysis to investigate the safety and efficacy of caplacizumab for the treatment of patients with iTTP. We searched electronic databases (PubMed, Embase, Cochrane Library, and Scopus) and reference lists of relevant articles to find articles published from 2015 to 2022. The time to normalization of the platelet count of the group caplacizumab is shorter than the group placebo (SMD = -0.72; 95% CI -0.88 to -0.56; P < 0.05). Caplacizumab reduced the incidence of mortality (OR = 0.41; 95% CI 0.18-0.92; P < 0.05), exacerbations (OR = 0.10; 95% CI 0.05-0.18; P < 0.05), and recurrence (OR = 0.17; 95% CI 0.06-0.50; P < 0.05). However, the bleeding events in the caplacizumab group were higher than those in the placebo group, especially severe bleeding events. There was no difference in ADAMTS13 activity and thromboembolic events between the two groups. Our analysis indicated that caplacizumab is effective and well tolerated for the treatment of iTTP. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022362370.
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Affiliation(s)
- Jia-Ying Peng
- College of Pediatrics, Guangzhou Medical University, Guangzhou, China
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3
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Capecchi M, Gazzola G, Agosti P, De Leo P, Mancini I, Ferrari B, Giannotta JA, Artoni A, Peyvandi F. Treatment of immune-mediated thrombotic thrombocytopenic purpura without plasma exchange. Haematologica 2024; 109:2019-2023. [PMID: 38385305 PMCID: PMC11141672 DOI: 10.3324/haematol.2023.284438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/13/2024] [Indexed: 02/23/2024] Open
Abstract
Not available.
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Affiliation(s)
- Marco Capecchi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; Gruppo Ospedaliero Moncucco - Clinica Moncucco, Division of Hematology, Lugano
| | - Giada Gazzola
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; Università degli Studi di Milano, Department of Oncology and Onco-hematology, Milan
| | - Pasquale Agosti
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan
| | - Pasqualina De Leo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Ilaria Mancini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Barbara Ferrari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Juri Alessandro Giannotta
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, and Fondazione Luigi Villa, Milan.
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4
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Allen C, Ito S, Butt A, Purcell A, Richmond R, Tormey CA, Krumholz HM, Cuker A, Goshua G. Cost-effectiveness of rapid vs in-house vs send-out ADAMTS13 testing for immune thrombotic thrombocytopenic purpura. Blood Adv 2024; 8:2279-2289. [PMID: 38502197 PMCID: PMC11116991 DOI: 10.1182/bloodadvances.2024012608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
ABSTRACT While awaiting confirmatory results, empiric therapy for patients suspected to have immune thrombotic thrombocytopenic purpura (iTTP) provides benefits and also accrues risks and costs. Rapid assays for ADAMTS13 may be able to avoid the cost and risk exposure associated with empiric treatment. We conducted, to our knowledge, the first cost-effectiveness evaluation of testing strategies with rapid vs traditional ADAMTS13 assays in patients with intermediate- to high-risk PLASMIC scores, with and without caplacizumab use. We built a Markov cohort simulation with 4 clinical base-case analyses: (1) intermediate-risk PLASMIC score with caplacizumab; (2) intermediate-risk PLASMIC score without caplacizumab; (3) high-risk PLASMIC score with caplacizumab; and (4) high-risk PLASMIC score without caplacizumab. Each of these evaluated 3 testing strategies: (1) rapid assay (<1-hour turnaround); (2) in-house fluorescence resonance energy transfer (FRET)-based assay (24-hour turnaround); and (3) send-out FRET-based assay (72-hour turnaround). The primary outcome was the incremental net monetary benefit reported over a 3-day time horizon and across accepted willingness-to-pay thresholds in US dollars per quality-adjusted life-year (QALY). While accruing the same amount of QALYs, the rapid assay strategy saved up to $46 820 (95% CI, $41 961-$52 486) per patient tested. No parameter variation changed the outcome. In probabilistic sensitivity analyses, the rapid assay strategy was favored in 100% (3 base cases and scenario analyses) and 99% (1 base-case and scenario analysis) across 100 000 Monte Carlo iterations within each. Rapid ADAMTS13 testing for patients with intermediate- or high-risk PLASMIC scores yields significant per patient cost savings, achieved by reducing the costs associated with unnecessary therapeutic plasma exchange and caplacizumab therapy in patients without iTTP.
