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Lester W. Immune thrombotic thrombocytopenic purpura in patients over 60 years of age: Diagnostic pitfalls and treatment strategy. Br J Haematol 2023; 203:704-705. [PMID: 37749067 DOI: 10.1111/bjh.19123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
Real-world registry studies of older patients with iTTP highlight diagnostic difficulties in comparison to patients less than 60 years of age with greater risk of renal injury, atypical neurological features and less profound cytopenia, which can result in diagnostic delays. However, there is no clear signal of significantly increased toxicity from full active treatment. Commentary on: Gómez-Seguí et al. Immune thrombotic thrombocytopenic purpura in older patients: results from the Spanish TTP Registry (REPTT). Br J Haematol 2023;203:860-871.
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Affiliation(s)
- Will Lester
- University Hospitals Birmingham, Birmingham, UK
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Gómez-Seguí I, Francés Aracil E, Mingot-Castellano ME, Vara Pampliega M, Goterris Viciedo R, García Candel F, Pascual Izquierdo C, Del Río Garma J, Guerra Domínguez L, Vicuña Andrés I, Garcia-Arroba Peinado J, Zalba Marcos S, Vidan Estévez JM, González Arias E, Campuzano Saavedra V, García Gala JM, Ortega Sanchez S, Martínez Nieto J, Pardo Gambarte L, Solé Rodríguez M, Fernández-Docampo M, Avila Idrovo LF, Hernández L, Cid J, de la Rubia Comos J. Immune thrombotic thrombocytopenic purpura in older patients: Results from the Spanish TTP Registry (REPTT). Br J Haematol 2023; 203:860-871. [PMID: 37723363 DOI: 10.1111/bjh.19109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/31/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
Immune thrombotic thrombocytopenic purpura (iTTP) is an ultra-rare disease that seldom occurs in the elderly. Few reports have studied the clinical course of iTTP in older patients. In this study, we have analysed the clinical characteristics at presentation and response to therapy in a series of 44 patients with iTTP ≥60 years at diagnosis from the Spanish TTP Registry and compared them with 209 patients with <60 years at diagnosis from the same Registry. Similar symptoms and laboratory results were described in both groups, except for a higher incidence of renal dysfunction among older patients (23% vs. 43.1%; p = 0.008). Front-line treatment in patients ≥60 years was like that administered in younger patients. Also, no evidence of a difference in clinical response and overall survival was seen in both groups. Of note, 14 and 25 patients ≥60 years received treatment with caplacizumab and rituximab, respectively, showing a favourable safety and efficacy profile, like that observed in patients <60 years.
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Affiliation(s)
- I Gómez-Seguí
- H. Universitario y Politécnico La Fe, Valencia, Spain
| | | | - M E Mingot-Castellano
- Hematology Department, Instituto de Biomedicina de Sevilla, H. U. Virgen del Rocio, Sevilla, Spain
| | | | | | | | | | - J Del Río Garma
- Complejo Hospitalario Universitario de Orense, Ourense, Spain
| | | | | | | | | | | | | | | | | | - S Ortega Sanchez
- Banc de Sang i Teixits, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J Martínez Nieto
- Instituto de Investigación Biomédica del Hospital Clínico San Carlos, Madrid, Spain
| | | | | | | | | | | | - J Cid
- H. Clínic, Barcelona, Spain
| | - J de la Rubia Comos
- H. Universitario y Politécnico La Fe, Valencia, Spain
- Hematology Department, Universidad Católica "San Vicente Mártir", Valencia, Spain
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Joseph A, Joly BS, Picod A, Veyradier A, Coppo P. The Specificities of Thrombotic Thrombocytopenic Purpura at Extreme Ages: A Narrative Review. J Clin Med 2023; 12:jcm12093068. [PMID: 37176509 PMCID: PMC10179719 DOI: 10.3390/jcm12093068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy (TMA) related to a severe ADAMTS13 deficiency, the specific von Willebrand factor (VWF)-cleaving protease. This deficiency is often immune-mediated (iTTP) and related to the presence of anti-ADAMTS13 autoantibodies that enhance its clearance or inhibit its VWF processing activity. iTTP management may be challenging at extreme ages of life. International cohorts of people with TTP report delayed diagnoses and misdiagnoses in children and elderly people. Child-onset iTTP shares many features with adult-onset iTTP: a female predominance, an idiopathic presentation, and the presence of neurological disorders and therapeutic strategies. Long-term follow-ups and a transition from childhood to adulthood are crucial to preventing iTTP relapses, in order to identify the occurrence of other autoimmune disorders and psychosocial sequelae. In contrast, older iTTP patients have an atypical clinical presentation, with delirium, an atypical neurological presentation, and severe renal and cardiac damages. They also have a poorer response to treatment and prognosis. Long-term sequelae are highly prevalent in older patients. Prediction scores for iTTP diagnoses are not used for children and have a lower sensitivity and specificity in patients over 60 years old. ADAMTS13 remains the unique biological marker that is able to definitely confirm or rule out the diagnosis of iTTP and predict relapses during follow-ups.
