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Liu Y, Li H, Hu C, Tan L, Yin P, Li Z, Zhou S, Su L. A real-world pharmacovigilance analysis for transthyretin inhibitors: findings from the FDA adverse event reporting database. Front Pharmacol 2024; 15:1368244. [PMID: 38873427 PMCID: PMC11169801 DOI: 10.3389/fphar.2024.1368244] [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: 01/10/2024] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
Objective The purpose of this study is to investigate the drug safety of three Transthyretin (TTR) inhibitors in the real world using the United States Food and Drug Administration Adverse Event Reporting System (FAERS) database. Methods This study extracted reports received by the FAERS database from the first quarter of 2018 to the third quarter of 2023 for descriptive analysis and disproportionality analysis. Safety signal mining was conducted at the Preferred Term (PT) level and the System Organ Class (SOC) level using reporting odds ratio (ROR). The characteristics of the time-to-onset curves were analyzed using the Weibull Shape Parameter (WSP). The cumulative incidence of TTR inhibitors was evaluated using the Kaplan-Meier method. Subgroup analyses were conducted based on whether the reporter was a medical professional. Results A total of 3,459 reports of adverse events (AEs) caused by TTR inhibitors as the primary suspect (PS) drug were extracted. The top three reported AEs for patisiran were fatigue, asthenia, and fall, with the most unexpectedly strong association being nonspecific reaction. The top three reported AEs for vutrisiran were fall, pain in extremity and malaise, with the most unexpectedly strong association being subdural haematoma. The top three reported AEs for inotersen were platelet count decreased, blood creatinine increased, and fatigue, with the most unexpectedly strong association being blood albumin decreased. Vitamin A decreased, arthralgia, and dyspnea were the same AEs mentioned in the drug labels of all three drugs, while malaise and asthenia were the same unexpected significant signals. This study offers evidence of the variability in the onset time characteristics of AEs associated with TTR inhibitors, as well as evidence of differences in adverse event reporting between medical professionals and non-medical professionals. Conclusion In summary, we compared the similarities and differences in drug safety of three TTR inhibitors in the real world using the FAERS database. The results indicate that not only do these three drugs share common AEs, but they also exhibit differences in drug safety profiles. This study contributes to enhancing the understanding of medical professionals regarding the safety of TTR inhibitors.
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Affiliation(s)
- Yuan Liu
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Hao Li
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Cheng Hu
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Tan
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Ping Yin
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zhihao Li
- Second Clinical College, Chongqing Medical University, Chongqing, China
| | - Shuangshan Zhou
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Su
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Carroll AS, Park SB, Lin CSY, Taylor MS, Kwok F, Simon NG, Reilly MM, Kiernan MC, Vucic S. Axonal excitability as an early biomarker of nerve involvement in hereditary transthyretin amyloidosis. Clin Neurophysiol 2024; 159:81-95. [PMID: 38377648 DOI: 10.1016/j.clinph.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/26/2023] [Accepted: 01/22/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVES The treatment of hereditary transthyretin amyloidosis polyneuropathy (ATTRv-PN) has been revolutionised by genetic therapies, with dramatic improvements in patient outcomes. Whilst the optimal timing of treatment initiation remains unknown, early treatment is desirable. Consequently, the aim of the study was to develop biomarkers of early nerve dysfunction in ATTRv-PN. METHODS Ulnar motor and sensory axonal excitability studies were prospectively undertaken on 22 patients with pathogenic hereditary transthyretin amyloid (ATTRv) gene variants, 12 with large fibre neuropathy (LF+) and 10 without (LF-), with results compared to age- and sex-matched healthy controls. RESULTS In motor axons we identified a continuum of change from healthy controls, to LF- and LF+ ATTRv with progressive reduction in hyperpolarising threshold electrotonus (TEh40(10-20 ms): p = 0.04, TEh40(20-40 ms): p = 0.01 and TEh40(90-10 ms): p = 0.01), suggestive of membrane depolarisation. In sensory axons lower levels of subexcitability were observed on single (SubEx) and double pulse (SubEx2) recovery cycle testing in LF+ (SubEx: p = 0.015, SubEx2: p = 0.015, RC(2-1): p = 0.04) suggesting reduced nodal slow potassium conductance, which promotes sensory hyperexcitability, paraesthesia and pain. There were no differences in sensory or motor excitability parameters when comparing different ATTRv variants. CONCLUSIONS These progressive changes seen across the disease spectrum in ATTRv-PN suggest that axonal excitability has utility to identify early and progressive nerve dysfunction in ATTRv, regardless of genotype. SIGNIFICANCE Axonal excitability is a promising early biomarker of nerve dysfunction in ATTRv-PN.