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Affiliation(s)
- Cecily Allen
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Ayesha Butt
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | | | | | - Christopher A. Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT
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5
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Saito K, Sakai K, Kubo M, Azumi H, Hamamura A, Ochi S, Amagase H, Kunieda H, Ogawa Y, Yagi H, Matsumoto M. Persistent ADAMTS13 inhibitor delays recovery of ADAMTS13 activity in caplacizumab-treated Japanese patients with iTTP. Blood Adv 2024; 8:2151-2159. [PMID: 38386976 PMCID: PMC11068500 DOI: 10.1182/bloodadvances.2023012451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/24/2024] Open
Abstract
ABSTRACT For patients with immune-mediated thrombotic thrombocytopenic purpura (iTTP), caplacizumab, a nanobody against von Willebrand factor A1 domain, has become crucial. Delayed normalization of ADAMTS13 activity during caplacizumab therapy has been identified. In a retrospective analysis, we compared platelet count, ADAMTS13 activity, its inhibitor, and anti-ADAMTS13 immunoglobulin G (IgG) levels in acute iTTP cases treated with caplacizumab (n = 14) or without it (n = 16). The median time from initial therapeutic plasma exchange (TPE) to the first rituximab administration was 12 days in the caplacizumab group (n = 11) and 10 days in the group without caplacizumab (n = 13). We evaluated ADAMTS13-related parameters at onset and once a week until day 28 after the first TPE. The number of days until the platelet counts reached ≥150 × 109/L was significantly shorter in the caplacizumab group than in the non-caplacizumab group. The median ADAMTS13 activity levels on days 14, 21, and 28 were significantly lower in the caplacizumab group. The median titers of the ADAMTS13 inhibitor and anti-ADAMTS13 IgG on the same days were significantly higher in the caplacizumab group. Furthermore, the median number of days from the first TPE until finally achieving an ADAMTS13 activity of ≥10% was significantly longer in the caplacizumab group than in the non-caplacizumab group (42 vs 23 days, P = .014). We observed delayed ADAMTS13 activity recovery and continued inhibitor and anti-ADAMTS13 IgG detection in patients with acute iTTP on caplacizumab, possibly because of the decreased number of TPEs and delayed frontline rituximab.
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Affiliation(s)
- Kenki Saito
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Kazuya Sakai
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Masayuki Kubo
- Department of Hematology, Nara Medical University, Kashihara, Japan
| | - Hidekazu Azumi
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Atsushi Hamamura
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Shinichi Ochi
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
| | - Hiroki Amagase
- Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hisako Kunieda
- Department of Hematology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | - Hideo Yagi
- Department of Hematology and Oncology, Nara Prefecture General Medical Center, Nara, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Japan
- Department of Hematology, Nara Medical University, Kashihara, Japan
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6
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Mingot-Castellano ME, García-Candel F, Martínez-Nieto J, García-Arroba J, de la Rubia-Comos J, Gómez-Seguí I, Paciello-Coronel ML, Valcárcel-Ferreiras D, Jiménez M, Cid J, Lozano M, García-Gala JM, Angós-Vazquez S, Vara-Pampliega M, Guerra-Domínguez L, Ávila-Idrobo LF, Oliva-Hernandez A, Zalba-Marcos S, Tallón-Ruiz I, Ortega-Sánchez S, Goterris-Viciedo R, Moreno-Jiménez G, Domínguez-Acosta L, Araiz-Ramírez M, Hernández-Mateos L, Flores-Ballesteros E, Del Río-Garma J, Pascual-Izquierdo C. ADAMTS13 recovery in acute thrombotic thrombocytopenic purpura after caplacizumab therapy. Blood 2024; 143:1807-1815. [PMID: 38237147 DOI: 10.1182/blood.2023022725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 03/25/2024] Open
Abstract
ABSTRACT Caplacizumab prevents the interaction between von Willebrand factor and platelets and is used to treat immune thrombotic thrombocytopenic purpura (iTTP). Its administration has been associated with a delay in ADAMTS13 activity restoration after plasma exchange (PEX) suspension. We analyzed the outcomes of 113 iTTP episodes, 75 of which were treated with caplacizumab, in 108 patients from the Spanish Registry of Thrombotic Thrombocytopenic Purpura. Caplacizumab shortened the time to platelet count normalization and reduced PEX requirement, exacerbations, and relapses. There was no difference in the time to achieve ADAMTS13 activity ≥20% after PEX end between caplacizumab-treated and nontreated episodes (median [interquartile range], 14.5 [7.7-27.2] vs 13.0 [8.0-29.0] days, P = .653). However, considering the 36 episodes in which caplacizumab was started ≤3 days after iTTP diagnosis, the time for ADAMTS13 restoration from PEX end was higher than in those episodes in which caplacizumab was started >3 days after iTTP diagnosis (20.0 [12.0-43.0] vs 11.0 [3.5-20.0] days, P = .003) or than in non-caplacizumab-treated episodes (P = .033). This finding could be related to a significantly shorter duration of PEX in early caplacizumab-treated episodes than in late caplacizumab-treated episodes (5.5 [4.0-9.0] vs 15.0 [11.0-21.5] days, P < .001) or non-caplacizumab-treated episodes (11.0 [6.0-26.0] days, P < .001). There were no differences in time to ADAMTS-13 restoration from PEX start (28.0 [17.2-47.5], 27.0 [19.0-37.5] and 29.5 [15.2-45.0] days in early caplacizumab-treated, late caplacizumab-treated and non-caplacizumab-treated episodes). Early administered caplacizumab does not prevent the requirement for immunosuppression but has beneficial effects by shortening PEX requirement without major safety concerns.
