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Loser V, Baumgartner T, Legardeur H, Panchaud A, Théaudin M. Patisiran exposure in early pregnancy: a case report. Ther Adv Neurol Disord 2024; 17:17562864241239755. [PMID: 38532802 PMCID: PMC10964446 DOI: 10.1177/17562864241239755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/28/2024] [Indexed: 03/28/2024] Open
Abstract
We describe here the first case of exposure to patisiran treatment, a small interfering RNA molecule, during early pregnancy of a 36-year-old woman with symptomatic hereditary transthyretin-related amyloidosis. There were no major complications during pregnancy and delivery, except for a postpartum hemorrhage due to uterine atony. Vitamin A levels had to be closely monitored during pregnancy, and vitamin A substitution adapted accordingly. There was no sign of minor or major congenital abnormalities of the baby. One month after delivery, the patient showed slight clinical and electrophysiological signs of neuropathy progression due to patisiran treatment withdrawal. Patisiran infusions were resumed 3 months after delivery. Due to the unknown teratogenic potential of patisiran, the risk of neuropathy worsening associated with withholding treatment must of course be weighed against a potential teratogenic risk of treatment during pregnancy. Vitamin A levels need to be closely assessed, and substitution must be adapted accordingly, to avoid embryofetal adverse outcome due to vitamin A deficiency or toxicity.
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Affiliation(s)
- Valentin Loser
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Rue du Bugnon 44, Lausanne 1011, Switzerland
| | - Thomas Baumgartner
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Hélène Legardeur
- Woman–Mother–Child Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Marie Théaudin
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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De Bleecker JL, Claeys KG, Delstanche S, Van Parys V, Baets J, Tilleux S, Remiche G. A retrospective survey of patients with hereditary transthyretin-mediated ( hATTR) amyloidosis treated with patisiran in real-world clinical practice in Belgium. Acta Neurol Belg 2023. [PMID: 36829087 DOI: 10.1007/s13760-023-02188-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 01/16/2023] [Indexed: 02/26/2023]
Abstract
INTRODUCTION Hereditary transthyretin-mediated (hATTR) amyloidosis, a genetic disease caused by mutations in the transthyretin gene, leads to progressive sensory and autonomic neuropathy and/or cardiomyopathy and is associated with renal and ophthalmologic manifestations and a poor prognosis. METHODS This is a retrospective study based on data collected from the medical records of patients with hATTR amyloidosis treated with patisiran between 01 July 2018 and 01 February 2021. Six Belgian neuromuscular reference centers participated, covering all patisiran-treated hATTR amyloidosis patients at the study time. This study was conducted to collect data requested in the context of the reimbursement of patisiran in Belgium. RESULTS Thirty-one patients were diagnosed with hATTR amyloidosis with polyneuropathy, Coutinho stage 1 or 2, and eligible for active treatment during the data collection period. Of the hATTR amyloidosis patients treated with patisiran (n = 12), seven and five had polyneuropathy stages 1 and 2, respectively. Six patients had cardiac symptoms (New York Heart Association class 2 or above). Follow-up information was available for nine patients. Following patisiran treatment, eight patients showed stable or improved assessments for most neurological or cardiological parameters. Only one patient presented with worsening statuses at the end of the data collection period. CONCLUSIONS The patients with hATTR amyloidosis in Belgium have similar baseline demographics and disease characteristics to those studied in the patisiran APOLLO study and show a similar therapeutic response in the real-world, altering the expected disease progression in most patients.
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Vieira R, Marta A, Ferreira A, Figueiredo A, Reis RF, Sampaio I, Menéres MJ. Modified Technique of Ex-PRESS ® Filtration Device Combined with a Scleral Pocket for Hereditary Transthyretin Amyloidosis ( hATTR) Secondary Open-Angle Glaucoma. Clin Ophthalmol 2023; 17:403-411. [PMID: 36748048 PMCID: PMC9899011 DOI: 10.2147/opth.s394360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/14/2022] [Indexed: 02/04/2023] Open
Abstract
Purpose To evaluate the effectiveness and safety of a modified approach using the Ex-PRESS® implant combined with a scleral pocket in the management of secondary open-angle glaucoma in hereditary transthyretin amyloidosis (hATTR) at our department. Methods This was a retrospective analysis. The primary endpoints included Intraocular pressure (IOP) evaluation (baseline, 1st day, 1st week, 1, 3, 6, 12 months and at last follow-up) and number of hypotensive drugs (baseline, 6th, 12th months and at last follow-up). As secondary endpoints surgical complications, the need for additional glaucoma surgery and LogMAR BCVA were evaluated. Qualified and complete success were defined as ≥ 30% IOP decrease from baseline, with or without additional medications, respectively. The minimum follow-up was 12 months. Results A total of 32 eyes were included with a mean follow-up of 2.4±2.9 years. IOP decreased significantly from baseline (27.4±4.4 mmHg) to 1st day (5.00±2.9 mmHg), 1st week (6.9±4.1 mmHg), 1st month (11.7±7.8 mmHg), 3rd month (11.6±6.1 mmHg), 6th month (13.1±6.8 mmHg), 12th month (12.0±3.5 mmHg) and last visit (11.8±2.4 mmHg), p<0.001. There was also a significant reduction in the number of antiglaucoma medications from baseline (3.8±0.6) and last follow-up (0.4±0.8), p<0.001. LogMAR BCVA remained stable (0.25±0.26 at baseline and 0.25±0.24 at last follow-up), p=0.767. Transient hypotony occurred in 17 eyes (53.1%), but only 11 (34.4%) exhibited anterior chamber shallowing and needed additional care, namely cycloplegic drops and viscoelastic injection. Complete surgical success was achieved in 22 eyes (68.8%) and qualified success in 6 eyes (18.8%). Four eyes (12.5%) needed additional glaucoma surgery. Conclusion The modified ExPRESS® technique appears to be effective, especially when low levels of IOP are required. Additionally, fewer anti-glaucoma drugs were necessary. In the other hand, hypotony was a common side effect with this procedure, although all patients were properly handled, preserving the surgical outcomes.
