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Rettl R, Calabretta R, Duca F, Binder C, Kronberger C, Willixhofer R, Poledniczek M, Donà C, Nitsche C, Beitzke D, Loewe C, Auer-Grumbach M, Bonderman D, Kastl S, Hengstenberg C, Badr Eslam R, Kastner J, Bergler-Klein J, Hacker M, Kammerlander A. Reduction in 99mTc-DPD myocardial uptake with therapy of ATTR cardiomyopathy. Amyloid 2024; 31:42-51. [PMID: 37599395 DOI: 10.1080/13506129.2023.2247136] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/22/2023]
Abstract
Aims: Novel ribonucleic acid interference (RNAi) therapeutics such as patisiran and inotersen have been shown to benefit neurologic disease course and quality of life in patients with hereditary transthyretin amyloidosis (ATTRv). We aimed to determine the impact of RNAi therapeutics on myocardial amyloid load using quantitative single photon emission computed tomography/computed tomography (SPECT/CT) imaging in patients with ATTRv-related cardiomyopathy (ATTRv-CM). We furthermore compared them with wild-type ATTR-CM (ATTRwt-CM) patients treated with tafamidis.Methods and results: ATTRv-CM patients underwent [99mTc]-radiolabeled diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) scintigraphy and quantitative SPECT/CT imaging before and after 12 months (IQR: 11.0-12.0) of treatment with RNAi therapeutics (patisiran: n = 5, inotersen: n = 4). RNAi treatment significantly reduced quantitative myocardial uptake as measured by standardised uptake value (SUV) retention index (baseline: 5.09 g/mL vs. follow-up: 3.19 g/mL, p = .028) in ATTRv-CM patients without significant improvement in cardiac function. Tafamidis treatment resulted in a significant reduction in SUV retention index (4.96 g/mL vs. 3.27 g/mL, p < .001) in ATTRwt-CM patients (historical control cohort: n = 40) at follow-up [9.0 months (IQR: 7.0-10.0)] without beneficial impact on cardiac function.Conclusions: RNAi therapeutics significantly reduce quantitative myocardial uptake in ATTRv-CM patients, comparable to tafamidis treatment in ATTRwt-CM patients, without impact on cardiac function. Serial 99mTc-DPD SPECT/CT imaging may be a valuable tool to quantify and monitor response to disease-specific therapies in both ATTRv-CM and ATTRwt-CM.
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Affiliation(s)
- René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Raffaella Calabretta
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christina Kronberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Robin Willixhofer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Michael Poledniczek
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Carolina Donà
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Dietrich Beitzke
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Michaela Auer-Grumbach
- Department of Orthopaedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine V, Favoriten Clinic, Vienna, Austria
| | - Stefan Kastl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roza Badr Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Jutta Bergler-Klein
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Andreas Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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Smerikarova M, Bozhanov S, Tournev I, Maslarska V. Variation of tafamidis plasma levels during the treatment of TTR amyloidosis patients with Glu89Gln mutation. Eur J Clin Pharmacol 2023; 79:1657-1664. [PMID: 37782393 DOI: 10.1007/s00228-023-03576-3] [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: 08/12/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE The transthyretin kinetic stabilizer tafamidis, used as a first-line therapy of amyloidosis patients, binds selectively to the transthyretin protein structure and thus prevents its dissociation. The limited information regarding tafamidis application in Glu89Gln amyloidosis patients imposed our research team to determine and evaluate its individual mean plasma levels and their biological variation. METHODS The present cohort study investigated Bulgarian amyloidosis patients, grouped by gender, age, and therapy duration. A total of sixty patients aged 40-75 years and therapy duration up to 9 years were included. A precise and accurate high-performance liquid chromatography method with ultraviolet detection was used for plasma concentration measurement. RESULTS Mean plasma concentrations were 5.13 ± 2.64 µmol/L and showed low intra-individual (18.50%) and high inter-individual variability (51.43%). No significant difference was observed between tafamidis plasma levels and therapy duration with p = 0.5941 (p < 0.05 considered significant), but a significant positive correlation was found between plasma concentration, gender, and age with obtained results about p-value 0.0001 and 0.0235, respectively. CONCLUSION The summary results of the study showed differences that may be based on some specific clinical features of the Glu89Gln mutation.
