1
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Chaurasiya PS, Khatri A, Gurung S, Karki S, Shahi S, Aryal L. Rituximab for acute plasma-refractory thrombotic thrombocytopenic purpura: A case report. Ann Med Surg (Lond) 2022; 82:104789. [PMID: 36268380 PMCID: PMC9577965 DOI: 10.1016/j.amsu.2022.104789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/20/2022] [Accepted: 09/25/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction and importance Thrombotic thrombocytopenic purpura (TTP) is a rare disease due to deficiency of ADAMTS13 which can present with anemia and thrombocytopenia. The study highlights the role of PLASMIC score in diagnosis and rituximab in the treatment of this condition. Case presentation Herein, we report a case of 38 years old female who had presented with fever, irritability, and altered sensorium. On investigations, she had hemolytic anemia, and thrombocytopenia with peripheral blood smear showing occasional schistocytes and managed with steroids and plasma exchange. As her platelet, LDH, and a few other lab parameters failed to normalize and met the criteria of refractory TTP, hence she was started on 5 cycles of rituximab and her condition improved. Clinical discussion Thrombotic thrombocytopenic purpura can be presumed based upon PLASMIC score where if the score is 5 or more while ADAMTS13 assay is required for confirmation. It is a life-threatening condition where treatment options include therapeutic plasma exchange (PEX), glucocorticoids, Rituximab, and caplacizumab. Rituximab is considered particularly in refractory cases. Conclusion Thrombotic thrombocytopenic purpura can lead to complications due to low platelet counts. Hence, early diagnosis and intervention are crucial to prevent such complications. Thrombotic thrombocytopenic purpura is a rare disease due to deficiency of ADAMTS13 where patients can present with anemia and thrombocytopenia. PLASMIC score can be used for presumptive diagnosis of this condition while ADAMTS13 assay is required for confirmation. Steroids and plasma exchange are the preferred treatment. In case of refractory cases, Rituximab can play a role to treat as well as prevent recurrence.
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2
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Subhan M, Scully M. Advances in the management of TTP. Blood Rev 2022; 55:100945. [DOI: 10.1016/j.blre.2022.100945] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 12/16/2022]
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3
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Galstyan GM, Maschan AA, Klebanova EE, Kalinina II. [Treatment of thrombotic thrombocytopenic purpura]. TERAPEVT ARKH 2021; 93:736-745. [PMID: 36286842 DOI: 10.26442/00403660.2021.06.200894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
The review discusses approaches to treatment of acquired thrombotic thrombocytopenic purpuгa (aTTP). In patients with aTTP plasma exchanges, glucocorticosteroids allow to stop an acute attack of TTP, and use of rituximab allows to achieve remission. In recent years, caplacizumab has been used. Treatment options such as cyclosporin A, bortezomib, splenectomy, N-acetylcysteine, recombinant ADAMTS13 are also described. Separately discussed issues of management of patients with TTP during pregnancy, and pediatric patients with TTP.
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Affiliation(s)
| | - A A Maschan
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
| | | | - I I Kalinina
- Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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4
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Redefining outcomes in immune TTP: an international working group consensus report. Blood 2021; 137:1855-1861. [PMID: 33529333 DOI: 10.1182/blood.2020009150] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/19/2021] [Indexed: 12/17/2022] Open
Abstract
Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a potentially fatal thrombotic microangiopathy caused by autoantibody-mediated severe deficiency of ADAMTS13. Standardized definitions of response, exacerbation, remission, and relapse were initially proposed in 2003 and modified by the International Working Group for TTP in 2017. These definitions, which have been widely used in clinical practice and research, are based primarily on the platelet count and are benchmarked against the timing of discontinuation of therapeutic plasma exchange (TPE). They do not incorporate ADAMTS13 activity or the temporizing effects on the platelet count of caplacizumab, a novel anti-von Willebrand factor (VWF) nanobody. In light of these limitations, the IWG aimed to develop revised consensus outcome definitions that incorporate ADAMTS13 activity and the effects of anti-VWF therapy, by using an estimate-talk-estimate approach. The updated definitions distinguish clinical remission and clinical relapse (defined primarily by platelet count) from ADAMTS13 remission and ADAMTS13 relapse (defined by ADAMTS13 activity). The revised definitions of exacerbation and remission are benchmarked against not only the timing of discontinuation of TPE but also that of anti-VWF therapy. Retrospective validation of the revised definitions is described, although they have yet to be prospectively validated. Clinical implications of the updated outcome definitions are also discussed and an example of their application to clinical practice is provided to highlight their clinical relevance.