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Affiliation(s)
- Rita Vieira
- Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto), Oporto, Portugal,Correspondence: Rita Vieira, Ophthalmology Department, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, Porto, 4099-001, Portugal, Tel +351913748812, Email
| | - Ana Marta
- Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto), Oporto, Portugal,Ophthalmology Teaching Department, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Oporto, Portugal
| | - André Ferreira
- Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto), Oporto, Portugal,Anamoty Department of Faculdade de Medicina da Universidade do Porto (FMUP), Oporto, Portugal
| | - Ana Figueiredo
- Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto), Oporto, Portugal
| | - Rita Falcão Reis
- Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto), Oporto, Portugal
| | - Isabel Sampaio
- Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto), Oporto, Portugal
| | - Maria João Menéres
- Ophthalmology Department of Centro Hospitalar Universitário do Porto (CHUPorto), Oporto, Portugal,Ophthalmology Teaching Department, Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Oporto, Portugal
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Silva-Hernández L, Horga Hernández A, Valls Carbó A, Guerrero Sola A, Montalvo-Moraleda MT, Galán Dávila L. Red flags in patients with hereditary transthyretin amyloidosis at diagnosis in a non-endemic area of Spain. Neurologia 2022:S2173-5808(22)00170-5. [PMID: 36396096 DOI: 10.1016/j.nrleng.2020.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/12/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Hereditary transthyretin (hATTR) amyloidosis with polyneuropathy is a rare multisystemic disease characterised by onset during adulthood and associated with poor prognosis if untreated. A set of signs and symptoms, commonly known as "red flags," have been proposed to assist in early detection of the disease; presence of red flags may suggest underlying hATTR amyloidosis in patients with progressive sensorimotor polyneuropathy. MATERIAL AND METHODS We analysed the frequency of red flags at the time of diagnosis in 30 patients with hATTR amyloidosis in a non-endemic area of Spain; onset was late in the majority of patients. RESULTS The frequencies of the red flags were as follows: bilateral carpal tunnel syndrome in 15 patients (50%), early autonomic dysfunction in 17 (56%), gastrointestinal problems in 14 (46.6%), unexplained weight loss in 8 (26.6%), heart disease in 12 (40%), asymptomatic cardiac findings in 13 (43.3%), kidney disease in one (3.3%), vitreous opacities in none, family history of neuropathy in 21 (70%), family history of heart disease in 15 (50%), and family history of gastrointestinal problems in 3 (10%). All patients presented at least one red flag at diagnosis, with a median of 4 red flags. CONCLUSION Red flags were common at the time of diagnosis, even in patients with late-onset hATTR amyloidosis. Presence of red flags in a patient with symmetrical sensorimotor polyneuropathy should serve as a warning sign, and lead to targeted diagnosis to rule out hATTR amyloidosis, independently of age of onset.
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Razvi Y, Patel RK, Fontana M, Gillmore JD. Cardiac Amyloidosis: A Review of Current Imaging Techniques. Front Cardiovasc Med 2021; 8:751293. [PMID: 34957240 PMCID: PMC8702802 DOI: 10.3389/fcvm.2021.751293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/11/2021] [Indexed: 12/15/2022] Open
Abstract
Systemic amyloidosis is a rare, heterogenous group of diseases characterized by extracellular infiltration and deposition of amyloid fibrils. Cardiac amyloidosis (CA) occurs when these fibrils deposit within the myocardium. Untreated, this inevitably leads to progressive heart failure and fatality. Historically, treatment has remained supportive, however, there are now targeted disease-modifying therapeutics available to patients with CA. Advances in echocardiography, cardiac magnetic resonance (CMR) and repurposed bone scintigraphy have led to a surge in diagnoses of CA and diagnosis at an earlier stage of the disease natural history. CMR has inherent advantages in tissue characterization which has allowed us to better understand the pathological disease process behind CA. Combined with specialist assessment and repurposed bone scintigraphy, diagnosis of CA can be made without the need for invasive histology in a significant proportion of patients. With existing targeted therapeutics, and novel agents being developed, understanding these imaging modalities is crucial to achieving early diagnosis for patients with CA. This will allow for early treatment intervention, accurate monitoring of disease course over time, and thereby improve the length and quality of life of patients with a disease that historically had an extremely poor prognosis. In this review, we discuss key radiological features of CA, focusing on the two most common types; immunoglobulin light chain (AL) and transthyretin (ATTR) CA. We highlight recent advances in imaging techniques particularly in respect of their clinical application and utility in diagnosis of CA as well as for tracking disease change over time.