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Affiliation(s)
- M Smerikarova
- Department of Chemistry, Faculty of Pharmacy, Medical University, Sofia, 1000, Bulgaria.
| | - S Bozhanov
- Department of Chemistry, Faculty of Pharmacy, Medical University, Sofia, 1000, Bulgaria
| | - I Tournev
- Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University, Sofia, Bulgaria
| | - V Maslarska
- Department of Chemistry, Faculty of Pharmacy, Medical University, Sofia, 1000, Bulgaria
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Tsai FJ, Jaeger M, Coelho T, Powers ET, Kelly JW. Tafamidis concentration required for transthyretin stabilisation in cerebrospinal fluid. Amyloid 2023; 30:279-289. [PMID: 36691999 PMCID: PMC10363573 DOI: 10.1080/13506129.2023.2167595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/21/2022] [Accepted: 01/07/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Hereditary transthyretin (TTR) amyloidosis (ATTRv) initially presents as a polyneuropathy and/or a cardiomyopathy. Central nervous system (CNS) pathology in ATTRv amyloidosis, including focal neurological episodes, dementia, cerebrovascular bleeding, and seizures, appears around a decade later. Wild-type (WT) TTR amyloidosis (ATTRwt) causes a cardiomyopathy. CNS pathology risk likely also increases in these patients as cardiomyopathy progresses. Herein, we study tafamidis-mediated TTR kinetic stabilisation in cerebrospinal fluid (CSF). METHODS Varying tafamidis concentrations (50-1000 nM) were added to CSF from healthy donors or ATTRv patients, and TTR stabilisation was measured via the decrease in dissociation rate. RESULTS Tafamidis meglumine (Vyndaqel) can be dosed at 20 or 80 mg QD. The latter dose is bioequivalent to a 61 mg QD dose of tafamidis free acid (Vyndamax). The tafamidis CSF concentration in ATTRv patients on 20 mg Vyndaqel is ∼125 nM. By linear extrapolation, we expect a CSF concentration of ∼500 nM at the higher dose. When tafamidis is added to healthy donor CSF at 125 or 500 nM, the WT TTR dissociation rate decreases by 42% or 87%, respectively. CONCLUSIONS Tafamidis stabilises TTR in CSF to what is likely a clinically meaningful extent at CSF concentrations achieved by the normal tafamidis dosing regimen.
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Affiliation(s)
- Felix J. Tsai
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Marcus Jaeger
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Teresa Coelho
- Unidade Corino de Andrade, Centro Hospitalar do Porto, Porto, Portugal
| | - Evan T. Powers
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Jeffery W. Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
- The Skaggs Institute for Chemical Biology, The Scripps Research Institute, CA, USA
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Rettl R, Duca F, Binder C, Dachs TM, Cherouny B, Camuz Ligios L, Mann C, Schrutka L, Dalos D, Charwat-Resl S, Badr Eslam R, Kastner J, Bonderman D. Impact of tafamidis on myocardial strain in transthyretin amyloid cardiomyopathy. Amyloid 2023; 30:127-137. [PMID: 36251806 DOI: 10.1080/13506129.2022.2131385] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
AIMS The impact of tafamidis on myocardial strain in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) have been barely investigated. We aimed to determine tafamidis-induced changes using serial speckle tracking echocardiography and to identify imaging parameters for specific therapy monitoring. METHODS AND RESULTS ATTR-CM patients underwent serial TTE with two-dimensional (2 D) speckle tracking imaging. Patients receiving tafamidis free acid 61 mg (n = 62) or tafamidis meglumine 20 mg (n = 21) once daily (QD) showed stable measurements at follow-up (61 mg: 8.5 months, 20 mg: 7.0 months) in LV global longitudinal strain (GLS) (61 mg: -11.75% vs. -11.58%, p = 0.534; 20 mg: -10.61% vs. -10.12%, p = 0.309), right ventricular (RV) GLS (61 mg: -14.18% vs. -13.72%, p = 0.377; 20 mg: -14.53% vs. -13.99%, p = 0.452) and left atrial (LA) reservoir strain (LASr; 61 mg: 8.80% vs. 9.42%, p = 0.283; 20 mg: 8.23% vs. 8.67%, p = 0.589), whereas treatment-naïve ATTR-CM patients (n = 54) had clear signs of disease progression at the end of the observation period (10.5 months; LV-GLS: -11.71% vs. -10.59%, p = 0.001; RV-GLS: -14.36% vs. -12.99%, p = 0.038; LASr: 10.67% vs. 8.41%, p = 0.005). Between-group comparison at follow-up revealed beneficial effects of tafamidis free acid 61 mg on LASr (p = 0.003) and the LV (LV-GLS: p = 0.030, interventricular septum (IVS): p = 0.006), resulting in clinical benefits (six-minute walk distance (6-MWD): p = 0.006, NT-proBNP: p= <0.001), while patients treated with tafamidis meglumine 20 mg QD showed positive effects on LASr (p = 0.039), but no differences with respect to the LV (LV-GLS: p = 0.274, IVS: p = 0.068) and clinical status (6-MWD: p = 0.124, NT-proBNP: p = 0.053) compared to the natural course. CONCLUSIONS Treatment with tafamidis free acid 61 mg in ATTR-CM patients delays the deterioration of LA and LV longitudinal function, resulting in significant clinical benefits compared with natural history. Serial TTE with 2 D speckle tracking imaging may be appropriate for disease-specific therapy monitoring.