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Affiliation(s)
- Antonia S Carroll
- Brain and Mind Centre, Faculty of Medicine and Health, Translational Research Collective University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia; Westmead Amyloidosis Centre, Westmead Hospital, University of Sydney, Sydney, Australia; Centre for Neuromuscular Disease, Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK.
| | - Susanna B Park
- Brain and Mind Centre, Faculty of Medicine and Health, School of Medical Sciences, University of Sydney, Sydney, Australia
| | - Cindy S Y Lin
- Brain and Mind Centre, Faculty of Medicine and Health, Translational Research Collective University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark S Taylor
- Westmead Amyloidosis Centre, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Fiona Kwok
- Westmead Amyloidosis Centre, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Neil G Simon
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Mary M Reilly
- Centre for Neuromuscular Disease, Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London, UK
| | - Matthew C Kiernan
- Brain and Mind Centre, Faculty of Medicine and Health, Translational Research Collective University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Steve Vucic
- Brain and Nerve Centre, Concord Hospital, University of Sydney, Sydney, Australia
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3
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Poli L, Labella B, Cotti Piccinelli S, Caria F, Risi B, Damioli S, Padovani A, Filosto M. Hereditary transthyretin amyloidosis: a comprehensive review with a focus on peripheral neuropathy. Front Neurol 2023; 14:1242815. [PMID: 37869146 PMCID: PMC10585157 DOI: 10.3389/fneur.2023.1242815] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/11/2023] [Indexed: 10/24/2023] Open
Abstract
Amyloidoses represent a group of diseases characterized by the pathological accumulation in the extracellular area of insoluble misfolded protein material called "amyloid". The damage to the tissue organization and the direct toxicity of the amyloidogenic substrates induce progressive dysfunctions in the organs involved. They are usually multisystem diseases involving several vital organs, such as the peripheral nerves, heart, kidneys, gastrointestinal tract, liver, skin, and eyes. Transthyretin amyloidosis (ATTR) is related to abnormalities of transthyretin (TTR), a protein that acts as a transporter of thyroxine and retinol and is produced predominantly in the liver. ATTR is classified as hereditary (ATTRv) and wild type (ATTRwt). ATTRv is a severe systemic disease of adults caused by mutations in the TTR gene and transmitted in an autosomal dominant manner with incomplete penetrance. Some pathogenic variants in TTR are preferentially associated with a neurological phenotype (progressive peripheral sensorimotor polyneuropathy); others are more frequently associated with restrictive heart failure. However, many mutations express a mixed phenotype with neurological and cardiological involvement. ATTRv is now a treatable disease. A timely and definite diagnosis is essential in view of the availability of effective therapies that have revolutionized the management of affected patients. The purpose of this review is to familiarize the clinician with the disease and with the correct diagnostic pathways in order to obtain an early diagnosis and, consequently, the possibility of an adequate treatment.