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Affiliation(s)
- Adrien Joseph
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Bérangère S Joly
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Adrien Picod
- Medical Intensive Care Unit, Saint-Louis Hospital, Public Assistance Hospitals of Paris, 75010 Paris, France
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
| | - Agnès Veyradier
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Biology Department, Lariboisière Hospital, Public Assistance Hospitals of Paris, 75006 Paris, France
- EA-3518, Clinical Research in Hematology, Immunology and Transplantation, Institut de Recherche Saint-Louis, Université de Paris, 75571 Paris, France
| | - Paul Coppo
- French Reference Center for Thrombotic Microangiopathies, 75012 Paris, France
- Hematology Department, Saint-Antoine hospital, Public Assistance Hospitals of Paris, 75571 Paris, France
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Selvakumar S, Liu A, Chaturvedi S. Immune thrombotic thrombocytopenic purpura: Spotlight on long-term outcomes and survivorship. Front Med (Lausanne) 2023; 10:1137019. [PMID: 36926315 PMCID: PMC10011081 DOI: 10.3389/fmed.2023.1137019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/03/2023] [Indexed: 03/06/2023] Open
Abstract
Advances in diagnosis and treatment have dramatically improved survival of acute immune thrombotic thrombocytopenic purpura (iTTP) and iTTP has evolved from an acute fatal condition to a chronic relapsing disorder. In addition to the risk of iTTP relapse, iTTP survivors are at risk of multiple adverse health outcomes including higher than expected rates of all-cause mortality, increased rates of stroke and other cardiovascular disease, and higher rates of morbidities such as obesity, hypertension, and autoimmune disorders. iTTP survivors also report neurocognitive impairment, depression, and reduced quality of life. Women with iTTP are at risk for recurrent iTTP, preeclampsia, and other maternal and fetal complications in subsequent pregnancies. ADAMTS13 activity during clinical remission has emerged as an important targetable risk factor for iTTP relapse and other outcomes including stroke and all-cause mortality. This review summarizes current literature regarding the epidemiology and potential mechanisms for adverse long-term sequelae of iTTP, outlines current best practices in iTTP survivorship care, and highlights a research agenda to improve long-term iTTP outcomes.
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Affiliation(s)
- Sruthi Selvakumar
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Angela Liu
- Division of Hematology and Oncology, Mount Sinai School of Medicine, New York, NY, United States
| | - Shruti Chaturvedi
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Reding MT, Pabinger I, Holme PA, Maas Enriquez M, Mancuso ME, Lalezari S, Miesbach W, Di Minno G, Klamroth R, Hermans C. Efficacy and safety of damoctocog alfa pegol prophylaxis in patients ⩾40 years with severe haemophilia A and comorbidities: post hoc analysis from the PROTECT VIII study. Ther Adv Hematol 2023; 14:20406207231166779. [PMID: 37113811 PMCID: PMC10126693 DOI: 10.1177/20406207231166779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/14/2023] [Indexed: 04/29/2023] Open
Abstract
Background Advances in treatment have enabled patients with haemophilia A to live longer and therefore may be subjected to comorbidities associated with ageing, in addition to disease-associated morbidities. There have been few reports to date on efficacy and safety of treatment specifically in patients with severe haemophilia A and comorbidities. Objective To explore the efficacy and safety of damoctocog alfa pegol prophylaxis in patients with severe haemophilia A aged ⩾40 years with comorbidities of interest. Design A post hoc analysis of data from the phase 2/3 PROTECT VIII study and its extension. Methods Bleeding and safety outcomes were analysed in a subgroup of patients aged ⩾40 years with ⩾1 comorbidity receiving damoctocog alfa pegol (BAY 94-9027; Jivi®) prophylaxis. Results Thirty-four patients with severe haemophilia A were included in this analysis, with a mean age of 49.4 years at time of enrolment. The most prevalent comorbidities were hepatitis C (n = 33; chronic, n = 23), hepatitis B (n = 8) and hypertension (n = 11). Four patients had human immunodeficiency virus. All received damoctocog alfa pegol prophylaxis for the entire study [median (range) time in study = 3.9 (1.0-6.9) years]. During the main study and extension, median total annualised bleeding rates (ABRs) (Q1; Q3) were 2.1 (0.0; 5.8) and 2.2 (0.6; 6.0), respectively; median joint ABRs were 1.9 (0.0; 4.4) and 1.6 (0.0; 4.0), respectively. Mean adherence with prophylaxis schedule was greater than 95% throughout the study. No deaths or thrombotic events were reported. Conclusion Efficacy, safety and adherence of damoctocog alfa pegol were confirmed in patients aged ⩾40 years with haemophilia A and one or more comorbidities, with data for up to 7 years supporting its use as a long-term treatment option in this group. Plain language summary Advances in treatment mean that people with haemophilia A are now living longer and, as a result, may have additional medical conditions that occur with ageing. We aimed to investigate the efficacy and safety of the long-acting replacement factor VIII damoctocog alfa pegol in people with severe haemophilia A who had additional medical conditions. To do this, we investigated the recorded information about patients aged 40 years of age or older who had been treated with damoctocog alfa pegol in a previously completed clinical trial. We found that the treatment was well-tolerated; no deaths or thrombotic events (undesirable clotting events) were reported. Treatment was efficacious in reducing bleeding in this group of patients. The findings support the use of damoctocog alfa pegol as a long-term treatment for older patients with haemophilia A and coexisting conditions.