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Affiliation(s)
- María-Eva Mingot-Castellano
- Department of Hematology, Hospital Universitario Virgen del Rocío, Seville, Spain
- Instituto de Biomedicina de Sevilla, Seville, Spain
| | | | | | - José García-Arroba
- Banc de Sang i Teixits, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Javier de la Rubia-Comos
- Department of Hematology, Hospital Universitario La Fe, Universidad Católica San Vicente Mártir, IIS La Fe, Valencia, Spain
| | - Inés Gómez-Seguí
- Department of Hematology, Hospital Universitario La Fe, Universidad Católica San Vicente Mártir, IIS La Fe, Valencia, Spain
| | | | | | - Moraima Jiménez
- Department of Hematology, Hospital Universitari Vall D'Hebron, Barcelona, Spain
| | - Joan Cid
- Department of Hemotherapy and Hemostasis, Apheresis and Cellular Therapy Unit, Clinical Institute of Hematological and Oncological Diseases, Instituto de Investigaciones Biomédicas August Pi i Sunyer, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Miquel Lozano
- Department of Hemotherapy and Hemostasis, Apheresis and Cellular Therapy Unit, Clinical Institute of Hematological and Oncological Diseases, Instituto de Investigaciones Biomédicas August Pi i Sunyer, Hospital Clínic de Barcelona, Barcelona, Spain
| | - José-María García-Gala
- Department of Hematology, Hospital Universitario Central de Asturias, Institute for Bio Health Investigation of Asturias, Oviedo, Spain
| | - Sonia Angós-Vazquez
- Department of Hematology, Hospital Universitario de Zaragoza, Zaragoza, Spain
| | | | - Luisa Guerra-Domínguez
- Department of Hematology, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | - Ana Oliva-Hernandez
- Department of Hematology, Hospital Universitario Nuestra Señora de la Candelaria, Tenerife, Spain
| | - Saioa Zalba-Marcos
- Department of Hematology, Hospital Universitario de Navarra, Pamplona, Spain
| | | | | | - Rosa Goterris-Viciedo
- Department of Hematology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Lourdes Domínguez-Acosta
- Department of Hematology, Hospital Universitario de Jerez de la Frontera, Jerez de la Frontera, Spain
| | | | - Luis Hernández-Mateos
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Elena Flores-Ballesteros
- Department of Hematology, Hospital Universitario Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Julio Del Río-Garma
- Department of Hematology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Cristina Pascual-Izquierdo
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Gregorio Marañon, Madrid, Spain
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Kalinina II, Antonova KS, Avdonin PV, Klebanova EE, Kotskaya NN, Kurnikova EE, Shutova AD, Matveev VE, Maschan AA. Successful Treatment of Acquired Thrombotic Thrombocytopenic Purpura With Caplacizumab Combined With Plasma Exchanges and Immune Suppression in 3 Children. J Pediatr Hematol Oncol 2024; 46:e220-e222. [PMID: 38447071 PMCID: PMC10956674 DOI: 10.1097/mph.0000000000002843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/29/2024] [Indexed: 03/08/2024]
Abstract
Acquired thrombotic thrombocytopenic (aTTP) purpura is a life-threatening condition that can lead to devastating thromboembolic events. Recently, caplacizumab has been shown to rapidly restore platelet numbers and reduce the risk of severe end-organ damage when added to plasma exchanges (PEXs) and immunosuppression (IST). Here, we report the outcomes in 3 children with aTTP who were treated with caplacizumab in combination with PEXs and IST. In all 3 patients, platelet count increased to >15,000/mm 3 in 24 h and normalized on day 4, whereas normalization of ADAMTS13 activity >50% and elimination of the inhibitor was achieved after 18 to 89 days. Epistaxis was observed in 2 patients and was the only side effect related to caplacizumab. Caplacizumab is a promising agent for first-line treatment of children with aTTP.
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Affiliation(s)
- Irina I. Kalinina
- Department of General Hematology, Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology
| | - Khristina S. Antonova
- Department of General Hematology, Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology
| | - Pavel V. Avdonin
- Laboratory of the Physiology of Receptors and Signal Pathways, N.K. Koltsov Institute of Developmental Biology
| | - Elizaveta E. Klebanova
- Express-Laboratory of ICU, National Research Center for Hematology, Moscow, Russian Federation
| | - Natalia N. Kotskaya
- Department of General Hematology, Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology
| | - Elena E. Kurnikova
- Department of Blood Transfusion, Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology
| | - Alexandra D. Shutova
- Department of General Hematology, Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology
| | - Victor E. Matveev
- Department of General Hematology, Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology
| | - Alexey A. Maschan
- Department of General Hematology, Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology
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Angelucci E, Artoni A, Fianchi L, Dovizio M, Iacolare B, Saragoni S, Esposti LD. Real-World Data Analysis of Patients Affected by Immune-Mediated Thrombotic Thrombocytopenic Purpura in Italy. J Clin Med 2024; 13:1342. [PMID: 38592185 PMCID: PMC10931660 DOI: 10.3390/jcm13051342] [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: 01/24/2024] [Revised: 02/23/2024] [Accepted: 02/24/2024] [Indexed: 04/10/2024] Open
Abstract
Background: The therapeutic management of immune-mediated thrombotic thrombocytopenic purpura (iTTP) has recently benefited from the introduction of caplacizumab, an agent directed at the inhibition of platelet aggregation. This real-world analysis investigated the epidemiology and the demographic and clinical characteristics of iTTP patients in Italy before and after caplacizumab introduction in 2020. Methods: Hospitalized adults with iTTP were included using the administrative databases of healthcare entities covering 17 million residents. Epidemiological estimates of iTTP considered the 3-year period before and after caplacizumab introduction. After stratification by treatment with or without caplacizumab, iTTP patients were characterized for their baseline features. Results: The annual incidence before and after 2020 was estimated in the range of 4.3-5.8 cases/million and 3.6-4.6 cases/million, respectively. From 2018 to 2022, 393 patients with iTTP were included, and 42 of them were treated with caplacizumab. Caplacizumab-treated patients showed better clinical outcomes, with tendentially shorter hospital stays and lower mortality rates (no treated patients died at either 1 month or 3 months after caplacizumab treatment initiation, compared to 10.5% and 11.1% mortality rates at 1 and 3 months, respectively, of the untreated ones). Conclusions: These findings may suggest that caplacizumab advent provided clinical and survival benefits for patients with iTTP.