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Affiliation(s)
- Loris Poli
- Unit of Neurology, Azienda Socio-Sanitaria Territoriale Spedali Civili, Brescia, Italy
| | - Beatrice Labella
- Unit of Neurology, Azienda Socio-Sanitaria Territoriale Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Stefano Cotti Piccinelli
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, Brescia, Italy
| | - Filomena Caria
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, Brescia, Italy
| | - Barbara Risi
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, Brescia, Italy
| | - Simona Damioli
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, Brescia, Italy
| | - Alessandro Padovani
- Unit of Neurology, Azienda Socio-Sanitaria Territoriale Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Massimiliano Filosto
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- NeMO-Brescia Clinical Center for Neuromuscular Diseases, Brescia, Italy
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4
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Basdavanos A, Maurer MS, Ives L, Derwin K, Ricchetti ET, Seitz W, Hanna M. Prevalence of Orthopedic Manifestations in Patients With Cardiac Amyloidosis With a Focus on Shoulder Pathologies. Am J Cardiol 2023; 190:67-74. [PMID: 36566619 DOI: 10.1016/j.amjcard.2022.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 10/17/2022] [Accepted: 11/04/2022] [Indexed: 12/24/2022]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is a restrictive cardiomyopathy that has been associated with multiple orthopedic pathologies years before it manifests in the heart. There have been no studies on the prevalence of a wide range of shoulder pathologies in patients with cardiac amyloidosis (CA). Due to the preferential deposition of transthyretin in the soft tissues and joints, we predicted a greater prevalence of shoulder pathologies and other orthopedic manifestations in patients with ATTR-CA. This single-center, retrospective, case-control study, analyzed 1,310 patients with CA, 830 with ATTR-CA, and 480 with light-chain CA (AL-CA) from a dedicated CA REDcap database. Odds ratios comparing patients with CA to the age-matched published estimate of over 300 million patients in the general population were determined for shoulder, hip, and knee arthroplasty. Years between a patient's first shoulder pathology (i.e., shoulder arthroplasty) and the year of their diagnosis with CA were determined using data from patients with a known date of surgery. Overall, patients with ATTR-CA compared with patients with AL-CA presented more frequently with shoulder pathologies (p <0.001) and at least 1 orthopedic manifestation (p <0.001). The odds of patients with ATTR-CA and AL-CA aged 60 years or older who underwent shoulder arthroplasty was 6.05 times greater (95% confidence interval 4.26 to 8.60) and 1.63 times greater (95% confidence interval 0.67 to 3.94), respectively, compared with age-matched controls. Shoulder pathologies and concomitant orthopedic pathologies are common in patients with ATTR-CA and may help identify patients with CA earlier in their disease progression for earlier intervention and treatment.
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Affiliation(s)
- Alyssa Basdavanos
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mathew S Maurer
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lauren Ives
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Kathleen Derwin
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Eric T Ricchetti
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
| | - William Seitz
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
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5
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Kaku MC, Bhadola S, Berk JL, Sanchorawala V, Connors LH, Lau KHV. Neurological manifestations of hereditary transthyretin amyloidosis: a focus on diagnostic delays. Amyloid 2022; 29:184-189. [PMID: 35253562 DOI: 10.1080/13506129.2022.2046557] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The recent availability of disease-modifying therapies for hereditary transthyretin amyloid (ATTRv) amyloidosis warrants urgency for earlier diagnosis and timely identification of active disease state among genetic carriers. METHODS We reviewed clinical neurological data of all patients with ATTRv amyloidosis with initial visits at our amyloidosis centre between January 2016 and December 2018. We abstracted the signs and symptoms of neurological manifestations, as well as rates and patterns of diagnostic testing. RESULTS Of 92 patients with 19 different transthyretin (TTR) mutations, 66 and 36% had symptoms attributed to large-fibre and small-fibre neuropathy, respectively, compared to 75 and 66% with corresponding examination findings. Thirty-six patients with V122I ATTR mutation had asymptomatic polyneuropathy identified on neurological examination, eight without concurrent cardiac disease. Seventy-three percent of patients had symptoms of carpal tunnel syndrome (CTS), while 26% had dysautonomia. The average delays between the onset of symptoms of large fibre neuropathy (LFN) or CTS to ATTRv amyloidosis diagnosis were 2.9 and 6.7 years, respectively. DISCUSSION Our study found higher rates of polyneuropathy by examination than patient-reported symptoms, especially among those with V122I TTR amyloidosis, signalling asymptomatic polyneuropathy. Our findings suggest the need for routine neurological examinations and other testing for genetic carriers to achieve earlier identification of active disease state.