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Affiliation(s)
- René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Bernhard Cherouny
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christopher Mann
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Lore Schrutka
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Silvia Charwat-Resl
- Division of Cardiology, Department of Internal Medicine V, Favoriten Clinic, Vienna, Austria
| | - Roza Badr Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Division of Cardiology, Department of Internal Medicine V, Favoriten Clinic, Vienna, Austria
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Monteiro C, Mesgarzadeh JS, Anselmo J, Fernandes J, Novais M, Rodrigues C, Powers DL, Powers ET, Coelho T, Kelly JW. Tafamidis polyneuropathy amelioration requires modest increases in transthyretin stability even though increases in plasma native TTR and decreases in non-native TTR do not predict response. Amyloid 2023; 30:81-95. [PMID: 36178172 PMCID: PMC9992127 DOI: 10.1080/13506129.2022.2126308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 08/23/2022] [Accepted: 09/13/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND TTR aggregation causes hereditary transthyretin (TTR) polyneuropathy (ATTRv-PN) in individuals with destabilised TTR variants. ATTRv-PN can be treated with ligands that bind TTR and prevent aggregation. One such ligand, tafamidis, is widely approved to treat ATTRv-PN. We explore how TTR stabilisation markers relate to clinical efficacy in 210 ATTRv-PN patients taking tafamidis. METHODS TTR concentration in patient plasma was measured before and after tafamidis treatment using assays for native or combined native + non-native TTR. TTR tetramer dissociation kinetics, which are slowed by tafamidis binding, were also measured. RESULTS Native TTR levels increased by 56.8% while combined native + non-native TTR levels increased by 3.1% after 24 months of tafamidis treatment, implying that non-native TTR decreased. Accordingly, the fraction of native TTR increased from 0.54 to 0.71 with tafamidis administration. Changes in native and non-native TTR levels were uncorrelated with clinical response to tafamidis. TTR tetramer dissociation generally slowed to an extent consistent with ∼40% of TTR being tafamidis-bound. Male non-responders had a lower extent of binding. CONCLUSIONS Native and non-native TTR concentration changes cannot be used as surrogate measures for therapeutic efficacy. Also, successful tafamidis therapy requires only moderate TTR stabilisation. Male patients may benefit from higher tafamidis doses.