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5
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Abou-Ismail MY, Arafah Y, Fu P, Cao S, Schmaier AH, Nayak L. Outcomes of Immune Thrombotic Thrombocytopenic Purpura (iTTP) With Upfront Cyclophosphamide vs. Rituximab. Front Med (Lausanne) 2020; 7:588526. [PMID: 33195351 PMCID: PMC7657267 DOI: 10.3389/fmed.2020.588526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Immune thrombotic thrombocytopenic purpura (iTTP) is a rare, life-threatening disorder managed with plasma exchange (PLEX) and steroids. Addition of rituximab (RTX) to initial disease treatment has been shown to lower future relapse rates. Information as to whether upfront cyclophosphamide (CTX) treatment is helpful in reducing relapse is not known. Methods: In a retrospective cohort study, we identified all patients at our institution diagnosed with iTTP between 2010 and 2019. We analyzed outcomes of cumulative incidence of relapse (CIR) and duration of remission. Results: Thirty Nine patients were studied. Group A (n = 10) included patients who received upfront PLEX and steroids alone, and Group B (n = 28) included those who received either upfront RTX (n = 23) or CTX (n = 5) in addition to PLEX and steroids. The 2-year CIR was 50% in Group A and 27.7% in Group B, with a median duration of remission of 43.6 months vs. 108.3 months, respectively (p = 0.04). Group A was associated with a HR=8.7 (95% CI: 1.27, 59.45), p = 0.027 for duration of remission. There was no significant difference between CTX and RTX in both outcomes of CIR and duration of remission. We observed a potential impact on remission duration based on the presenting absolute neutrophil count (HR = 0.74, 95% CI: 0.58, 0.96) and serum creatinine (HR = 1.42, 95% CI: 1.03, 1.94). Conclusion: There was no significant difference in iTTP relapse outcomes between upfront RTX and CTX. Absolute neutrophil count and serum creatinine may have a role in predicting relapse. Larger, prospective studies are needed to evaluate these findings.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Yasmin Arafah
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Pingfu Fu
- Case Western Reserve University, Cleveland, OH, United States
| | - Shufen Cao
- Case Western Reserve University, Cleveland, OH, United States
| | - Alvin H Schmaier
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Lalitha Nayak
- Case Western Reserve University, Cleveland, OH, United States.,Division of Hematology and Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
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6
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How targeted therapy disrupts the treatment paradigm for acquired TTP: the risks, benefits, and unknowns. Blood 2019; 134:415-420. [DOI: 10.1182/blood.2019000954] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/13/2019] [Indexed: 12/13/2022] Open
Abstract
Abstract
Insights into immune-mediated thrombotic thrombocytopenic purpura (iTTP) pathophysiology have led to novel targeted therapies. Immunomodulatory strategies target anti-ADAMTS13 antibodies: rituximab is effective in inducing responses in refractory/relapsed TTP and increasing relapse-free survival; caplacizumab targets the von Willebrand factor–platelet interaction to hasten platelet count recovery and reduce mortality and TTP-related ischemic events. Bortezomib and recombinant ADAMTS13 are under investigation. This review examines how targeted therapies are disrupting current treatment paradigms to improve outcomes of iTTP.
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7
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Günay N, Pınarbaşı AS, Dursun İ, Yel S, Poyrazoğlu MH, Düşünsel R. A child with anemia, thrombocytopenia, renal failure and elevated amylase, and lipase enzymes: Answers. Pediatr Nephrol 2019; 34:1219-1221. [PMID: 30569311 DOI: 10.1007/s00467-018-4169-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 11/27/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Neslihan Günay
- Department of Pediatrics, Division of Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey.
| | - Ayşe Seda Pınarbaşı
- Department of Pediatrics, Division of Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - İsmail Dursun
- Department of Pediatrics, Division of Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Sibel Yel
- Department of Pediatrics, Division of Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Muammer Hakan Poyrazoğlu
- Department of Pediatrics, Division of Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Ruhan Düşünsel
- Department of Pediatrics, Division of Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
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8
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Abstract
PURPOSE OF REVIEW Acquired thrombotic thrombocytopenic purpura is an immune-mediated thrombotic microangiopathy caused by antibodies to ADAMTS13 (A Disintegrin And Metalloproteinase with a ThromboSpondin type 1 motif, member 13). Standard treatment with therapeutic plasma exchange and immunosuppression with steroids results in high remission and low mortality rates. However, a number of patients remain refractory to frontline therapy and/or experience multiple relapses. This study reviews emerging therapies for thrombotic thrombocytopenic purpura. RECENT FINDINGS Studies indicate that reducing anti-ADAMTS13 antibody levels through B-cell depletion or proteasome inhibition is effective for the management of refractory disease. Preliminary reports examining anti-CD20 therapy for the treatment of initial disease or as maintenance therapy for seropositive patients suggest the addition of immunosuppression in other disease phases may delay relapse. Exciting developments in targeted therapies to von Willebrand Factor and recombinant ADAMTS13 hold promise for transforming disease management. SUMMARY Approximately half of patients diagnosed with acquired thrombotic thrombocytopenic purpura experience refractory and/or relapsing disease. For these patients, a hematologic remission may be an insufficient therapeutic goal. With recent developments, it is now possible to envision a multifaceted approach targeting disease mechanisms that may dramatically improve outcomes for this otherwise debilitating disease.
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9
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Masias C, Cataland SR. Novel therapies in thrombotic thrombocytopenic purpura. Res Pract Thromb Haemost 2018; 2:19-26. [PMID: 30046703 PMCID: PMC6055500 DOI: 10.1002/rth2.12066] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/13/2017] [Indexed: 12/25/2022] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is characterized by microangiopathic hemolytic anemia and a consumptive thrombocytopenia, as a result of severe deficiency of ADAMTS13. The standard of care of the acute episode is treatment with plasma exchange and immunosuppression. After the acute episode is resolved, patients face a significant risk of relapse and long-term complications associated with significant morbidity and even mortality. Novel treatments have been under development and will be discussed in this review. Caplacizumab, a nanobody that blocks the interaction between VWF and platelets, has shown promising results in decreasing the time to recover from the acute events that will hopefully translate into long-term clinical benefit for patients. In addition, identifying biomarkers to allow us to better predict the risk for relapse and the development of these long-term complications in patients with TTP are a few of the challenges that require our attention moving forward.