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Affiliation(s)
- Michelle C Kaku
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA
| | - Shivkumar Bhadola
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA
| | - John L Berk
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA
| | | | - Lawreen H Connors
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA
| | - K H Vincent Lau
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, USA
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6
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Carroll A, Dyck PJ, de Carvalho M, Kennerson M, Reilly MM, Kiernan MC, Vucic S. Novel approaches to diagnosis and management of hereditary transthyretin amyloidosis. J Neurol Neurosurg Psychiatry 2022; 93:668-678. [PMID: 35256455 PMCID: PMC9148983 DOI: 10.1136/jnnp-2021-327909] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/12/2022] [Indexed: 12/27/2022]
Abstract
Hereditary transthyretin amyloidosis (ATTRv) is a severe, adult-onset autosomal dominant inherited systemic disease predominantly affecting the peripheral and autonomic nervous system, heart, kidney and the eyes. ATTRv is caused by mutations of the transthyretin (TTR) gene, leading to extracellular deposition of amyloid fibrils in multiple organs including the peripheral nervous system. Typically, the neuropathy associated with ATTRv is characterised by a rapidly progressive and disabling sensorimotor axonal neuropathy with early small-fibre involvement. Carpal tunnel syndrome and cardiac dysfunction frequently coexist as part of the ATTRv phenotype. Although awareness of ATTRv polyneuropathy among neurologists has increased, the rate of misdiagnosis remains high, resulting in significant diagnostic delays and accrued disability. A timely and definitive diagnosis is important, given the emergence of effective therapies which have revolutionised the management of transthyretin amyloidosis. TTR protein stabilisers diflunisal and tafamidis can delay the progression of the disease, if treated early in the course. Additionally, TTR gene silencing medications, patisiran and inotersen, have resulted in up to 80% reduction in TTR production, leading to stabilisation or slight improvement of peripheral neuropathy and cardiac dysfunction, as well as improvement in quality of life and functional outcomes. The considerable therapeutic advances have raised additional challenges, including optimisation of diagnostic techniques and management approaches in ATTRv neuropathy. This review highlights the key advances in the diagnostic techniques, current and emerging management strategies, and biomarker development for disease progression in ATTRv.
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Affiliation(s)
- Antonia Carroll
- Brain and Mind Centre, Faculty of Medicine and Health, Translational Research Collective, University of Sydney and Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - P James Dyck
- Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mamede de Carvalho
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisboa, Portugal
| | - Marina Kennerson
- Northcott Neuroscience Laboratory, ANZAC Research Institute, Molecular Medicine Laboratory Concord Repatriation General Hospital, and Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mary M Reilly
- MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, London, UK
| | - Matthew C Kiernan
- Bushell Chair of Neurology, Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia.,Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Steve Vucic
- Brain and Nerve Research Center, Concord Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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7
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Huda A, Castaño A, Niyogi A, Schumacher J, Stewart M, Bruno M, Hu M, Ahmad FS, Deo RC, Shah SJ. A machine learning model for identifying patients at risk for wild-type transthyretin amyloid cardiomyopathy. Nat Commun 2021; 12:2725. [PMID: 33976166 PMCID: PMC8113237 DOI: 10.1038/s41467-021-22876-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 03/31/2021] [Indexed: 12/21/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy, an often unrecognized cause of heart failure, is now treatable with a transthyretin stabilizer. It is therefore important to identify at-risk patients who can undergo targeted testing for earlier diagnosis and treatment, prior to the development of irreversible heart failure. Here we show that a random forest machine learning model can identify potential wild-type transthyretin amyloid cardiomyopathy using medical claims data. We derive a machine learning model in 1071 cases and 1071 non-amyloid heart failure controls and validate the model in three nationally representative cohorts (9412 cases, 9412 matched controls), and a large, single-center electronic health record-based cohort (261 cases, 39393 controls). We show that the machine learning model performs well in identifying patients with cardiac amyloidosis in the derivation cohort and all four validation cohorts, thereby providing a systematic framework to increase the suspicion of transthyretin cardiac amyloidosis in patients with heart failure.