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Affiliation(s)
- Emanuele Angelucci
- U.O. Ematologia e Terapie Cellulari, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy;
| | - Andrea Artoni
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milano, Italy;
| | - Luana Fianchi
- Dipartimento Scienze Radiologiche, Radioterapiche ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy;
| | - Melania Dovizio
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy; (M.D.); (B.I.); (S.S.)
| | - Biagio Iacolare
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy; (M.D.); (B.I.); (S.S.)
| | - Stefania Saragoni
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy; (M.D.); (B.I.); (S.S.)
| | - Luca Degli Esposti
- CliCon S.r.l. Società Benefit, Health, Economics & Outcomes Research, 40137 Bologna, Italy; (M.D.); (B.I.); (S.S.)
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9
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Neupane N, Thapa S, Mahmoud A, Bhattarai A, KC A, Shikhrakar S, Gurusinghe S, Kuiodes P. Does Caplacizumab for the management of thrombotic thrombocytopenic purpura increase the risk of relapse, exacerbation, and bleeding? An updated systematic review and meta-analysis based on revised criteria by the International Working Group for thrombotic thrombocytopenic purpura. EJHAEM 2024; 5:178-190. [PMID: 38406548 PMCID: PMC10887272 DOI: 10.1002/jha2.833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 11/05/2023] [Accepted: 11/07/2023] [Indexed: 02/27/2024]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening condition marked by abnormal blood clotting and organ damage. Caplacizumab is a potential treatment for the TTP management. This systematic review and meta-analysis aimed to assess Caplacizumab's effectiveness and safety in the TTP management. A comprehensive database search identified nine studies, including randomized controlled trials and observational studies. Primary outcomes included TTP exacerbation, relapse, and major bleeding. Major bleeding risk was evaluated using updated definitions recommended by the International TTP Working Group in 2021. Revised criteria proposed by the IWG for TTP recurrence were employed for a comprehensive assessment of Caplacizumab's impact on relapse and exacerbation. Analysis revealed Caplacizumab significantly reduced all-cause mortality in TTP patients. Some studies raised concerns about bleeding risk, but overall, it did not significantly differ from standard treatment. Likewise, there was no significant difference in TTP relapse rates between Caplacizumab and standard care. This study supports Caplacizumab as a potential adjunct therapy for TTP. However, careful consideration of its advantages and risks is crucial in clinical practice. Further research is needed to address concerns related to adverse effects like bleeding risk and relapse rates associated with Caplacizumab in the TTP management. The findings emphasize the importance of weighing potential benefits and risks when considering Caplacizumab as an adjunct therapy for TTP.
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Affiliation(s)
- Niraj Neupane
- Rochester General HospitalDepartment of Internal MedicineRochesterNew YorkUSA
| | | | - Amir Mahmoud
- Rochester General HospitalDepartment of Internal MedicineRochesterNew YorkUSA
| | | | - Anil KC
- Patan Academy of Health SciencesPatanNepal
| | | | - Sayuri Gurusinghe
- University of BuffaloDepartment of Internal MedicineBuffaloNew YorkUSA
| | - Peter Kuiodes
- Lipson Cancer Center, Rochester General HospitalDepartment of HematologyNew YorkUSA
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10
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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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11
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Arnaud A, Schilsky S, Lucia J, Maia M, Laredo F, Marques AP, Okada H, Roberts AW. Outcomes and Costs in Patients with Immune Thrombotic Thrombocytopenic Purpura Receiving Front-Line Versus Delayed Caplacizumab: A US Hospital Database Study. Clin Appl Thromb Hemost 2024; 30:10760296241241525. [PMID: 38523315 PMCID: PMC10962044 DOI: 10.1177/10760296241241525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/22/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024] Open
Abstract
European real-world data indicate that front-line treatment with caplacizumab is associated with improved clinical outcomes compared with delayed caplacizumab treatment. The objective of the study was to describe the characteristics, treatment patterns, and outcomes in hospitalized patients with an immune-mediated thrombotic thrombocytopenic purpura (iTTP) episode treated with front-line versus delayed caplacizumab in the US. This retrospective cohort analysis of a US hospital database included adult patients (≥18 years) with an acute iTTP episode (a diagnosis of thrombotic microangiopathy and ≥1 therapeutic plasma exchange [TPE] procedure) from January 21, 2019, to February 28, 2021. Unadjusted baseline characteristics, treatment patterns, healthcare resource utilization, and costs were compared between patients who received front-line versus delayed (<2 vs ≥2 days after TPE initiation) caplacizumab treatment. Out of 39 patients, 16 (41.0%) received front-line and 23 (59.0%) received delayed treatment with caplacizumab. Baseline characteristics and symptoms were similar between the two groups. Patients who received front-line caplacizumab treatment had significantly fewer TPE administrations (median: 5.0 vs 12.0); and a significantly shorter hospital stay (median: 9.0 days vs 16.0 days) than patients receiving delayed caplacizumab therapy. Both of these were significantly lower in comparison of means (t-test P < .01). Median inpatient costs (inclusive of caplacizumab costs) were 54% higher in the delayed treated patients than in the front-line treated patients (median: $112 711 vs $73 318). TPE-specific cost was lower in the front-line treated cohort (median: $6 989 vs $10 917). In conclusion, front-line treatment with caplacizumab had shorter hospitalizations, lower healthcare resource utilization, and lower costs than delayed caplacizumab treatment after TPE therapy.