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Affiliation(s)
- Camila Masias
- Department of MedicineOhio State UniversityColumbusOHUSA
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10
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Uhl L, Kiss JE, Malynn E, Terrell DR, Vesely SK, George JN. Rituximab for thrombotic thrombocytopenic purpura: lessons from the STAR trial. Transfusion 2017; 57:2532-2538. [DOI: 10.1111/trf.14193] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 05/01/2017] [Accepted: 05/08/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Lynne Uhl
- Beth Israel Deaconess Medical Center
- Harvard Medical SchoolBoston Massachusetts
| | | | | | | | - Sara K. Vesely
- University of Oklahoma Health Sciences CenterOklahoma City Oklahoma
| | - James N. George
- University of Oklahoma Health Sciences CenterOklahoma City Oklahoma
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11
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Froissart A, Veyradier A, Hié M, Benhamou Y, Coppo P. Rituximab in autoimmune thrombotic thrombocytopenic purpura: A success story. Eur J Intern Med 2015; 26:659-65. [PMID: 26293834 DOI: 10.1016/j.ejim.2015.07.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/30/2015] [Accepted: 07/31/2015] [Indexed: 11/20/2022]
Abstract
Despite a significant improvement of thrombotic thrombocytopenic purpura (TTP) prognosis since the use of plasma exchange, morbidity and mortality remained significant because of poor response to standard treatment or exacerbations and relapses. Rituximab, a chimeric monoclonal antibody directed against the B-lymphocyte CD20 antigen, has shown a particular interest in this indication. Recent studies also reported strong evidence for its efficiency in the prevention of relapses. This review addresses these recent progresses and still opened questions in this topic: should rituximab be proposed in all patients at the acute phase? Should all patients benefit from a preemptive treatment? Is the infectious risk acceptable in this context?
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Affiliation(s)
- Antoine Froissart
- Service de médecine interne, CHI, Créteil, France; Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France
| | - Agnès Veyradier
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie biologique, Hôpital Lariboisière, Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Miguel Hié
- Service de Médecine Interne, Hôpital la Pitié-Salpétrière, Paris, France
| | - Ygal Benhamou
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service de médecine interne, CHU Charles Nicolle, Rouen, France
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques, AP-HP, Paris, France; Service d'hématologie, Hôpital Saint Antoine, Paris, France; Inserm U1009, Institut Gustave Roussy, Villejuif, France.
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12
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Sauvètre G, Grange S, Froissart A, Veyradier A, Coppo P, Benhamou Y. La révolution des anticorps monoclonaux dans la prise en charge des microangiopathies thrombotiques. Rev Med Interne 2015; 36:328-38. [DOI: 10.1016/j.revmed.2014.10.364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 08/22/2014] [Accepted: 10/24/2014] [Indexed: 12/15/2022]
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13
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Kinnaman KA, Binder WD, Nadel ES, Brown DFM. Petechiae, anemia, and thrombocytopenia. J Emerg Med 2015; 48:461-465. [PMID: 25661311 DOI: 10.1016/j.jemermed.2014.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 12/21/2014] [Indexed: 06/04/2023]
Affiliation(s)
- Karen A Kinnaman
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - William D Binder
- Department of Emergency Medicine, Brown University School of Medicine, Providence, RI
| | - Eric S Nadel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David F M Brown
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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14
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How I treat refractory thrombotic thrombocytopenic purpura. Blood 2015; 125:3860-7. [PMID: 25784681 DOI: 10.1182/blood-2014-11-551580] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/07/2015] [Indexed: 01/01/2023] Open
Abstract
Acquired thrombotic thrombocytopenic purpura (TTP) is characterized by thrombocytopenia and microangiopathic hemolytic anemia (MAHA) without an obvious cause, and may include fever, mild renal failure, and neurologic deficits. It is characterized by a deficiency of the von Willebrand factor (VWF) cleaving enzyme, ADAMTS13 (a disintegrin and metalloproteinase, with a thrombospondin type 1 motif, member 13), resulting in formation of microthrombi in the high sheer environment of the microvasculature. This causes microvascular occlusion, MAHA, and organ ischemia. Diagnosis is based on the presence of clinical symptoms, laboratory aberrations consistent with MAHA, decreased ADAMTS13 activity, and possibly presence of anti-ADAMTS13 autoantibodies. Upfront treatment of acute TTP includes plasma exchange and corticosteroids. A significant number of patients are refractory to this treatment and will require further interventions. There are limited data and consensus on the management of the refractory TTP patient. Management involves simultaneously ruling out other causes of thrombocytopenia and MAHA, while also considering other treatments. In this article, we describe our management of the patient with refractory TTP, and discuss use of rituximab, increased plasma exchange, splenectomy, and immunosuppressive options, including cyclophosphamide, vincristine, and cyclosporine. We also review recent evidence for the potential roles of bortezomib and N-acetylcysteine, and explore new therapeutic approaches, including recombinant ADAMTS13 and anti-VWF therapy.
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15
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The role of rituximab in the management of patients with acquired thrombotic thrombocytopenic purpura. Blood 2015; 125:1526-31. [PMID: 25573992 DOI: 10.1182/blood-2014-10-559211] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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16
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Scully M, Goodship T. How I treat thrombotic thrombocytopenic purpura and atypical haemolytic uraemic syndrome. Br J Haematol 2014; 164:759-66. [PMID: 24387053 PMCID: PMC4163720 DOI: 10.1111/bjh.12718] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Thrombotic thrombocytopenic purpura (TTP) and atypical haemolytic uraemic syndrome (aHUS) are acute, rare life‐threatening thrombotic microangiopathies that require rapid diagnosis and treatment. They are defined by microangiopathic haemolytic anaemia and thrombocytopenia, with renal involvement primarily in aHUS and neurological and cardiological sequelae in TTP. Prompt treatment for most cases of both conditions is with plasma exchange initially and monoclonal therapy (rituximab in TTP and eculizumab in aHUS) as the mainstay of therapy. Here we discuss the diagnosis and therapy for both disorders.
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Affiliation(s)
- Marie Scully
- Department of Haematology, University College London Hospital, London, UK
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17
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B-Cell Targeted Therapies in Autoimmune Cytopenias and Thrombosis. MILESTONES IN DRUG THERAPY 2014. [PMCID: PMC7123699 DOI: 10.1007/978-3-0348-0706-7_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ever since the advent of Rituximab and subsequently the emergence of other compounds targeting B cells, a cornucopia of medical applications have been found for this family of compounds. After their establishment as standard of care in many conditions such as rituximab in lymphoma and rheumatoid arthritis, they have been progressively found to aid in the treatment of many other conditions. This area constituted a fertile area of research in the past 12 years. Physicians have investigated the B-cell depleting agents use in cases of autoimmune hematologic cytopenias such as immune thrombocytopenia, Evans syndrome, cold and warm autoimmune hemolytic anemia, and other thrombophilic disorders such as the antiphospholipid syndrome and thrombocytopenic purpura. This chapter presents a historical perspective reviewing the various studies that have been published in this field. In addition, it offers a current assessment of the evidence regarding the use of B-cell depleting agents in the aforementioned conditions.