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Affiliation(s)
- Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Rishi K Patel
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
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Minutoli F, Di Bella G, Mazzeo A, Laudicella R, Gentile L, Russo M, Vita G, Baldari S. Serial scanning with 99mTc-3, 3-diphosphono-1, 2-propanodicarboxylic acid ( 99mTc-DPD) for early detection of cardiac amyloid deposition and prediction of clinical worsening in subjects carrying a transthyretin gene mutation. J Nucl Cardiol 2021; 28:1949-1957. [PMID: 31741327 DOI: 10.1007/s12350-019-01950-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/07/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND To determine the capability of 99mTc-DPD scintigraphy to detect early cardiac involvement and predict clinical worsening in transthyretin (TTR) gene mutation patients. METHODS Eleven mutated subjects with normal interventricular septum (IVS) thickness, NT-proBNP level and no cardiac symptoms underwent three seriate 99mTc-DPD scans (visually and semiquantitatively analyzed), and was followed-up for 5-8-years. RESULTS Six patients showed no myocardial accumulation in all scans. Increased IVS thickness occurring in one patient 4 years after the last scan was the only abnormal finding in these patients; no cardiac symptoms developed during the follow-up. In three patients, cardiac radiotracer uptake was found at enrollment; other laboratory/instrumental abnormal findings occurred later and cardiac symptoms developed during the follow-up period. Two patients had a negative 99mTc-DPD scan at enrollment and showed cardiac uptake in the following scans. Increased mean left-ventricular (LV) wall thickness was found 3 years after positive scintigraphy; NT-proBNP increased later in one patient. These patients developed cardiac symptoms during the follow-up period. CONCLUSIONS 99mTc-DPD scan detects cardiac involvement in subjects with TTR gene mutation earlier than ECG, echocardiography and biochemical markers, occurring some years before the fulfillment of current diagnostic criteria for cardiac amyloidosis. A positive 99mTc-DPD scan predicts cardiac symptoms onset.
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Affiliation(s)
- F Minutoli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - G Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - A Mazzeo
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - R Laudicella
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy.
| | - L Gentile
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - M Russo
- Nemo Sud Clinical Centre, University Hospital "G. Martino", Messina, Italy
| | - G Vita
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - S Baldari
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
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Kleefeld F, Knebel F, Eurich D, Schatka I, Blüthner E, Schönfeld S, Amthauer H, Hahn K. Familial Oculo-Leptomeningeal Transthyretin Amyloidosis Caused by Leu55Arg Mutation. J Neuromuscul Dis 2021; 7:515-519. [PMID: 32741838 DOI: 10.3233/jnd-200542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Hereditary transthyretin amyloidosis (hATTR amyloidosis) is a multisystemic disease usually presenting in a mixed neurological and cardiological phenotype. We present a case of hATTR amyloidosis associated with Leu55Arg mutation causing a form of familial oculo-leptomeningeal amyloidosis. Two brothers and their mother presented with severe autonomic neuropathy, loss of visual acuity and lepto-meningeal involvement. One patient suffered subarachnoid hemorrhage as a possible complication of cerebral involvement. The patients suffered from treatment-refractory weight loss and recurring vitreous opacities. RNA interference-based treatment has led to stabilization of autonomic and peripheral neuropathy but has had no effect on ocular symptoms.
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Affiliation(s)
- Felix Kleefeld
- Amyloidosis Center Charité Berlin (ACCB), Charité-Universitätsmedizin Berlininstitution>, Charitéplatz 1, Berlin, Germany
| | - Fabian Knebel
- Amyloidosis Center Charité Berlin (ACCB), Charité-Universitätsmedizin Berlininstitution>, Charitéplatz 1, Berlin, Germany
| | - Dennis Eurich
- Amyloidosis Center Charité Berlin (ACCB), Charité-Universitätsmedizin Berlininstitution>, Charitéplatz 1, Berlin, Germany
| | - Imke Schatka
- Amyloidosis Center Charité Berlin (ACCB), Charité-Universitätsmedizin Berlininstitution>, Charitéplatz 1, Berlin, Germany
| | - Elisabeth Blüthner
- Amyloidosis Center Charité Berlin (ACCB), Charité-Universitätsmedizin Berlininstitution>, Charitéplatz 1, Berlin, Germany
| | - Shideh Schönfeld
- Amyloidosis Center Charité Berlin (ACCB), Charité-Universitätsmedizin Berlininstitution>, Charitéplatz 1, Berlin, Germany
| | - Holger Amthauer
- Amyloidosis Center Charité Berlin (ACCB), Charité-Universitätsmedizin Berlininstitution>, Charitéplatz 1, Berlin, Germany
| | - Katrin Hahn
- Amyloidosis Center Charité Berlin (ACCB), Charité-Universitätsmedizin Berlininstitution>, Charitéplatz 1, Berlin, Germany
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Gentile L, Russo M, Luigetti M, Bisogni G, Di Paolantonio A, Romano A, Guglielmino V, Arimatea I, Sabatelli M, Toscano A, Vita G, Mazzeo A. Patisiran in hATTR Amyloidosis: Six-Month Latency Period before Efficacy. Brain Sci 2021; 11:515. [PMID: 33921571 DOI: 10.3390/brainsci11040515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 01/29/2023] Open
Abstract
Hereditary amyloidosis associated with mutations in the transthyretin gene (hATTR) is a progressive devastating disease, with a fatal outcome occurring within 10years after onset. In recent years, TTR gene silencing therapy appeared as a promising therapeutic strategy, showing evidence that disease progression can be slowed and perhaps reversed. We report here 18 subjects affected by hATTR amyloidosis treated with patisiran, a small interfering RNA acting as TTR silencer, and evaluated with a PND score, the NIS and NIS-LL scale, and a Norfolk QOL-DN questionnaire at baseline and then every 6 months. A global clinical stabilizationwas observed for the majority of the patients, with mild-moderate improvements in some cases, even in advanced disease stage (PND score > 2). Analysis of NIS, NIS-LL and Norfolk QOL-DN results, and PND score variation suggest the possible presence of a 6-month latency period prior to benefit of treatment.