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12
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Tse B, Buchholz M, Pavenski K. Management of immune thrombotic thrombocytopenic purpura with caplacizumab: a Canadian, single-centre, real-world experience. Platelets 2023; 34:2157807. [PMID: 36636834 DOI: 10.1080/09537104.2022.2157807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
When combined with therapeutic plasma exchange (TPE) and immunosuppression, upfront universal administration of caplacizumab was shown to be effective in the management of immune thrombotic thrombocytopenic purpura (iTTP). However, access to this drug remains challenging in many jurisdictions. We retrospectively review results of a single-institution experience with caplacizumab over a 3-year period. During the study period, we treated 48 patients with iTTP, of which 11 (23%) received caplacizumab. Eight of these 11 patients (73%) were female; the median age was 45 years (IQR 37.0-58.5). All received TPE within 24 h of admission (median 9 exchanges, IQR 7.0-12.5), and high-dose steroids. Caplacizumab was initiated for a median of 6 days after admission (IQR 2.5-8.0) and continued for a median of 26 days (IQR 14.0-33.0). Five patients (45%) had refractory disease at caplacizumab initiation. Ten patients (91%) survived, reaching clinical remission. Platelet normalization was reached with a median of 4 days following caplacizumab initiation (IQR 1.5-4.0). Complications included minor bleeding (n = 1) and local allergic reaction (n = 1). No patients experienced TTP exacerbation; relapse occurred in two patients (18%) over 1-5 years of follow-up. Caplacizumab appeared to be effective and safe, despite delayed initiation and in the setting of refractory disease.
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Affiliation(s)
- Brandon Tse
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Megan Buchholz
- Kidney and Metabolism Program, St. Michael's Hospital, Toronto, ON, Canada
| | - Katerina Pavenski
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON, Canada
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13
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Wali JA, Quigley BM, Schaefer B. Successful Use of Bortezomib in an Adolescent with Refractory TTP. Case Rep Hematol 2023; 2023:8173903. [PMID: 38046988 PMCID: PMC10693465 DOI: 10.1155/2023/8173903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/04/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023] Open
Abstract
With increasing early and upfront use of rituximab and caplacizumab in the modern management of immune-mediated thrombotic thrombocytopenic purpura (iTTP), the risk of refractory disease is expected to decline. However, despite the use of adequate initial therapy, a small subset of patients develop a refractory disease which is difficult to manage. Bortezomib has come to be known as a safe and effective treatment option for refractory iTTP, but its use in children is limited. Here, we describe the case of an adolescent patient with refractory iTTP who had a satisfactory and sustained response to the use of bortezomib.