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18
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Hans R, Sharma RR, Marwaha N. Combination of rituximab with therapeutic plasma exchange in a refractory case of thrombotic thrombocytopenic purpura (TTP). Transfus Apher Sci 2013; 49:231-3. [DOI: 10.1016/j.transci.2012.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 09/19/2012] [Indexed: 11/30/2022]
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19
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Gianfaldoni G, Antonioli E, Mannelli F, Vannucchi AM, Bosi A. Chronic Relapsing Thrombotic Thrombocytopenic Purpura Successfully Treated with Rituximab: Case Report. J Chemother 2013; 17:449-51. [PMID: 16167526 DOI: 10.1179/joc.2005.17.4.449] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Plasma therapy is a cornerstone in the treatment of idiopathic Thrombotic Thrombocytopenic Purpura (TTP); however about one-third of patients relapse. In this subset of patients different immunosuppressive approaches have been reported with variable efficacy. We describe the case of an 11-year-long chronic relapsing TTP, requiring frequent plasma exchange procedures and treated unsuccessfully with several immunosuppressive agents. On the occasion of a further relapse, the patient was treated with rituximab, and achieved normalization of hematological values and clinical status for about one year. Upon further relapse, rituximab therapy was started again successfully. A monthly administration was performed with the aim of maintaining the clinical and hematological response stable. In conclusion, rituximab is a safe and effective alternative to other immunosuppressive therapies for chronic relapsing TTP patients.
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Affiliation(s)
- G Gianfaldoni
- Department of Hematology, University of Florence, University Hospital Careggi, Florence, Italy
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20
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Goyal J, Adamski J, Lima JL, Marques MB. Relapses of thrombotic thrombocytopenic purpura after treatment with rituximab. J Clin Apher 2013; 28:390-4. [DOI: 10.1002/jca.21289] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 06/10/2013] [Accepted: 06/19/2013] [Indexed: 11/12/2022]
Affiliation(s)
- Jatinder Goyal
- Department of Medicine; University of Alabama at Birmingham; Birmingham Alabama
| | - Jill Adamski
- Department of Pathology; University of Alabama at Birmingham; Birmingham Alabama
| | | | - Marisa B. Marques
- Department of Pathology; University of Alabama at Birmingham; Birmingham Alabama
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21
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Efficacy of rituximab in acute refractory or chronic relapsing non-familial idiopathic thrombotic thrombocytopenic purpura: a systematic review with pooled data analysis. J Thromb Thrombolysis 2012; 34:347-59. [DOI: 10.1007/s11239-012-0723-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Bhagirath VC, Kelton JG, Moore J, Arnold DM. Rituximab maintenance for relapsed refractory thrombotic thrombocytopenic purpura. Transfusion 2012; 52:2517-23. [DOI: 10.1111/j.1537-2995.2012.03635.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Ejaz AA, Asmar A, Alsabbagh MM, Ahsan N. Rituximab in immunologic glomerular diseases. MAbs 2012; 4:198-207. [PMID: 22377738 PMCID: PMC3361655 DOI: 10.4161/mabs.4.2.19286] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 12/26/2011] [Accepted: 01/07/2012] [Indexed: 02/06/2023] Open
Abstract
Experimental data suggest that the B-cell antigen CD20 may play a significant role in the pathogenesis of many diseases including glomerular diseases. These and other findings underpin the central concept of B-cell-depleting therapies that target CD20 antigen as treatments for lupus nephritis, idiopathic membranous nephropathy, focal segmental glomerulosclerosis, cryglobulinemic glomerulonephritis, antibody mediated renal allograft rejection and recurrent glomerulonephritis in renal allograft. Use of rituximab as a B-cell depleting therapy has been associated with clinical improvement and has emerged as a possible adjunct or alternative treatment option in this field of nephrology.
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Affiliation(s)
- A Ahsan Ejaz
- Department of Nephrology; Hypertension and Transplantation; University of Florida; Gainesville, FL USA
| | - Abdo Asmar
- Department of Clinical Sciences; University of Central Florida; Orlando, FL USA
| | - Mourad M Alsabbagh
- Department of Nephrology; Hypertension and Transplantation; University of Florida; Gainesville, FL USA
| | - Nasimul Ahsan
- Fayetteville Veterans Administration Medical Center; Fayetteville, NC USA
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Patschan D, Korsten P, Behlau A, Vasko R, Heeg M, Sweiss N, Müller GA, Koziolek M. Idiopathic combined, autoantibody-mediated ADAMTS-13/factor H deficiency in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome in a 17-year-old woman: a case report. J Med Case Rep 2011; 5:598. [PMID: 22206706 PMCID: PMC3307521 DOI: 10.1186/1752-1947-5-598] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 12/29/2011] [Indexed: 11/10/2022] Open
Abstract
Introduction Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome is a life-threatening condition with various etiopathogeneses. Without therapy approximately 90% of all patients die from the disease. Case presentation We report the case of a 17-year-old Caucasian woman with widespread hematomas and headache. Due to hemolytic anemia, thrombocytopenia, and schistocytosis, thrombotic thrombocytopenic purpura-hemolytic uremic syndrome was suspected and plasma exchange therapy was initiated immediately. Since her thrombocyte level did not increase during the first week of therapy, plasma treatment had to be intensified to a twice-daily schedule. Further diagnostics showed markedly reduced activities of both ADAMTS-13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 - also known as von Willebrand factor-cleaving protease) and factor H. Test results for antibodies against both proteins were positive. While plasma exchange therapy was continued, rituximab was given once weekly for four consecutive weeks. After the last dose, thrombocytes and activities of ADAMTS-13 and factor H increased into the normal range. Our patient improved and was discharged from the hospital. Conclusions Since no clinical symptoms/laboratory findings indicated a malignant or specific autoimmune-mediated disorder, the diagnosis made was thrombotic thrombocytopenic purpura-hemolytic uremic syndrome due to idiopathic combined, autoantibody-mediated ADAMTS-13/factor H deficiency.