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Affiliation(s)
- Cecília Monteiro
- Department of Chemistry, The Scripps Research Institute,
10550 N Torrey Pines Rd, La Jolla, CA 92037, USA
| | - Jaleh S. Mesgarzadeh
- Department of Chemistry, The Scripps Research Institute,
10550 N Torrey Pines Rd, La Jolla, CA 92037, USA
| | - João Anselmo
- Unidade Corino de Andrade, Centro Hospitalar do Porto,
Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Joana Fernandes
- Unidade Corino de Andrade, Centro Hospitalar do Porto,
Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Marta Novais
- Unidade Corino de Andrade, Centro Hospitalar do Porto,
Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Carla Rodrigues
- Unidade Corino de Andrade, Centro Hospitalar do Porto,
Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - David L. Powers
- Department of Mathematics, Clarkson University, Potsdam, NY
13676, USA
| | - Evan T. Powers
- Department of Chemistry, The Scripps Research Institute,
10550 N Torrey Pines Rd, La Jolla, CA 92037, USA
| | - Teresa Coelho
- Unidade Corino de Andrade, Centro Hospitalar do Porto,
Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
- Department of Neurophysiology, Centro Hospitalar do Porto,
Largo do Prof. Abel Salazar, 4099-001 Porto, Portugal
| | - Jeffery W. Kelly
- Department of Chemistry, The Scripps Research Institute,
10550 N Torrey Pines Rd, La Jolla, CA 92037, USA
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Oral Therapy for the Treatment of Transthyretin-Related Amyloid Cardiomyopathy. Int J Mol Sci 2022; 23:ijms232416145. [PMID: 36555787 PMCID: PMC9788438 DOI: 10.3390/ijms232416145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
The care of systemic amyloidosis has improved dramatically due to improved awareness, accurate diagnostic tools, the development of powerful prognostic and companion biomarkers, and a continuous flow of innovative drugs, which translated into the blooming of phase 2/3 interventional studies for light chain (AL) and transthyretin (ATTR) amyloidosis. The unprecedented availability of effective drugs ignited great interest across various medical specialties, particularly among cardiologists who are now recognizing cardiac amyloidosis at an extraordinary pace. In all amyloidosis referral centers, we are observing a substantial increase in the prevalence of wild-type transthyretin (ATTRwt) cardiomyopathy, which is now becoming the most common form of cardiac amyloidosis. This review focuses on the oral drugs that have been recently introduced for the treatment of ATTR cardiac amyloidosis, for their ease of use in the clinic. They include both old repurposed drugs or fit-for-purpose designed compounds which bind and stabilize the TTR tetramer, thus reducing the formation of new amyloid fibrils, such as tafamidis, diflunisal, and acoramidis, as well as fibril disruptors which have the potential to promote the clearance of amyloid deposits, such as doxycycline. The development of novel therapies is based on the advances in the understanding of the molecular events underlying amyloid cardiomyopathy.
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Roy A, Peterson A, Marchant N, Alvir J, Bhambri R, Bredl Z, Benjumea D, Kemner J, Parasuraman B. Baseline characteristics and secondary medication adherence among Medicare patients diagnosed with transthyretin amyloid cardiomyopathy and/or receiving tafamidis prescriptions: A retrospective analysis of a Medicare cohort. J Manag Care Spec Pharm 2022; 28:766-777. [PMID: 35737856 PMCID: PMC10372989 DOI: 10.18553/jmcp.2022.28.7.766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underdiagnosed, life-threatening condition that mostly affects older persons. In May 2019, regulatory approval of tafamidis provided the first pharmacologic treatment of ATTR-CM. In the pivotal phase 3 Transthyretin Amyloidosis Cardiomyopathy Clinical Trial (ATTR-ACT), 97.2% of patients were classified as adherent (defined as taking ≥ 80% of scheduled doses). Given its recent approval, there is limited real-world evidence examining patient adherence to tafamidis. OBJECTIVE: To evaluate adherence patterns, demographics, and clinical characteristics of patients in the United States receiving tafamidis prescriptions through Medicare. Secondarily, we aimed to evaluate concomitant medications filled by this patient population. METHODS: We conducted a retrospective cohort study of US Medicare claims data, limited by the Health Insurance Portability and Accountability Act of 1996, in adult patients with an adjudicated pharmacy claim for tafamidis (tafamidis free acid 61-mg capsule once daily or tafamidis meglumine four 20-mg capsules once daily) between May 1, 2019, and June 30, 2021. Gaps in therapy were measured using day gaps between prescription refills and continuous measure of medication gaps. Implementation adherence was assessed through modified medication possession ratio (MPRm), medication refill adherence (MRA), and proportion of days covered (PDC). Patients were grouped based on Medicare coverage. Patients were analyzed by subgroups based on age and at the zip code level, via distressed communities index quartiles and rural-urban tiers. RESULTS: A total of 3,558 patients who received a prescription fill of a tafamidis formulation were identified using Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) claims data from May 1, 2019, to June 30, 2021. The characteristics of this patient population were consistent with published literature, as 98.6% were older than 65 years, 53.4% were between 75 years and 84 years, and 81.5% were male. In the patient population receiving tafamidis refills, adherence was high across all 3 measures, with mean MPRm greater than 90% and mean MRA greater than 80%, across all age groups. Mean PDC adherence rates were 79% or more across all age groups. Concomitant medications were generally indicated for heart failure and thrombosis. Among monotherapy groups with similar demographic makeup, adherence was significantly higher among users of tafamidis free acid vs tafamidis meglumine (P < 0.0001 across all mean adherence measures). CONCLUSIONS: Our results demonstrate that real-world adherence to tafamidis in the Medicare population is high, regardless of age, zip code-level socioeconomic quartile, or geography. Adherence was higher among patients receiving tafamidis free acid, suggesting that the enhanced convenience of a single capsule once daily may positively contribute to adherence among patients with ATTR-CM. DISCLOSURES: Darrin Benjumea is an employee of Genesis Research who has been contracted by Pfizer, Inc., for involvement in this study. Andrew Peterson is an employee of University of the Sciences who has been contracted by Pfizer, Inc., for involvement in this study. Zach Bredl is an employee of Care Journey who has been contracted by Pfizer, Inc., for involvement in this study. Anuja Roy, Nick Marchant, Jose Alvir, Rahul Bhambri, Jason Kemner, and Bhash Parasuraman are employees of Pfizer, Inc., and own stock and/or stock options. This study was supported by Pfizer, Inc.