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Affiliation(s)
- Junaid Ahmad Wali
- Department of Internal Medicine, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Brian M. Quigley
- Division of Behavioral Medicine, Department of Medicine, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Beverly Schaefer
- Department of Pediatrics, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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14
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Gavriilaki E, Nikolousis E, Koravou EE, Dimou-Besikli S, Kartsios C, Papakonstantinou A, Mpanti A, Pontikoglou C, Kalpadaki C, Bitsani A, Tassi I, Touloumenidou T, Chatziconstantinou T, Papathanasiou M, Syrigou A, Ztriva E, Kaiafa G, Mandala E, Mellios Z, Karakasis D, Kourakli A, Symeonidis A, Kapsali E, Papadaki HH, Lalayanni C, Sakellari I. Caplacizumab for immune thrombotic thrombocytopenic purpura: real-world multicenter data. Front Med (Lausanne) 2023; 10:1226114. [PMID: 37901415 PMCID: PMC10600458 DOI: 10.3389/fmed.2023.1226114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 09/27/2023] [Indexed: 10/31/2023] Open
Abstract
Given the limited real-world data of caplacizumab, our multicenter real-world study was designed to assess the safety and efficacy of caplacizumab in immune thrombotic thrombocytopenic pupura (iTTP), compared to historic controls. We have studied 70 patients: 23 in the caplacizumab and 47 in the historic control group. Plasma exchange was applied in all episodes except for two patients that denied plasma exchange. Rituximab as first-line treatment was more common in the caplacizumab group compared to historic control. Caplacizumab (10 mg daily) was given at a median on day 7 (1-43) from initial diagnosis for 32 (6-47) dosages. In the caplacizumab group, a median of 12 (8-23) patients required plasma exchange sessions versus 14 (6-32) in the control group. Caplacizumab administration did not produce any grade 3 complications or major hemorrhagic events. After a median of 19.0 (2.6-320) months since the iTTP diagnosis, 5 deaths occurred (4 in the control group and 1 in the caplacizumab group, p = 0.310). Caplacizumab patients achieved early platelet normalization and ADAMTS13 activity normalization at the end of treatment. Relapse was observed only in 2/23 (9%) caplacizumab patients, compared to 29/47 (62%) historic controls (p < 0.001). Overall, caplacizumab is safe and effective in treating iTTP, including cases refractory to plasma exchange, re-administration, and cases without previous plasma exchange treatment. No major hemorrhagic events were observed. Cessation of dosing guided by ADAMTS13 has ensured a low relapse rate.
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Affiliation(s)
- Eleni Gavriilaki
- BMT Unit - Department of Hematology, G. Papanicolaou Hospital, Thessaloniki, Greece
| | | | | | | | | | | | - Anastasia Mpanti
- Department of Hematology, Papageorgiou Hospital, Thessaloniki, Greece
| | | | - Christina Kalpadaki
- Department of Hematology, University of Crete School of Medicine, Crete, Greece
| | - Aikaterini Bitsani
- First Department of Internal Medicine, LAIKO General Hospital, Athens, Greece
| | - Ilianna Tassi
- Department of Hematology, University Hospital, Ioannina, Greece
| | | | | | - Maria Papathanasiou
- BMT Unit - Department of Hematology, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Antonia Syrigou
- BMT Unit - Department of Hematology, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Eleutheria Ztriva
- 1st Medical Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgia Kaiafa
- 1st Medical Propaedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evdokia Mandala
- 4th Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Zois Mellios
- Department of Hematology, Evangelismos Hospital, Athens, Greece
| | | | - Alexandra Kourakli
- Division of Hematology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Argiris Symeonidis
- Division of Hematology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Eleni Kapsali
- Department of Hematology, University Hospital, Ioannina, Greece
| | | | - Chrysavgi Lalayanni
- BMT Unit - Department of Hematology, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Ioanna Sakellari
- BMT Unit - Department of Hematology, G. Papanicolaou Hospital, Thessaloniki, Greece
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15
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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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16
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Adimora I, Zhang B, Idowu M. Recurrent Strokes in a Woman with a History of Thrombotic Thrombocytopenic Purpura. Case Rep Med 2023; 2023:7070189. [PMID: 37564991 PMCID: PMC10412150 DOI: 10.1155/2023/7070189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 05/04/2023] [Accepted: 05/18/2023] [Indexed: 08/12/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a microangiopathy characterized by mechanical hemolytic anemia, resulting in end-organ damage. We describe a case of TTP which presented as an ischemic stroke. The patient presented with stroke as the primary manifestation of TTP despite a normal platelet count and mildly elevated lactate dehydrogenase level (LDH). The patient underwent two transfusions of fresh frozen plasma (FFP), and ADAMTS13 levels confirmed the diagnosis of TTP after discharge. This case demonstrates the importance of maintaining a high index of suspicion for TTP in the setting of normal laboratory values and reveals the many atypical manifestations of TTP.
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Affiliation(s)
- Ijele Adimora
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, 6431 Fannin St., Houston, TX 77030, USA
| | - Bingnan Zhang
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
| | - Modupe Idowu
- Division of Hematology, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, 6431 Fannin St., Houston, TX 77030, USA
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17
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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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18
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Soto-Mora JA, Gómez-Espitia LM, Lasalvia P, Castellanos Moreno CA, Casallas Vanegas CA, Londoño Gutiérrez SA. Effectiveness and safety of caplacizumab in acquired thrombotic thrombocytopenic purpura: health technology assessment and classification according to the methodology established in Colombia. Int J Technol Assess Health Care 2023; 39:e48. [PMID: 37476982 DOI: 10.1017/s0266462323000442] [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] [Indexed: 07/22/2023]
Abstract
OBJECTIVES Acquired thrombotic thrombocytopenic purpura (aTTP) is a rare hematological disease whose clinical management includes caplacizumab along with plasma exchange and immunosuppression, according to international guidelines. Caplacizumab has been available in Colombia since 2022. This study seeks to determine the therapeutic classification of caplacizumab according to the methodology of the Instituto de Evaluación Tecnológica en Salud. METHODS The classification was carried out through a deliberative process following the modified Delphi technique, with a panel of experts, made up of four hemato-oncologists, a pharmaceutical chemist, and a patient. The results of effectiveness and safety obtained through a systematic review, therapeutic thresholds (clinical significance), and degree of acceptability (willingness to use the technology) were used for the classification. RESULTS Fourteen effectiveness and safety outcomes were submitted for the classification process. Caplacizumab showed clinical significance for some effectiveness outcomes, was not considered inferior in terms of safety, and displayed acceptability of use. Through consensus, the panel determined that caplacizumab plus the standard regimen is superior to the standard regimen in terms of treatment response and composite outcome, and no different for the other effectiveness and safety outcomes. Likewise, in overall terms, the panel determined that caplacizumab together with the standard regimen is superior to the standard regimen. CONCLUSION Treatment with caplacizumab together with the standard regimen was considered superior to the standard regimen for the treatment of patients with aTTP, as it showed clinically significant benefits in critical outcomes for decision making, and a safety profile no different to its comparator.