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Affiliation(s)
| | - Ingrid Pabinger
- University Clinic for Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Pål Andrè Holme
- Department of Haematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Milan, Italy; Humanitas University, Milan, Italy
| | - Shadan Lalezari
- National Haemophilia Centre, Chaim Sheba Medical Centre, Tel Aviv University, Tel Aviv, Israel
| | | | - Giovanni Di Minno
- Department of Clinical and Experimental Medicine, University of Naples Federico II, Naples, Italy
| | | | - Cedric Hermans
- Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Louvain, Belgium
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Abstract
The last 2 decades have witnessed considerable advances in our understanding of thrombotic thrombocytopenic purpura (TTP). However, there is still some ambiguity regarding the precise nature of this disease, especially with respect to nervous system involvement and the correct nomenclature. This article seeks to summarize the clinical manifestations of TTP and the associated diseases. We describe TTP complicated with cerebrovascular disease, spinal cord injury, posterior reversible encephalopathy syndrome (PRES), anxious-depressive symptoms, and cognitive decline. TTP with spinal cord injury is rarely reported. For better clarity, we discuss the case of a 57-year-old woman who was diagnosed with neuromyelitis optica spectrum disease (NMOSD) with atypical TTP. The concurrent occurrence of NMOSD and TTP in this patient is consistent with the characteristics of acquired autoimmunity. We highlight the importance of early recognition of TTP in patients with atypical presentation who may not have the expected clinical or laboratory findings. This is particularly important in TTP patients with other concomitant autoimmune diseases or age-related comorbid conditions.
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Affiliation(s)
- Hui Zhu
- Department of Neurology, The First Hospital, Jilin University, Changchun, China
| | - Jing-Yao Liu
- Department of Neurology, The First Hospital, Jilin University, Changchun, China
- * Correspondence: Jing-Yao Liu, Department of Neurology, The First Hospital, Jilin University, Jilin Road, No. 3302, Changchun 130031, China (e-mail: , )
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Adeyemi A, Razakariasa F, Chiorean A, de Passos Sousa R. Epidemiology, treatment patterns, clinical outcomes, and disease burden among patients with immune-mediated thrombotic thrombocytopenic purpura in the United States. Res Pract Thromb Haemost 2022; 6:e12802. [PMID: 36176310 PMCID: PMC9481884 DOI: 10.1002/rth2.12802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/19/2022] [Accepted: 08/17/2022] [Indexed: 11/11/2022] Open
Abstract
Background Immune-mediated thrombotic thrombocytopenic purpura (iTTP) is a life-threatening thrombotic microangiopathy. Due to its rarity, epidemiology and real-world outcomes data are scarce. Objectives The aim was to assess epidemiology, treatment patterns, clinical outcomes, and disease burden in patients with iTTP in the United States. Methods This longitudinal, retrospective observational study of the Optum-Humedica database included patients with an iTTP diagnosis (≥1 documented ADAMTS13 activity less than 10% or one or more iTTP episodes) from January 2007 to December 2019. Results Of 666 patients with an iTTP diagnosis between October 2015 and December 2019, 302 (45%) had one or more iTTP episodes. The pooled annual incidence of documented iTTP during this period was 3.43/million, and the annual incidence of one or more iTTP episodes was 1.81/million. Patients with one or more iTTP episodes received a median of six therapeutic plasma exchange (TPE) sessions per episode; 86% received corticosteroids, and 59% received rituximab. Exacerbations occurred in 17% (52/302) and relapse in 11% (34/302); 34% (103/302) had one or more thromboembolic events. Mortality rates during the study period were 25% (167/666) among all patients with iTTP diagnosis, and 14% (41/302) among patients with one or more iTTP episodes. In the assessment of disease burden (January 2007 to September 2019), patients in the iTTP cohort (n = 514) presented with a mean of 14 comorbidities, compared with 3 in a matched non-iTTP cohort (n = 2570). In a cluster analysis, duration of iTTP episode and mortality rate were greater in older versus younger patients. Conclusions Despite treatment with TPE and immunosuppressants, patients with iTTP have high risk of morbidity and mortality, demonstrating the need for more effective therapies.
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Affiliation(s)
- Ayoade Adeyemi
- Sanofi Cambridge Massachusetts USA.,Present address: Alexion Boston Massachusetts USA
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