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Iannazzo S. A comparative analysis of international health technology assessments for novel gene silencing therapies: patisiran and inotersen. Glob Reg Health Technol Assess 2021; 8:14-21. [PMID: 36627862 DOI: 10.33393/grhta.2021.2193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/08/2021] [Indexed: 01/13/2023] Open
Abstract
Objectives Using the case study of patisiran and inotersen, we conducted a narrative comparative analysis of the health technology assessment (HTA) agency appraisals of these two first-in-class transthyretin gene silencers, which represent exceptional advances in the treatment of hereditary transthyretin-mediated (hATTR) amyloidosis, a rare and multisystemic disease. Despite the impact of each product on the treatment landscape, the majority of HTAs are only considered standard of care as a comparator, resulting in a void of information and limited comprehension of the clinical and pharmacoeconomic differences between the two treatments. Methods A search was conducted internationally for HTA reports, and only instances where assessment decisions for both treatments were publicly available were included in the present analysis. The HTA reports were analyzed broadly for the assessment of clinical and pharmacoeconomic evidence. Only economic models considering both patisiran and inotersen were included in this analysis. Results A total of nine agencies with public assessment reports for both treatments were identified. HTA agency assessments for both treatments were essentially positive; however, differences were noted in the final recommendations, place in treatment or reimbursed indications, and in the narrative of the evaluations. Only the Canadian Agency for Drugs and Technologies in Health (CADTH) assessment for patisiran evaluated an economic model comparing the two treatments. Conclusions The differences summarized in this comparative analysis may provide a more comprehensive overview of the two treatments.
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Alcantara M, Mezei MM, Baker SK, Breiner A, Dhawan P, Fiander A, Fine NM, Hahn C, Katzberg HD, Khayambashi S, Massie R, Matte G, Putko B, Siddiqi Z, Delgado D, Bril V. Canadian Guidelines for Hereditary Transthyretin Amyloidosis Polyneuropathy Management. Can J Neurol Sci 2021;:1-12. [PMID: 33631091 DOI: 10.1017/cjn.2021.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hereditary transthyretin-mediated (hATTR) amyloidosis is a progressive disease caused by mutations in the TTR gene leading to multisystem organ dysfunction. Pathogenic TTR aggregation, misfolding, and fibrillization lead to deposition of amyloid in multiple body organs and frequently involve the peripheral nerve system and the heart. Common neurologic manifestations include: sensorimotor polyneuropathy (PN), autonomic neuropathy, small-fiber PN, and carpal tunnel syndrome. Many patients have significant progression due to diagnostic delays as hATTR PN is not considered within the differential diagnosis. Recently, two effective novel disease-modifying therapies, inotersen and patisiran, were approved by Health Canada for the treatment of hATTR PN. Early diagnosis is crucial for the timely introduction of these disease-modifying treatments that reduce impairments, improve quality of life, and extend survival. In this guideline, we aim to improve awareness and outcomes of hATTR PN by making recommendations directed to the diagnosis, monitoring, and treatment in Canada.
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Nativi-Nicolau JN, Karam C, Khella S, Maurer MS. Screening for ATTR amyloidosis in the clinic: overlapping disorders, misdiagnosis, and multiorgan awareness. Heart Fail Rev 2021; 27:785-793. [PMID: 33609196 PMCID: PMC9033715 DOI: 10.1007/s10741-021-10080-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 01/09/2023]
Abstract
Amyloid transthyretin (ATTR) amyloidosis is a clinically heterogeneous and fatal disease that results from deposition of insoluble amyloid fibrils in various organs and tissues, causing progressive loss of function. The objective of this review is to increase awareness and diagnosis of ATTR amyloidosis by improving recognition of its overlapping conditions, misdiagnosis, and multiorgan presentation. Cardiac manifestations include heart failure, atrial fibrillation, intolerance to previously prescribed antihypertensives, sinus node dysfunction, and atrioventricular block, resulting in the need for permanent pacing. Neurologic manifestations include progressive sensorimotor neuropathy (e.g., pain, weakness) and autonomic dysfunction (e.g., erectile dysfunction, chronic diarrhea, orthostatic hypotension). Non-cardiac red flags often precede the diagnosis of ATTR amyloidosis and include musculoskeletal manifestations (e.g., carpal tunnel syndrome, lumbar spinal stenosis, spontaneous rupture of the distal tendon biceps, shoulder and knee surgery). Awareness and recognition of the constellation of symptoms, including cardiac, neurologic, and musculoskeletal manifestations, will help with early diagnosis of ATTR amyloidosis and faster access to therapies, thereby slowing the progression of this debilitating disease.