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Affiliation(s)
- Daniel Patschan
- Department of Nephrology and Rheumatology, University Medicine Göttingen, Germany.
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25
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Abstract
In 1924, Dr Eli Moschcowitz described a 16-year-old adolescent girl with abrupt onset of petechiae, hemolytic anemia, followed by paralysis, coma, and death. Autopsy showed widespread hyaline thrombi in the terminal arterioles and capillaries of various organs. The syndrome described by Moschowitz is now known as thrombotic thrombocytopenic purpura.
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Barcellini W, Zanella A. Rituximab therapy for autoimmune haematological diseases. Eur J Intern Med 2011; 22:220-9. [PMID: 21570637 DOI: 10.1016/j.ejim.2010.12.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 12/21/2010] [Accepted: 12/22/2010] [Indexed: 01/19/2023]
Abstract
Autoimmune haematological diseases are characterized by the production of antibodies against blood proteins or cells, and comprise primary immune thrombocytopenia, autoimmune haemolytic anaemia, acquired haemophilia, and thrombotic thrombocytopenic purpura. Current treatments for these disorders include corticosteroids, cytotoxic drugs and splenectomy, which may be associated with significant systemic toxicity and/or morbility. B cells play a key role in both the development and perpetuation of autoimmunity, since they produce autoantibodies but also function as antigen-presenting cells, and release immunomodulatory cytokines. Rituximab, an anti-CD20 monoclonal antibody that specifically depletes B cells, may be an effective treatment strategy for patients with autoimmune disorders. This article reviews data of the literature, showing that patients with autoimmune haematological diseases can respond to rituximab irrespective of age and number or type of prior treatments. These data suggest that rituximab provides an effective and well-tolerated treatment option for these conditions.
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Affiliation(s)
- Wilma Barcellini
- U.O. Ematologia 2, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.
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27
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Jayabose S, Dunbar J, Nowicki TS, Tugal O, Ozkaynak MF, Sandoval C. Rituximab therapy to prevent relapse in chronic relapsing thrombotic thrombocytopenic purpura (TTP) in a child. Pediatr Hematol Oncol 2011; 28:167-72. [PMID: 20469972 DOI: 10.3109/08880011003739414] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Our patient first developed thrombotic thrombocytopenic purpura (TTP) at age 10 years with an initial platelet count of 10,000/microL. She achieved remission with plasmapheresis (PE), but suffered 2 relapses in the next 2 years, each approximately 1 year from PE, with ADAMTS13 levels of <5%. Early in her third remission, with vincristine (weekly x 4 doses) and prednisone (for 2 weeks) her ADAMTS13 increased to 99% in 24 weeks, but decreased to <4% in the next 38 weeks. After 4 weekly doses of rituximab (375 mg/m(2)), her ADAMTS13 level reached 101% in 9 weeks and has remained consistently above 97% on bimonthly monitoring for more than a year. She remains in continuous clinical and hematologic remission with an ADAMTS13 level of 108% at 60 weeks from rituximab therapy and 124 weeks from her second relapse. This case report suggests that monitoring ADAMTS13 level at regular intervals in recurrent TTP may help us identify patients at risk for further relapse; and such a relapse may be prevented, or at least delayed with timely rituximab therapy, thus reducing morbidity from relapsed TTP and its treatment.
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Affiliation(s)
- Somasundaram Jayabose
- Department of Pediatrics, New York Medical College, Valhalla, New York 10595, USA. s
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28
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Dierickx D, Delannoy A, Saja K, Verhoef G, Provan D. Anti-CD20 monoclonal antibodies and their use in adult autoimmune hematological disorders. Am J Hematol 2011; 86:278-91. [PMID: 21328427 DOI: 10.1002/ajh.21939] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 11/15/2010] [Accepted: 11/16/2010] [Indexed: 12/14/2022]
Abstract
Autoimmune hematological disorders encompass a broad group of hematological conditions characterized by the loss of self-tolerance to a variety of antigens. Despite good response to first-line therapy in the majority of patients, relapses are common, necessitating new and safe therapeutic options. The anti-CD20 monoclonal antibody rituximab has led to substantial improvement in the treatment of malignant and immune-mediated disorders involving B cells. Although experience with rituximab in immune-mediated hematological disorders is rarely supported by randomized trials, there is now substantial experience with rituximab suggesting that anti-CD20 therapy is an effective and well-tolerated alternative to immunosuppressive therapy in these disorders. However, caution is needed based on recent reports describing-sometimes severe-rituximab-related complications.
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Affiliation(s)
- Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium.