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Affiliation(s)
- Jahir A Soto-Mora
- Department of Evidence-Based Medicine, NeuroEconomix, Bogotá, Colombia
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19
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Mingot-Castellano ME, Izquierdo CP, Del Rio Garma J. Spanish registry of thrombotic thrombocytopenic purpura (REPTT): Data evidence and new developments. Transfus Apher Sci 2023:103725. [PMID: 37202322 DOI: 10.1016/j.transci.2023.103725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Immuno Thrombotic thrombocytopenic purpura (iTTP) is a rare and potentially fatal disorder characterized by systemic microvascular thrombosis because of a severe deficiency of ADAMTS13. It is difficult to generate knowledge about TTP because of its low incidence and the lack of clinical trials. Most of the evidence on diagnosis, treatment, and prognosis has been generated from real-world data registries. In 2004, the Spanish Apheresis Group (GEA) implemented the Spanish registry of TTP (REPTT) with 438 patients suffering 684 acute episodes in 53 hospitals up to January 2022. REPTT has studied several aspects of TTP in Spain. The iTTP incidence in Spain our country is 2.67 (95 % CI 1.90-3.45) and the prevalence is 21.44 (95 % CI % 19.10-23.73) patients per million inhabitants. The refractoriness incidence is 4.8 % and exacerbation incidence was 8.4 %, with a median of follow-up of 131.5 months (IQR: 14-178 months). In a 2018 review, the mortality in the first episode due to TTP was 7.8 %. We have also found that de novo episodes require fewer PEX procedures than relapses. Since June 2023, REPTT will involve Spain and Portugal, with a recommended sampling protocol and new variables to improve the neurological, vascular and quality of life evaluation of these patients. The main strength of this project will be the involvement of a combined population of more than 57 million inhabitants, which implies an annual incidence of close to 180 acute episodes per year. This will allow us to provide better answers to questions like treatment efficacy, associated morbidity and mortality, and the possible neurocognitive and cardiac sequelae.
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Affiliation(s)
- María Eva Mingot-Castellano
- Servicio de Hematología, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla. Sevilla, Spain.
| | - Cristina Pascual Izquierdo
- Servicio de Hematología, Hospital Universitario Gregorio Marañón, Instituto de Investigación Gregorio Marañón, Madrid, Spain
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20
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He J, Qi J, Han H, Xu X, Li X, Song X, Han Y. Efficacy and safety of caplacizumab in the treatment of thrombotic thrombocytopenic purpura: a systematic review and meta-analysis. Expert Rev Hematol 2023; 16:377-385. [PMID: 37045600 DOI: 10.1080/17474086.2023.2202850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy. Several studies have demonstrated the efficy of caplacizumab in iTTP. However, the effect on different populations remains controversial. Therefore, we performed a systematic review and meta-analysis to assess the effectiveness and safety of caplacizumab for treating iTTP. MATERIALS AND METHODS We searched PubMed, Embase, and the Cochrane Library for studies until March 24, 2023. Participants were hospitalized patients with iTTP. Interventions included caplacizumab versus placebo or standard of care (SOC). Outcomes assessed included all-cause mortality, exacerbation, relapse, refractory, time-to-platelet-count-recovery, length of TPE and hospital stay, bleeding, and thrombosis. RESULTS A total of 1119 patients from eight studies were subjected to meta-analysis. The results of the meta-analysis showed that iTTP patients treated with caplacizumab achieved a reduction in mortality (RR 0.38, 95% CI: 0.19-0.75), exacerbation (RR 0.29, 95% CI: 0.14-0.61) and refractory (RR 0.50, 95% CI: 0.31-0.81). Besides, adding caplacizumab to SOC was associated with a shorten time-to-platelet-count-recovery (MD -2.31, 95% CI: -3.86 to -0.77) and the length of TPE (MD -4.61, 95% CI: -6.20 to -3.02). In terms of safety, the bleeding rate was higher in the caplacizumab group (RR 1.57, 95% CI: 1.21-2.02), while there was no significant difference in hospital stay and thrombosis between the two groups. CONCLUSIONS Caplacizumab is an effective treatment for patients with iTTP, especially in reducing all-cause mortality, exacerbations, refractoriness, and the time-to-platelet-count-recovery. Although the risk of bleeding may be increased, it is generally modest and manageable.