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Affiliation(s)
- Jose N Nativi-Nicolau
- Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, USA.
| | - Chafic Karam
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Sami Khella
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mathew S Maurer
- Department of Medicine, Columbia University, New York, NY, USA
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Marques JH, Malheiro L, Malheiro J, Oliveira L, Menéres MJ, Beirão JM. Pupillometry: An objective test to assess endocular hereditary transthyretin amyloidosis. Eur J Ophthalmol 2021; 32:637-642. [PMID: 33601896 DOI: 10.1177/1120672121997294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To automatically study the pupillary light reflex in patients with hereditary transthyretin-associated amyloidosis (hATTR). METHODS Prospective cross-sectional observational study in patients with hATTR with unilateral scalloped iris. Pupillary light reflex of scalloped iris eyes (21 eyes) were compared with non-scalloped iris eyes (21 eyes, paired eyes of the same patients) and also with a control group of 20 healthy eyes, using static and dynamic pupillometry with the Metrovision® MonPack One. RESULTS No patient presented evident neurological involvment of the cranial nerves. No significant differences were found in the pupillary diameters under standardized lighting conditions (static pupillometry) among groups. In dynamic pupillometry, the amplitude of contraction, the velocity of contraction and the velocity of dilation were statistically significantly lower in eyes with scalloped iris, comparing both with the contralateral non-scalloped iris eyes (p < 0.001 for all) and with eyes from healthy subjects (p < 0.05 for all). CONCLUSION A scalloped iris reflects a more advanced endocular hATTR and it is associated with an altered pupillary light reflex. Pupillometry may be a quick, simple, and portable test to objectively evaluate ocular amyloid deposition in hATTR eyes. Pupillary light reflex may not be reliable to evaluate neurological dysfunction in these patients.
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Affiliation(s)
- João Heitor Marques
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Luísa Malheiro
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Jorge Malheiro
- Nephrology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Luís Oliveira
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria João Menéres
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - João Melo Beirão
- Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
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De Lillo A, Pathak GA, De Angelis F, Di Girolamo M, Luigetti M, Sabatelli M, Perfetto F, Frusconi S, Manfellotto D, Fuciarelli M, Polimanti R. Epigenetic profiling of Italian patients identified methylation sites associated with hereditary transthyretin amyloidosis. Clin Epigenetics 2020; 12:176. [PMID: 33203445 PMCID: PMC7672937 DOI: 10.1186/s13148-020-00967-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/03/2020] [Indexed: 11/10/2022] Open
Abstract
Hereditary transthyretin (TTR) amyloidosis (hATTR) is a rare life-threatening disorder caused by amyloidogenic coding mutations located in TTR gene. To understand the high phenotypic variability observed among carriers of TTR disease-causing mutations, we conducted an epigenome-wide association study (EWAS) assessing more than 700,000 methylation sites and testing epigenetic difference of TTR coding mutation carriers vs. non-carriers. We observed a significant methylation change at cg09097335 site located in Beta-secretase 2 (BACE2) gene (standardized regression coefficient = -0.60, p = 6.26 × 10-8). This gene is involved in a protein interaction network enriched for biological processes and molecular pathways related to amyloid-beta metabolism (Gene Ontology: 0050435, q = 0.007), amyloid fiber formation (Reactome HSA-977225, q = 0.008), and Alzheimer's disease (KEGG hsa05010, q = 2.2 × 10-4). Additionally, TTR and BACE2 share APP (amyloid-beta precursor protein) as a validated protein interactor. Within TTR gene region, we observed that Val30Met disrupts a methylation site, cg13139646, causing a drastic hypomethylation in carriers of this amyloidogenic mutation (standardized regression coefficient = -2.18, p = 3.34 × 10-11). Cg13139646 showed co-methylation with cg19203115 (Pearson's r2 = 0.32), which showed significant epigenetic differences between symptomatic and asymptomatic carriers of amyloidogenic mutations (standardized regression coefficient = -0.56, p = 8.6 × 10-4). In conclusion, we provide novel insights related to the molecular mechanisms involved in the complex heterogeneity of hATTR, highlighting the role of epigenetic regulation in this rare disorder.
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Affiliation(s)
| | - Gita A Pathak
- Department of Psychiatry, Yale University School of Medicine, VA CT Healthcare Center, VA CT 116A2, 950 Campbell Avenue, West Haven, CT, USA
- VA CT Healthcare Center, West Haven, CT, USA
| | - Flavio De Angelis
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
- Department of Psychiatry, Yale University School of Medicine, VA CT Healthcare Center, VA CT 116A2, 950 Campbell Avenue, West Haven, CT, USA
- VA CT Healthcare Center, West Haven, CT, USA
| | - Marco Di Girolamo
- Clinical Pathophysiology Center, Fatebenefratelli Foundation -'San Giovanni Calibita' Fatebenefratelli Hospital, Rome, Italy
| | - Marco Luigetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Neurologia, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mario Sabatelli
- Università Cattolica del Sacro Cuore, Rome, Italy
- Centro Clinico NEMO Adulti, Rome, Italy
| | - Federico Perfetto
- Regional Amyloid Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Sabrina Frusconi
- Genetic Diagnostics Unit, Laboratory Department, Careggi University Hospital, Florence, Italy
| | - Dario Manfellotto
- Clinical Pathophysiology Center, Fatebenefratelli Foundation -'San Giovanni Calibita' Fatebenefratelli Hospital, Rome, Italy
| | - Maria Fuciarelli
- Department of Biology, University of Rome Tor Vergata, Rome, Italy
| | - Renato Polimanti
- Department of Psychiatry, Yale University School of Medicine, VA CT Healthcare Center, VA CT 116A2, 950 Campbell Avenue, West Haven, CT, USA.
- VA CT Healthcare Center, West Haven, CT, USA.