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Affiliation(s)
| | | | | | | | | | | | - Mo Hu
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Faraz S Ahmad
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rahul C Deo
- Brigham and Women's Hospital, Boston, MA, USA
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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8
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Russo M, Obici L, Bartolomei I, Cappelli F, Luigetti M, Fenu S, Cavallaro T, Chiappini MG, Gemelli C, Pradotto LG, Manganelli F, Leonardi L, My F, Sampaolo S, Briani C, Gentile L, Stancanelli C, Di Buduo E, Pacciolla P, Salvi F, Casagrande S, Bisogni G, Calabrese D, Vanoli F, Di Iorio G, Antonini G, Santoro L, Mauro A, Grandis M, Di Girolamo M, Fabrizi GM, Pareyson D, Sabatelli M, Perfetto F, Rapezzi C, Merlini G, Mazzeo A, Vita G. ATTRv amyloidosis Italian Registry: clinical and epidemiological data. Amyloid 2020; 27:259-265. [PMID: 32696671 DOI: 10.1080/13506129.2020.1794807] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION ATTRv amyloidosis is worldwide spread with endemic foci in Portugal and Sweden, Japan, Brazil, Maiorca, and Cyprus. A national Registry was developed to characterise the epidemiology and genotype-phenotype correlation of ATTRv amyloidosis in Italy and to allow a better planning of diagnostic and therapeutic services. METHODS Fifteen Italian referral centres for amyloidosis spread all over the country have contributed to the Registry. RESULTS Four-hundred-forty-seven subjects were enrolled, 187 asymptomatic carriers and 260 affected patients. Thirty-one different mutations were recorded. The seven most represented genetic variants were significantly different in terms of age at onset, clinical features and geographical distribution. National prevalence is 4.33/million with higher values in Southern Italy. Overall symptoms of polyneuropathy were present at disease onset in about half of the patients, symptoms of cardiomyopathy in a quarter of patients, the rest referring carpal tunnel syndrome, dysautonomia or lumbar spinal stenosis. 52.6% of patients were in FAP stage 1, 20.4% in stage 2 and 13.5% in stage 3, while 13.5% patients had no neuropathy, presenting only cardiological symptoms. CONCLUSIONS We presented an epidemiological study based on collaboration among referral centres for ATTRv amyloidosis spread in all the Italian territory, using web-based Registry. It provided a detailed map of the regional distribution of the disease. The increased awareness of the disease among general practitioners and medical specialists has contributed to reduce the diagnostic delay and the rate of misdiagnosis. The Registry will allow to collect also future information about clinical and instrumental follow-up.
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Affiliation(s)
- Massimo Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Laura Obici
- IRCCS Fondazione Policlinico San Matteo, University of Pavia, Amyloidosis Research and Treatment Center, Pavia, Italy
| | | | - Francesco Cappelli
- Department of Internal and Experimental Medicine, University of Florence, Florence, Italy
| | - Marco Luigetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS. UOC Neurologia, Rome, Italy
| | - Silvia Fenu
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Tiziana Cavallaro
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Maria Grazia Chiappini
- Fatebenefratelli Foundation-'San Giovanni Calibita' Fatebenefratelli Hospital, Clinical Pathophysiology Center, Rome, Italy
| | - Chiara Gemelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Luca Guglielmo Pradotto
- San Giuseppe Hospital, IRCCS-Istituto Auxologico Italiano, Division of Neurology and Neurorehabilitation, Piancavallo, Italy.,Department of Neuroscience, University of Turin, Turin, Italy
| | - Fiore Manganelli
- Department of Neurosciences Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Luca Leonardi
- Unit of Neuromuscular Diseases, Department of Neurology, Mental Health and Sensory Organs (NESMOS), Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Filomena My
- Division of Neurology, Ospedale V. Fazzi, Lecce, Italy
| | - Simone Sampaolo
- Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Chiara Briani
- Department of Neuroscience, Neurology Unit, University of Padova School of Medicine and Surgery, Padova, Italy
| | - Luca Gentile
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Claudia Stancanelli
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Eleonora Di Buduo
- IRCCS Fondazione Policlinico San Matteo, University of Pavia, Amyloidosis Research and Treatment Center, Pavia, Italy
| | - Paolo Pacciolla
- IRCCS Fondazione Policlinico San Matteo, University of Pavia, Amyloidosis Research and Treatment Center, Pavia, Italy
| | - Fabrizio Salvi
- Amyloidosis Centre, University of Bologna, Bologna, Italy
| | - Silvia Casagrande
- Department of Internal and Experimental Medicine, University of Florence, Florence, Italy
| | | | | | - Fiammetta Vanoli
- Unit of Neuromuscular Diseases, Department of Neurology, Mental Health and Sensory Organs (NESMOS), Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Giuseppe Di Iorio