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Affiliation(s)
| | - Andrew Peterson
- Department of Pharmacy Practice and Pharmacy Administration, Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA
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Badr Eslam R, Öztürk B, Rettl R, Capelle CDJ, Qin H, Binder C, Dachs TM, Camuz Ligios L, Duca F, Dalos D, Schrutka L, Alasti F, Kastner J, Vila G, Bonderman D. Impact of Tafamidis and Optimal Background Treatment on Physical Performance in Patients With Transthyretin Amyloid Cardiomyopathy. Circ Heart Fail 2022; 15:e008381. [PMID: 35766028 DOI: 10.1161/circheartfailure.121.008381] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with transthyretin amyloid cardiomyopathy, tafamidis was shown to slow the decline in 6-minute walking distance as compared with placebo. We aimed to define the impact of tafamidis and optimal background treatment on functional capacity as determined by cardiopulmonary exercise testing (CPET). METHODS Seventy-eight consecutive patients were enrolled in the study. They underwent CPET at baseline, and outcome defined as death or heart failure hospitalization was obtained for a time period of up to 30 months. Fifty-four patients completed a follow-up CPET at 9±3 months (range, 4-16 months). Improvement in peak VO2 at follow-up was defined as ∆peak VO2≥1.0 mL/(kg·min), stable peak VO2 was defined as 0≤∆peak VO2<1.0 mL/(kg·min), and decline in peak VO2 was defined by ∆peak VO2<0 mL/(kg·min). RESULTS Baseline peak VO2>14 mL/(kg·min) as well as minute ventilation/carbon dioxide production slope≤34 were associated with a lower risk of death or heart failure hospitalization (P=0.002, P=0.007, respectively). In 54 patients, who received tafamidis and underwent repeat CPET testing, an improvement in physical performance (P=0.002) was observed at follow-up. When comparing pre and post-treatment parameters, 29 patients (54%) showed an increase in percent predicted peak VO2 (P<0.0001), an improvement of peak VO2 (P<0.0001), and better physical performance at follow-up (P<0.0001). Patients with stable or improved peak VO2 had less advanced heart disease at baseline (P=0.046). CONCLUSIONS Our findings demonstrate that baseline peak VO2 and baseline minute ventilation/carbon dioxide production slope predict outcomes and an improvement in physical performance as measured by CPET was observed in patients receiving tafamidis, who had less advanced disease at baseline, emphasizing the importance of early diagnosis.
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Affiliation(s)
- Roza Badr Eslam
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Begüm Öztürk
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - René Rettl
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Christophe Denis Josef Capelle
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Hong Qin
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Lore Schrutka
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Farideh Alasti
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria (F.A.)