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Affiliation(s)
- Jingyi He
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
| | - Jiaqian Qi
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
| | - Haohao Han
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
| | - Xiaoyan Xu
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
| | - Xueqian Li
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
| | - Xiaofei Song
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
| | - Yue Han
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu province, China
- Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu province, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, Jiangsu province, China
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21
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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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Gómez-Seguí I, Pascual Izquierdo C, Mingot Castellano ME, de la Rubia Comos J. An update on the pathogenesis and diagnosis of thrombotic thrombocytopenic purpura. Expert Rev Hematol 2023; 16:17-32. [PMID: 36537217 DOI: 10.1080/17474086.2023.2159803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Severe ADAMTS13 deficiency defines thrombotic thrombocytopenic purpura (TTP). ADAMTS13 is responsible for VWF cleavage. In the absence of this enzyme, widespread thrombi formation occurs, causing microangiopathic anemia and thrombocytopenia and leading to ischemic organ injury. Understanding ADAMTS13 function is crucial to diagnose and manage TTP, both in the immune and hereditary forms. AREAS COVERED The role of ADAMTS13 in coagulation homeostasis and the consequences of its deficiency are detailed. Other factors that modulate the consequences of ADAMTS13 deficiency are explained, such as complement system activation, genetic predisposition, or the presence of an inflammatory status. Clinical suspicion of TTP is crucial to start prompt treatment and avoid mortality and sequelae. Available techniques to diagnose this deficiency and detect autoantibodies or gene mutations are presented, as they have become faster and more available in recent years. EXPERT OPINION A better knowledge of TTP pathophysiology is leading to an improvement in diagnosis and follow-up, as well as a customized treatment in patients with TTP. This scenario is necessary to define the role of new targeted therapies already available or coming soon and the need to better diagnose and monitor at the molecular level the evolution of the disease.
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Affiliation(s)
- Inés Gómez-Seguí
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Avda, Fernando Abril Martorell, 106, 46026, Valencia, Spain
| | - Cristina Pascual Izquierdo
- Servicio de Hematología y Hemoterapia, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Gregorio Marañón, Calle Dr. Esquerdo 46, 28007, Madrid, Spain
| | - María Eva Mingot Castellano
- Servicio de Hematología, Área de Banco de Sangre y Establecimiento de Tejidos, Hospital Universitario Virgen del Rocío, Calle Manuel Siurot s/n, 41013, Sevilla, Spain
| | - Javier de la Rubia Comos
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Avda, Fernando Abril Martorell, 106, 46026, Valencia, Spain.,School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
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Goshua G, Bendapudi PK. Evidence-Based Minireview: Should caplacizumab be used routinely in unselected patients with immune thrombotic thrombocytopenic purpura? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:491-494. [PMID: 36485149 PMCID: PMC9820987 DOI: 10.1182/hematology.2022000412] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- George Goshua
- Section of Hematology, Yale University School of Medicine, New Haven, CT
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Pavan K Bendapudi
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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Pape LJ, Hambach J, Gebhardt AJ, Rissiek B, Stähler T, Tode N, Khan C, Weisel K, Adam G, Koch-Nolte F, Bannas P. CD38-specific nanobodies allow in vivo imaging of multiple myeloma under daratumumab therapy. Front Immunol 2022; 13:1010270. [PMID: 36389758 PMCID: PMC9647632 DOI: 10.3389/fimmu.2022.1010270] [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: 08/02/2022] [Accepted: 10/03/2022] [Indexed: 08/30/2023] Open
Abstract
RATIONALE Recent studies have demonstrated the feasibility of CD38-specific antibody constructs for in vivo imaging of multiple myeloma. However, detecting multiple myeloma in daratumumab-pretreated patients remains difficult due to overlapping binding epitopes of the CD38-specific imaging antibody constructs and daratumumab. Therefore, the development of an alternative antibody construct targeting an epitope of CD38 distinct from that of daratumumab is needed. We report the generation of a fluorochrome-conjugated nanobody recognizing such an epitope of CD38 to detect myeloma cells under daratumumab therapy in vitro, ex vivo, and in vivo. METHODS We conjugated the CD38-specific nanobody JK36 to the near-infrared fluorescent dye Alexa Fluor 680. The capacity of JK36AF680 to bind and detect CD38-expressing cells pretreated with daratumumab was evaluated on CD38-expressing tumor cell lines in vitro, on primary myeloma cells from human bone marrow biopsies ex vivo, and in a mouse tumor model in vivo. RESULTS Fluorochrome-labeled nanobody JK36AF680 showed specific binding to CD38-expressing myeloma cells pretreated with daratumumab in vitro and ex vivo and allowed for specific imaging of CD38-expressing xenografts in daratumumab-pretreated mice in vivo. CONCLUSIONS Our study demonstrates that a nanobody recognizing a distinct, non-overlapping epitope of CD38 allows the specific detection of myeloma cells under daratumumab therapy in vitro, ex vivo, and in vivo.
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Affiliation(s)
- Luca Julius Pape
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Hambach
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Josephine Gebhardt
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Rissiek
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Stähler
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Natalie Tode
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cerusch Khan
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katja Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friedrich Koch-Nolte
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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