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29
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Binder WD, Traum AZ, Makar RS, Colvin RB. Case records of the Massachusetts General Hospital. Case 37-2010. A 16-year-old girl with confusion, anemia, and thrombocytopenia. N Engl J Med 2010; 363:2352-61. [PMID: 21142538 DOI: 10.1056/nejmcpc0910929] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- William D Binder
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
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30
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Rituximab for managing relapsing or refractory patients with idiopathic thrombotic thrombocytopenic purpura--haemolytic uraemic syndrome. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2010; 8:203-10. [PMID: 20671883 DOI: 10.2450/2009.0101-09] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Revised: 08/06/2009] [Indexed: 11/21/2022]
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31
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Lombardi AM, Berti de Marinis G, Scandellari R, Magalini F, Sansoni P, Ballerini PF, Vettore S, Candeo N, Marson P, De Silvestro G, Fabris F. Clinical biological remission induced by rituximab in acute refractory chronic relapsing TTP. Thromb Res 2010; 126:e154-6. [DOI: 10.1016/j.thromres.2010.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 02/03/2010] [Accepted: 02/04/2010] [Indexed: 10/19/2022]
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32
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Caramazza D, Quintini G, Abbene I, Malato A, Saccullo G, Coco LL, Di Trapani R, Palazzolo R, Barone R, Mazzola G, Rizzo S, Ragonese P, Aridon P, Abbadessa V, Siragusa S. Relapsing or refractory idiopathic thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: the role of rituximab. Transfusion 2010; 50:2753-60. [DOI: 10.1111/j.1537-2995.2010.02763.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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33
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Long-term follow-up of idiopathic thrombotic thrombocytopenic purpura treated with rituximab. Ann Hematol 2010; 89:1029-33. [PMID: 20422413 DOI: 10.1007/s00277-010-0968-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 04/13/2010] [Indexed: 12/30/2022]
Abstract
Rituximab may be used to treat patients with thrombotic thrombocytopenic purpura (TTP) refractory to plasma exchange or recurrent disease. While initial response rates are reported to be high, long-term follow-up data of patients treated with rituximab are not available to date, however important to estimate the safety and benefit of this treatment. Twelve patients with non-familial idiopathic TTP refractory to plasma exchange or with recurrent disease treated with rituximab between 2000 and 2008 were reexamined. The median follow-up was 49.6 months, ranging from 11 to 97 months. All patients achieved initial complete remission after application of rituximab. During follow-up, nine patients remained disease-free and three patients suffered from recurrent disease. All patients with recurrent disease responded to subsequent rituximab therapy. No long-term side effects were noted during the follow-up period. In conclusion, rituximab represents an effective second-line treatment option in relapsing or refractory TTP. Still, patients need to be closely monitored for relapses with extended follow-up.
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Dexamethasone plus rituximab yields higher sustained response rates than dexamethasone monotherapy in adults with primary immune thrombocytopenia. Blood 2010; 115:2755-62. [DOI: 10.1182/blood-2009-07-229815] [Citation(s) in RCA: 190] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Abstract
Previous observational studies suggest that rituximab may be useful in the treatment of primary immune thrombocytopenia (ITP). This randomized trial investigated rituximab efficacy in previously untreated adult ITP patients with a platelet count of 20 × 109/L or less. One hundred three patients were randomly assigned to receive 40 mg/d dexamethasone for 4 days with or without 375 mg/m2 rituximab weekly for 4 weeks. Patients who were refractory to dexamethasone alone received salvage therapy with dexamethasone plus rituximab. Sustained response (ie, platelet count ≥ 50 × 109/L at month 6 after treatment initiation), evaluable in 101 patients, was greater in patients treated with dexamethasone plus rituximab (n = 49) than in those treated with dexamethasone alone (n = 52; 63% vs 36%, P = .004, 95% confidence interval [95% CI], 0.079-0.455). Patients in the experimental arm showed increased incidences of grade 3 to 4 adverse events (10% vs 2%, P = .082, 95% CI, −0.010 to 0.175), but incidences of serious adverse events were similar in both arms (6% vs 2%, P = .284, 95% CI, −0.035 to 0.119). Dexamethasone plus rituximab was an effective salvage therapy in 56% of patients refractory to dexamethasone. The combination of dexamethasone and rituximab improved platelet counts compared with dexamethasone alone. Thus, combination therapy may represent an effective treatment option before splenectomy. This study is registered at http://clinicaltrials.gov as NCT00770562.
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35
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Kishnani PS, Goldenberg PC, DeArmey SL, Heller J, Benjamin D, Young S, Bali D, Smith SA, Li JS, Mandel H, Koeberl D, Rosenberg A, Chen YT. Cross-reactive immunologic material status affects treatment outcomes in Pompe disease infants. Mol Genet Metab 2010; 99:26-33. [PMID: 19775921 PMCID: PMC3721340 DOI: 10.1016/j.ymgme.2009.08.003] [Citation(s) in RCA: 280] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Accepted: 08/18/2009] [Indexed: 10/20/2022]
Abstract
Deficiency of acid alpha glucosidase (GAA) causes Pompe disease, which is usually fatal if onset occurs in infancy. Patients synthesize a non-functional form of GAA or are unable to form native enzyme. Enzyme replacement therapy with recombinant human GAA (rhGAA) prolongs survival in infantile Pompe patients but may be less effective in cross-reactive immunologic material (CRIM)-negative patients. We retrospectively analyzed the influence of CRIM status on outcome in 21 CRIM-positive and 11 CRIM-negative infantile Pompe patients receiving rhGAA. Patients were from the clinical setting and from clinical trials of rhGAA, were 6 months of age, were not invasively ventilated, and were treated with IV rhGAA at a cumulative or total dose of 20 or 40 mg/kg/2 weeks. Outcome measures included survival, invasive ventilator-free survival, cardiac status, gross motor development, development of antibodies to rhGAA, and levels of urinary Glc(4). Following 52 weeks of treatment, 6/11 (54.5%) CRIM-negative and 1/21 (4.8%) CRIM-positive patients were deceased or invasively ventilated (p<0.0001). By age 27.1 months, all CRIM-negative patients and 4/21 (19.0%) CRIM-positive patients were deceased or invasively ventilated. Cardiac function and gross motor development improved significantly more in the CRIM-positive group. IgG antibodies to rhGAA developed earlier and serotiters were higher and more sustained in the CRIM-negative group. CRIM-negative status predicted reduced overall survival and invasive ventilator-free survival and poorer clinical outcomes in infants with Pompe disease treated with rhGAA. The effect of CRIM status on outcome appears to be mediated by antibody responses to the exogenous protein.