- Second Division of Neurology, Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Giovanni Antonini
- Unit of Neuromuscular Diseases, Department of Neurology, Mental Health and Sensory Organs (NESMOS), Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | - Lucio Santoro
- Department of Neurosciences Reproductive and Odontostomatological Sciences, University Federico II, Naples, Italy
| | - Alessandro Mauro
- San Giuseppe Hospital, IRCCS-Istituto Auxologico Italiano, Division of Neurology and Neurorehabilitation, Piancavallo, Italy.,Department of Neuroscience, University of Turin, Turin, Italy
| | - Marina Grandis
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Marco Di Girolamo
- Fatebenefratelli Foundation-'San Giovanni Calibita' Fatebenefratelli Hospital, Clinical Pathophysiology Center, Rome, Italy
| | - Gian Maria Fabrizi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Davide Pareyson
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mario Sabatelli
- Fondazione Policlinico Universitario A. Gemelli IRCCS. UOC Neurologia, Rome, Italy
| | - Federico Perfetto
- Department of Internal and Experimental Medicine, University of Florence, Florence, Italy
| | - Claudio Rapezzi
- Department of Cardiology, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital GVM, Care and Research, Cotignola, Italy
| | - Giampaolo Merlini
- IRCCS Fondazione Policlinico San Matteo, University of Pavia, Amyloidosis Research and Treatment Center, Pavia, Italy
| | - Anna Mazzeo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppe Vita
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Abstract
IMPORTANCE Many patients with systemic amyloidosis are underdiagnosed. Overall, 25% of patients with immunoglobulin light chain (AL) amyloidosis die within 6 months of diagnosis and 25% of patients with amyloid transthyretin (ATTR) amyloidosis die within 24 months of diagnosis. Effective therapy exists but is ineffective if end-organ damage is severe. OBJECTIVE To provide evidence-based recommendations that could allow clinicians to diagnose this rare set of diseases earlier and enable accurate staging and counseling about prognosis. EVIDENCE REVIEW A comprehensive literature search was conducted by a reference librarian with publication dates from January 1, 2000, to December 31, 2019. Key search terms included amyloid, amyloidosis, nephrotic syndrome, heart failure preserved ejection fraction, and peripheral neuropathy. Exclusion criteria included case reports, non-English-language text, and case series of fewer than 10 patients. The authors independently selected and appraised relevant literature. FINDINGS There was a total of 1769 studies in the final data set. Eighty-one articles were included in this review, of which 12 were randomized clinical trials of therapy that included 3074 patients, 9 were case series, and 3 were cohort studies. The incidence of AL amyloidosis is approximately 12 cases per million persons per year and there is an estimated prevalence of 30 000 to 45 000 cases in the US and European Union. The incidence of variant ATTR amyloidosis is estimated to be 0.3 cases per year per million persons with a prevalence estimate of 5.2 cases per million persons. Wild-type ATTR is estimated to have a prevalence of 155 to 191 cases per million persons. Amyloidosis should be considered in the differential diagnosis of adult nondiabetic nephrotic syndrome; heart failure with preserved ejection fraction, particularly if restrictive features are present; unexplained hepatomegaly without imaging abnormalities; peripheral neuropathy with distal sensory symptoms, such as numbness, paresthesia, and dysesthesias (although the autonomic manifestations occasionally may be the presenting feature); and monoclonal gammopathy of undetermined significance with atypical clinical features. Staging can be performed using blood testing only. Therapeutic decision-making for AL amyloidosis involves choosing between high-dose chemotherapy and stem cell transplant or bortezomib-based chemotherapy. There are 3 therapies approved by the US Food and Drug Administration for managing ATTR amyloidosis, depending on clinical phenotype. CONCLUSIONS AND RELEVANCE All forms of amyloidosis are underdiagnosed. All forms now have approved therapies that have been demonstrated to improve either survival or disability and quality of life. The diagnosis should be considered in patients that have a multisystem disorder involving the heart, kidney, liver, or nervous system.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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De Lillo A, De Angelis F, Di Girolamo M, Luigetti M, Frusconi S, Manfellotto D, Fuciarelli M, Polimanti R. Phenome-wide association study of TTR and RBP4 genes in 361,194 individuals reveals novel insights in the genetics of hereditary and wildtype transthyretin amyloidoses. Hum Genet 2019; 138:1331-1340. [DOI: 10.1007/s00439-019-02078-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/22/2019] [Indexed: 12/30/2022]
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