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Luigetti M, Romozzi M, Bisogni G, Cardellini D, Cavallaro T, Di Paolantonio A, Fabrizi GM, Fenu S, Gentile L, Grandis M, Marucci G, Massucco S, Mazzeo A, Pareyson D, Romano A, Russo M, Schenone A, Tagliapietra M, Tozza S, Vita G, Sabatelli M. hATTR Pathology: Nerve Biopsy Results from Italian Referral Centers. Brain Sci 2020; 10:E780. [PMID: 33114611 DOI: 10.3390/brainsci10110780] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/11/2020] [Accepted: 10/23/2020] [Indexed: 12/19/2022] Open
Abstract
Pathological evidence of amyloid on nerve biopsy has been the gold standard for diagnosis in hereditary transthyretin amyloidosis polyneuropathy (hATTR-PN) for a long time. In this article, we reviewed the pathological findings of a large series of sural nerve biopsies from a cohort of hATTR-PN patients, collected by different Italian referral centers. Patients and Methods: We reviewed clinical and pathological data from hATTR-PN patients, diagnosed and followed in five Italian referral centers for peripheral neuropathies. Diagnosis was formulated after a positive genetic test for transthyretin (TTR) mutations. Sural nerve biopsy was performed according to standard protocols. Results: Sixty-nine sural nerve biopsies from hATTR-PN patients were examined. Congo red positive deposits were found in 73% of cases. Only the Phe64Leu mutation failed to show amyloid deposits in a high percentage of biopsies (54%), as already described. Unusual pathological findings, such as myelin abnormalities or inflammatory infiltrates, were detected in occasional cases. Conclusions: Even if no longer indicated to confirm hATTR-PN clinical suspicion, nerve biopsy remains, in expert hands, a rapid and inexpensive tool to detect amyloid deposition. In Italy, clinicians should be aware that a negative biopsy does not exclude hATTR-PN, particularly for Phe64Leu, one of the most frequent mutations in this country.
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Gertz M, Adams D, Ando Y, Beirão JM, Bokhari S, Coelho T, Comenzo RL, Damy T, Dorbala S, Drachman BM, Fontana M, Gillmore JD, Grogan M, Hawkins PN, Lousada I, Kristen AV, Ruberg FL, Suhr OB, Maurer MS, Nativi-Nicolau J, Quarta CC, Rapezzi C, Witteles R, Merlini G. Avoiding misdiagnosis: expert consensus recommendations for the suspicion and diagnosis of transthyretin amyloidosis for the general practitioner. BMC Fam Pract 2020; 21:198. [PMID: 32967612 PMCID: PMC7513485 DOI: 10.1186/s12875-020-01252-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/25/2020] [Indexed: 03/04/2023]
Abstract
BACKGROUND Transthyretin amyloidosis (also known as ATTR amyloidosis) is a systemic, life-threatening disease characterized by transthyretin (TTR) fibril deposition in organs and tissue. A definitive diagnosis of ATTR amyloidosis is often a challenge, in large part because of its heterogeneous presentation. Although ATTR amyloidosis was previously considered untreatable, disease-modifying therapies for the treatment of this disease have recently become available. This article aims to raise awareness of the initial symptoms of ATTR amyloidosis among general practitioners to facilitate identification of a patient with suspicious signs and symptoms. METHODS These consensus recommendations for the suspicion and diagnosis of ATTR amyloidosis were developed through a series of development and review cycles by an international working group comprising key amyloidosis specialists. This working group met to discuss the barriers to early and accurate diagnosis of ATTR amyloidosis and develop a consensus recommendation through a thorough search of the literature performed using PubMed Central. RESULTS The cardiac and peripheral nervous systems are most frequently involved in ATTR amyloidosis; however, many patients often also experience gastrointestinal and other systemic manifestations. Given the multisystemic nature of symptoms, ATTR amyloidosis is often misdiagnosed as a more common disorder, leading to significant delays in the initiation of treatment. Although histologic evaluation has been the gold standard to confirm ATTR amyloidosis, a range of tools are available that can facilitate early and accurate diagnosis. Of importance, genetic testing should be considered early in the evaluation of a patient with unexplained peripheral neuropathy. CONCLUSIONS A diagnostic algorithm based on initial red flag symptoms and manifestations of cardiac or neurologic involvement will facilitate identification by the general practitioner of a patient with clinically suspicious symptoms, enabling subsequent referral of the patient to a multidisciplinary specialized medical center.
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Affiliation(s)
- Morie Gertz
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - David Adams
- Referral Center for FAP, Neurology Department, APHP, INSERM U 1195, Université Paris-Sud, Le Kremlin Bicêtre, France
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - João Melo Beirão
- Ophthalmology Service, Hospital de Santo António, Porto, Portugal
| | | | | | - Raymond L Comenzo
- John C. Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
| | - Thibaud Damy
- Department of Cardiology, Referral Center for Cardiac Amyloidosis, GRC Amyloid Research Institute, DHU A-TVB, APHP CHU Henri Mondor and Université Paris Est Créteil, Créteil, France
| | | | - Brian M Drachman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, UK
| | | | - Martha Grogan
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, UK
| | | | | | - Frederick L Ruberg
- Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Ole B Suhr
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | | | | | | | - Ronald Witteles
- Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center Foundation, IRCCS Policlinico San Matteo, San Matteo, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Silva-Hernández L, Horga Hernández A, Valls Carbó A, Guerrero Sola A, Montalvo-Moraleda MT, Galán Dávila L. Red flags in patients with hereditary transthyretin amyloidosis at diagnosis in a non-endemic area of Spain. Neurologia 2020; 38:S0213-4853(20)30212-7. [PMID: 32896462 DOI: 10.1016/j.nrl.2020.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/18/2020] [Accepted: 06/12/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Hereditary transthyretin (hATTR) amyloidosis with polyneuropathy is a rare multisystemic disease characterised by onset during adulthood and associated with poor prognosis if untreated. A set of signs and symptoms, commonly known as "red flags," have been proposed to assist in early detection of the disease; presence of red flags may suggest underlying hATTR amyloidosis in patients with progressive sensorimotor polyneuropathy. MATERIAL AND METHODS We analysed the frequency of red flags at the time of diagnosis in 30 patients with hATTR amyloidosis in a non-endemic area of Spain; onset was late in the majority of patients. RESULTS The frequencies of the red flags were as follows: bilateral carpal tunnel syndrome in 15 patients (50%), early autonomic dysfunction in 17 (56%), gastrointestinal problems in 14 (46.6%), unexplained weight loss in 8 (26.6%), heart disease in 12 (40%), asymptomatic cardiac findings in 13 (43.3%), kidney disease in one (3.3%), vitreous opacities in none, family history of neuropathy in 21 (70%), family history of heart disease in 15 (50%), and family history of gastrointestinal problems in 3 (10%). All patients presented at least one red flag at diagnosis, with a median of 4 red flags. CONCLUSION Red flags were common at the time of diagnosis, even in patients with late-onset hATTR amyloidosis. Presence of red flags in a patient with symmetrical sensorimotor polyneuropathy should serve as a warning sign, and lead to targeted diagnosis to rule out hATTR amyloidosis, independently of age of onset.