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Affiliation(s)
- Priya S Kishnani
- Department of Pediatrics, Division of Medical Genetics, Duke University Medical Center, Box 103856 DUMC, 4th Floor GSRBI, 595 LaSalle Street, Durham, NC 27710, USA.
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36
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37
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Elliott MA, Heit JA, Pruthi RK, Gastineau DA, Winters JL, Hook CC. Rituximab for refractory and or relapsing thrombotic thrombocytopenic purpura related to immune-mediated severe ADAMTS13-deficiency: a report of four cases and a systematic review of the literature. Eur J Haematol 2009; 83:365-72. [DOI: 10.1111/j.1600-0609.2009.01292.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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38
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Bouw MC, Dors N, van Ommen H, Ramakers-van Woerden NL. Thrombotic thrombocytopenic purpura in childhood. Pediatr Blood Cancer 2009; 53:537-42. [PMID: 19544391 DOI: 10.1002/pbc.22094] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare disease, especially in childhood, and has a high mortality rate in the absence of appropriate treatment. It is characterised by microangiopathic haemolytic anaemia and consumptive thrombocytopenia. TTP may be difficult to distinguish from haemolytic uraemic syndrome (HUS) because of similar clinical manifestations and laboratory findings. In the past, TTP and HUS have often been considered to represent variable expressions of a single entity. Our increased understanding of the pathogenesis of TTP has in turn resulted in significant improvements in its treatment and outcomes. Several immunomodulating agents are currently being used with variable outcomes.
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Affiliation(s)
- Maria C Bouw
- Department of Paediatrics, Meander Medical Centre, Amersfoort, The Netherlands
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39
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Rapid response and sustained remission by rituximab in four cases of plasma-exchange-failed acute thrombotic thrombocytopenic purpura. Int J Hematol 2009; 89:398-399. [DOI: 10.1007/s12185-009-0274-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2008] [Accepted: 02/09/2009] [Indexed: 11/25/2022]
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40
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Manea M, Karpman D. Molecular basis of ADAMTS13 dysfunction in thrombotic thrombocytopenic purpura. Pediatr Nephrol 2009; 24:447-58. [PMID: 18807073 DOI: 10.1007/s00467-008-0986-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 07/14/2008] [Accepted: 07/18/2008] [Indexed: 10/21/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathic disorder characterized by thrombocytopenia, hemolytic anemia, neurological and renal manifestations, and fever. It is associated with dysfunctional von Willebrand factor (VWF) proteolysis and the occurrence of VWF- and platelet-rich thrombi in the microcirculation of multiple organs, including the kidneys. Von Willebrand factor is a large glycoprotein that circulates in plasma as a series of multimers, and it plays a major role in primary hemostasis by inducing the formation of platelet plugs at sites of vascular injury and high-shear stress. Its activity is dependent on the sizes of the multimers, with ultra-large (UL) VWF multimers being biologically very potent. The ULVWF multimers are rapidly degraded upon their secretion from endothelial cells in normal individuals but not in the circulation of TTP patients, causing the formation of disseminated thrombi in the latter. The defective breakdown of VWF is attributed to a severely deficient activity of the VWF-cleaving protease ADAMTS13, a plasma metalloprotease synthesized in the liver, kidneys, and endothelium. This protease rapidly degrades VWF-platelet strings under flow by proteolytic cleavage of the VWF subunit, thereby regulating the size of the platelet thrombus. Congenital TTP occurs due to ADAMTS13 mutations, with the usual debut occurring during the first years of life, while acquired TTP is associated with auto-antibodies against ADAMTS13.
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Affiliation(s)
- Minola Manea
- Department of Pediatrics, Clinical Sciences Lund, Lund University, 22185, Lund, Sweden
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41
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Jasti S, Coyle T, Gentile T, Rosales L, Poiesz B. Rituximab as an adjunct to plasma exchange in TTP: a report of 12 cases and review of literature. J Clin Apher 2009; 23:151-6. [PMID: 18712712 DOI: 10.1002/jca.20172] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Idiopathic thrombotic thrombocytopenic purpura (TTP) is caused by the production of autoantibodies against the Von Willebrand factor cleaving enzyme. This provides a rationale for the use of rituximab in this disease. We report a retrospective review of 12 patients treated with rituximab for TTP refractory to plasma exchange. Eleven patients were treated during initial presentation, and one patient was treated for recurrent relapse. Ten patients responded to treatment. Median time to response after first dose of rituximab was 10 days (5-32). Of the 11 patients treated during initial presentation, nine remain free of relapse after a median follow-up of 57+ months (1+-79+). Two patients died during initial treatment. One patient was lost to follow-up 1 month after achieving complete response. The patient treated for recurrent disease during second relapse remained disease free for 2years, relapsed and was treated again with rituximab, and was in remission for 22 months. She relapsed again, was retreated, and has now been in remission for 21+ months. We conclude that rituximab is an useful addition to plasma exchange treatment in TTP, but its exact role and dosing need to be verified in prospective studies.