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Affiliation(s)
- L Silva-Hernández
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España.
| | | | - A Valls Carbó
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
| | - A Guerrero Sola
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
| | | | - L Galán Dávila
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
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Dyck PJB, Kincaid JC, Wiesman JF, Polydefkis M, Litchy WJ, Mauermann ML, Ackermann EJ, Guthrie S, Pollock M, Jung SW, Baker BF, Dyck PJ. mNIS+7 and lower limb function in inotersen treatment of hereditary transthyretin-mediated amyloidosis. Muscle Nerve 2020; 62:502-508. [PMID: 32654212 PMCID: PMC7540053 DOI: 10.1002/mus.27022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 07/02/2020] [Accepted: 07/07/2020] [Indexed: 01/28/2023]
Abstract
Introduction Inotersen, an antisense oligonucleotide inhibitor of transthyretin (TTR) protein production, demonstrated significant benefit versus placebo in the modified Neuropathy Impairment Score (NIS) +7 neurophysiologic tests (mNIS+7) in patients with hereditary TTR‐mediated amyloidosis (hATTR) with polyneuropathy. This analysis assessed the mNIS+7 components by anatomic location and the lower limb function (LLF) test. Methods Adults with hATTR in the NEURO‐TTR trial (NCT01737398) were randomly assigned to receive weekly doses of subcutaneous inotersen 300 mg or placebo for 65 weeks. The mNIS+7 and LLF were assessed at 35 and 66 weeks. Results All major mNIS+7 components (muscle weakness, muscle stretch reflexes, sensation) and the LLF showed significant efficacy in patients receiving inotersen versus placebo; however, NIS‐reflexes (upper limb), touch pressure (upper and lower limbs), and heart rate during deep breathing did not show significant effects. Discussion The results of this analysis reinforce the beneficial effect of inotersen on slowing neuropathy progression in patients with hATTR polyneuropathy. See article on pages 509–515 in this issue.
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Affiliation(s)
| | - John C. Kincaid
- Department of NeurologyIndiana UniversityIndianapolisIndianaUSA
| | | | | | | | | | | | | | | | | | | | - Peter J. Dyck
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
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18
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Dyck PJB, Coelho T, Waddington Cruz M, Brannagan TH, Khella S, Karam C, Berk JL, Polydefkis MJ, Kincaid JC, Wiesman JF, Litchy WJ, Mauermann ML, Ackermann EJ, Baker BF, Jung SW, Guthrie S, Pollock M, Dyck PJ. Neuropathy symptom and change: Inotersen treatment of hereditary transthyretin amyloidosis. Muscle Nerve 2020; 62:509-515. [PMID: 32654156 PMCID: PMC7540369 DOI: 10.1002/mus.27023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 07/02/2020] [Accepted: 07/07/2020] [Indexed: 12/16/2022]
Abstract
Introduction Hereditary transthyretin‐mediated amyloidosis (hATTR) manifests as multisystem dysfunction, including progressive polyneuropathy. Inotersen, an antisense oligonucleotide, improved the course of neuropathic impairment in patients with hATTR in the pivotal NEURO‐TTR study (NCT01737398). To determine inotersen's impact on symptoms and patients’ neuropathy experience, we performed a post hoc analysis of the Neuropathy Symptoms and Change (NSC) score. Methods Stage 1 or 2 hATTR patients were randomized to receive weekly subcutaneous inotersen or placebo for 65 weeks. NSC score was assessed at baseline and 35 and 66 weeks. Results At 66 weeks, inotersen‐treated patients had symptom stabilization as compared with worsening in patients receiving placebo, based on total NSC score. There were also improvements in the subdomains of muscle weakness, sensory, pain, and autonomic symptoms, and for various individual items. Discussion Inotersen treatment stabilized neuropathy symptoms, including autonomic symptoms, in patients with hATTR according to NSC score. Thus, the NSC may be an effective measure to assess neuropathy progression and patients’ neuropathy experience in clinical practice. See article on pages 502–508 in this issue.
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Affiliation(s)
- P James B Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Teresa Coelho
- Department of Neurosciences, Centro Hospitalar do Porto, Porto, Portugal
| | - Marcia Waddington Cruz
- Department of Neurology, Federal University of Rio de Janeiro, University Hospital, Rio de Janeiro, Brazil
| | - Thomas H Brannagan
- Department of Peripheral Neuropathy, Columbia University Medical Center, New York, New York, USA
| | - Sami Khella
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chafic Karam
- Department of Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | - John L Berk
- Department of Medicine, Boston University, Boston, Massachusetts, USA
| | | | - John C Kincaid
- Department of Neurology, Indiana University, Indianapolis, Indiana, USA
| | - Janice F Wiesman
- Department of Neurology, New York University, New York, New York, USA
| | | | | | | | | | | | | | | | - Peter J Dyck
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
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Adams D, Ando Y, Beirão JM, Coelho T, Gertz MA, Gillmore JD, Hawkins PN, Lousada I, Suhr OB, Merlini G. Expert consensus recommendations to improve diagnosis of ATTR amyloidosis with polyneuropathy. J Neurol 2021; 268:2109-22. [PMID: 31907599 DOI: 10.1007/s00415-019-09688-0] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022]
Abstract
Amyloid transthyretin (ATTR) amyloidosis with polyneuropathy (PN) is a progressive, debilitating, systemic disease wherein transthyretin protein misfolds to form amyloid, which is deposited in the endoneurium. ATTR amyloidosis with PN is the most serious hereditary polyneuropathy of adult onset. It arises from a hereditary mutation in the TTR gene and may involve the heart as well as other organs. It is critical to identify and diagnose the disease earlier because treatments are available to help slow the progression of neuropathy. Early diagnosis is complicated, however, because presentation may vary and family history is not always known. Symptoms may be mistakenly attributed to other diseases such as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), idiopathic axonal polyneuropathy, lumbar spinal stenosis, and, more rarely, diabetic neuropathy and AL amyloidosis. In endemic countries (e.g., Portugal, Japan, Sweden, Brazil), ATTR amyloidosis with PN should be suspected in any patient who has length-dependent small-fiber PN with autonomic dysfunction and a family history of ATTR amyloidosis, unexplained weight loss, heart rhythm disorders, vitreous opacities, or renal abnormalities. In nonendemic countries, the disease may present as idiopathic rapidly progressive sensory motor axonal neuropathy or atypical CIDP with any of the above symptoms or with bilateral carpal tunnel syndrome, gait disorders, or cardiac hypertrophy. Diagnosis should include DNA testing, biopsy, and amyloid typing. Patients should be followed up every 6–12 months, depending on the severity of the disease and response to therapy. This review outlines detailed recommendations to improve the diagnosis of ATTR amyloidosis with PN.
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Rüger J, Ioannou S, Castanotto D, Stein CA. Oligonucleotides to the (Gene) Rescue: FDA Approvals 2017-2019. Trends Pharmacol Sci 2020; 41:27-41. [PMID: 31836192 DOI: 10.1016/j.tips.2019.10.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/24/2019] [Accepted: 10/31/2019] [Indexed: 12/19/2022]
Abstract
Four decades have passed since oligonucleotides were first used to manipulate gene expression. There were few FDA approvals prior to 2016, mostly of drugs that eventually exhibited poor performance in the market. The aura of their younger siRNA relatives had also faded during the past 15 years. However, several FDA approvals have occurred in the past 4 years, restoring hope that a new era has dawned in oligonucleotide/siRNA clinical therapeutics. Here, we review the field of oligonucleotide therapeutics and provide an update on FDA approvals of oligonucleotides from 2017 until the second quarter of 2019. We take into consideration the ethical issues looming over the still somewhat limited efficacy of these molecules, the toxicity of treatment, and the exorbitant cost of these therapeutic agents, which limits accessibility for many.
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Gertz MA, Mauermann ML, Grogan M, Coelho T. Advances in the treatment of hereditary transthyretin amyloidosis: A review. Brain Behav 2019; 9:e01371. [PMID: 31368669 PMCID: PMC6749475 DOI: 10.1002/brb3.1371] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Amyloid transthyretin amyloidosis (ATTR) is a progressive and often fatal disease caused by the buildup of mutated (hereditary ATTR [hATTR]; also known as ATTR variant [ATTRv]) or normal transthyretin (wild-type ATTR) throughout the body. Two new therapies-inotersen, an antisense oligonucleotide therapy, and patisiran, an RNA interference therapy-received marketing authorization and represent a significant advance in the treatment of amyloidosis. Herein, we describe the clinical presentation of ATTR, commonly used procedures in its diagnosis, and current treatment landscape for ATTR, with a focus on hATTR. METHODS A PubMed search from 2008 to September 2018 was conducted to review the literature on ATTR. RESULTS Until recently, there have been few treatment options for polyneuropathy of hATTR. Inotersen and patisiran substantially reduce the amyloidogenic precursor protein transthyretin and have demonstrated efficacy in patients with early- and late-stage disease and in slowing or improving neuropathy progression. In contrast, established therapies, such as liver transplantation, typically reserved for patients with early-stage disease, and tafamidis, indicated for the treatment of early-stage disease in Europe, or diflunisal, a nonsteroidal anti-inflammatory drug that is used off-label, are associated with side effects and/or unclear efficacy in certain patient populations. Thus, inotersen and patisiran are positioned to be the preferred therapeutic modalities. CONCLUSIONS Important differences between inotersen and patisiran, including formulation, dosing, requirements for premedications, and safety monitoring, require an understanding and knowledge of each treatment for informed decision making.
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Affiliation(s)
| | | | | | - Teresa Coelho
- Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
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