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Affiliation(s)
- Sushama Jasti
- Division of Hematology/Oncology, SUNY Upstate Medical University, Syracuse, New York, USA
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42
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Lee S, Lee JH, Choi Y, Yu JH, Chun YH, Choi WJ, Jung SS. A Case Report of Rituximab Therapy for Recurrent Thrombotic Thrombocytopenia Purpura. THE KOREAN JOURNAL OF HEMATOLOGY 2009. [DOI: 10.5045/kjh.2009.44.3.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Seungbum Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Je-Hwan Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yunsuk Choi
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Hee Yu
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yoon Hee Chun
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Won Jung Choi
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang-Su Jung
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Dierickx D, De Rycke A, Vanderschueren S, Delannoy A. New treatment options for immune-mediated hematological disorders. Eur J Intern Med 2008; 19:579-86. [PMID: 19046722 DOI: 10.1016/j.ejim.2007.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Accepted: 08/28/2007] [Indexed: 01/19/2023]
Abstract
In recent years, there has been a tremendous increase in the number of clinical studies with monoclonal antibodies and small molecules in the treatment of hematological malignancies. Clinical observations have shown that some of these molecules may also aid in the treatment of immune-mediated hematological disorders. Moreover, immunotherapy has become an important treatment cornerstone in other, non-hematological, auto-immune diseases. This paper reviews the current state of the use of these new molecules in the treatment of the most frequently encountered immune-mediated hematological disorders: auto-immune hemolytic anemia (AIHA), idiopathic thrombocytopenic purpura (ITP), and thrombotic thrombocytopenic purpura (TTP).
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MESH Headings
- Adrenal Cortex Hormones/therapeutic use
- Anemia, Hemolytic, Autoimmune/drug therapy
- Anemia, Hemolytic, Autoimmune/immunology
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Clinical Trials as Topic
- Drug Therapy, Combination
- Evidence-Based Medicine
- Hematologic Diseases/drug therapy
- Hematologic Diseases/immunology
- Humans
- Immunologic Factors/therapeutic use
- Immunosuppressive Agents/therapeutic use
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombotic Thrombocytopenic/drug therapy
- Purpura, Thrombotic Thrombocytopenic/immunology
- Rituximab
- Splenectomy
- Treatment Outcome
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Affiliation(s)
- Daan Dierickx
- UZ Gasthuisberg, Department of Hematology, Leuven, Belgium.
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44
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Neutralizing antibodies to therapeutic enzymes: considerations for testing, prevention and treatment. Nat Biotechnol 2008; 26:901-8. [PMID: 18688246 DOI: 10.1038/nbt.1484] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lysosomal storage diseases are characterized by deficiencies in lysosomal enzymes, allowing accumulation of target substrate in cells and eventually causing cell death. Enzyme replacement therapy is the principal treatment for most of these diseases. However, these therapies are often complicated by immune responses to the enzymes, blocking efficacy and causing severe adverse outcomes by neutralizing product activity. It is thus crucial to understand the relationships between genetic mutations, endogenous residual enzyme proteins (cross-reactive immunologic material), development of neutralizing antibodies and their impact on clinical outcomes of lysosomal storage diseases. For patients in whom neutralizing antibodies may cause severe adverse clinical outcomes, it is paramount to develop tolerance inducing protocols to preclude, where predictable, or treat such life-threatening responses.
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45
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Le purpura thrombotique thrombocytopénique acquis de l’adulte : actualités. Rev Med Interne 2008; 29:794-800. [DOI: 10.1016/j.revmed.2007.09.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Accepted: 09/10/2007] [Indexed: 11/17/2022]
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Hundae A, Peskoe S, Grimsley E, Patel S. Rituximab Therapy for Refractory Thrombotic Thrombocytopenic Purpura and Autoimmune-Mediated Thrombocytopenia in Systemic Lupus Erythematosus. South Med J 2008; 101:943-4. [DOI: 10.1097/smj.0b013e3181809ebd] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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47
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HALIM AG, SOEHARDY Z, SHAHRIR MS, ROZITA M, LOO CY, RASHIDI S, NORELLA KONG CT. Rituximab in recalcitrant thrombotic thrombocytopenic purpura secondary to systemic lupus erythematosus. Int J Rheum Dis 2008. [DOI: 10.1111/j.1756-185x.2008.00334.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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48
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Kameda T, Dobashi H, Kittaka K, Susaki K, Yamaoka G, Arai K, Tokuda M, Ishida T. Two cases of refractory thrombotic thrombocytopenic purpura associated with collagen vascular disease were significantly improved by rituximab treatment. Clin Rheumatol 2007; 26:2159-2162. [PMID: 17562094 DOI: 10.1007/s10067-007-0631-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2007] [Revised: 04/03/2007] [Accepted: 04/11/2007] [Indexed: 11/26/2022]
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare disorder of small vessels. TTP is associated with deficiency of the von Willebrand factor-cleaving protease, ADAMTS13, and its inhibitor. Low ADAMTS13 activity is present in most of idiopathic TTP patients. The prognosis of TTP was improved by plasma exchange treatment, which replaces the ADAMTS13 and removes ADAMTS13 inhibitor. However, ADAMTS13 activity is normal in some TTP patients. These are found among the secondary TTP patients associated with collagen disease, hematopoietic stem cell transplantation, malignancy, or drugs. In addition, most of them do not respond to plasma exchange. On the other hand, several reports demonstrated that rituximab, which is an anti-CD20 monoclonal antibody, is effective for refractory TTP cases caused by ADAMTS13 deficiency. It is considered that the effect of rituximab is associated with disappearance of ADAMTS13 inhibitor. However, rituximab therapy was effective for the TTP patients with normal ADAMTS13 activity in our cases. We considered another mechanism of rituximab for TTP cases.
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Affiliation(s)
- Tomohiro Kameda
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Hiroaki Dobashi
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.
| | - Katsuharu Kittaka
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Kentaro Susaki
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Genji Yamaoka
- Department of Clinical Laboratory, Kagawa University Hospital, Kagawa, Japan
| | - Ken Arai
- Department of Clinical Laboratory, Kagawa University Hospital, Kagawa, Japan
| | | | - Toshihiko Ishida
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
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Schleinitz N, Ebbo M, Mazodier K, Poullin P, Bernit E, Veit V, Veyradier A, Fakhouri F, Kaplanski G, Harle JR. Rituximab as preventive therapy of a clinical relapse in TTP with ADAMTS13 inhibitor. Am J Hematol 2007; 82:417-8. [PMID: 17266057 DOI: 10.1002/ajh.20764] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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