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
| | - Greisa Vila
- Division of Endocrinology and Metabolism, Department of Internal Medicine III (G.V.), Medical University of Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II (R.B.E., B.O., R.R., C.D.J.C., H.Q., C.B., T.-M.D., L.C.L., F.D., D.D., L.S., J.K., D.B.), Medical University of Vienna, Austria
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9
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Treatment of Transthyretin Amyloid Cardiomyopathy: The Current Options, the Future, and the Challenges. J Clin Med 2022; 11:jcm11082148. [PMID: 35456241 PMCID: PMC9031576 DOI: 10.3390/jcm11082148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 12/13/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressively debilitating, rare disease associated with high mortality. ATTR-CM occurs when TTR amyloid protein builds up in the myocardium along with different organs, most commonly the peripheral and the autonomic nervous systems. Managing the cardiac complications with standard heart failure medications is difficult due to the challenge to maintain a balance between the high filling pressure associated with restricted ventricular volume and the low cardiac output. To date, tafamidis is the only agent approved for ATTR-CM treatment. Besides, several agents, including green tea, tolcapone, and diflunisal, are used off-label in ATTR-CM patients. Novel therapies using RNA interference also offer clinical promise. Patisiran and inotersen are currently approved for ATTR-polyneuropathy of hereditary origin and are under investigation for ATTR-CM. Monoclonal antibodies in the early development phases carry hope for amyloid deposit clearance. Despite several drug candidates in the clinical development pipeline, the small ATTR-CM patient population raises several challenges. This review describes current and future therapies for ATTR-CM and sheds light on the clinical development hurdles facing them.
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10
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Elliott P, Drachman BM, Gottlieb SS, Hoffman JE, Hummel SL, Lenihan DJ, Ebede B, Gundapaneni B, Li B, Sultan MB, Shah SJ. Long-Term Survival With Tafamidis in Patients With Transthyretin Amyloid Cardiomyopathy. Circ Heart Fail 2021; 15:e008193. [PMID: 34923848 PMCID: PMC8763250 DOI: 10.1161/circheartfailure.120.008193] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: Tafamidis is approved in many countries for the treatment of transthyretin amyloid cardiomyopathy. This study reports data on the long-term efficacy of tafamidis from an ongoing long-term extension (LTE) to the pivotal ATTR-ACT (Tafamidis in Transthyretin Cardiomyopathy Clinical Trial). Methods: Patients with transthyretin amyloid cardiomyopathy who completed ATTR-ACT could enroll in an LTE, continuing with the same tafamidis dose or, if previously treated with placebo, randomized (2:1) to tafamidis meglumine 80 or 20 mg. All patients in the LTE transitioned to tafamidis free acid 61 mg (bioequivalent to tafamidis meglumine 80 mg) following a protocol amendment. In this interim analysis, all-cause mortality was assessed in patients treated with tafamidis meglumine 80 mg in ATTR-ACT continuing in the LTE, compared with those receiving placebo in ATTR-ACT transitioning to tafamidis in the LTE. Results: Median follow-up was 58.5 months in the continuous tafamidis group (n=176) and 57.1 months in the placebo to tafamidis group (n=177). There were 79 (44.9%) deaths with continuous tafamidis and 111 (62.7%) with placebo to tafamidis (hazard ratio, 0.59 [95% CI, 0.44–0.79]; P<0.001). Mortality was also reduced in the continuous tafamidis (versus placebo to tafamidis) subgroups of: variant transthyretin amyloidosis (0.57 [0.33–0.99]; P=0.05) and wild-type transthyretin amyloidosis (0.61 [0.43–0.87]; P=0.006); and baseline New York Heart Association class I and II (0.56 [0.38–0.82]; P=0.003) and class III (0.65 [0.41–1.01]; P=0.06). Conclusions: In the LTE, patients initially treated with tafamidis in ATTR-ACT had substantially better survival than those first treated with placebo, highlighting the importance of early diagnosis and treatment in transthyretin amyloid cardiomyopathy. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01994889 and NCT02791230.
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Affiliation(s)
| | - Brian M Drachman
- Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia (B.M.D.)
| | | | | | - Scott L Hummel
- University of Michigan and Ann Arbor Veterans Affairs Health System (S.L.H.)
| | - Daniel J Lenihan
- Washington University School of Medicine, St. Louis, MO (D.J.L.)
| | | | | | | | | | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
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11
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Smerikarova M, Bozhanov S, Maslarska V, Tournev I. Determination of Tafamidis Plasma Concentrations in Amyloidosis Patients with Glu89Gln Mutation by HPLC-UV Detection. J Chromatogr Sci 2021; 60:840-847. [PMID: 34897414 DOI: 10.1093/chromsci/bmab132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Indexed: 11/14/2022]
Abstract
Present study describes a high-performance liquid chromatography method for the determination of the potent kinetic stabilizer-Tafamidis in human plasma. It was approved for medical use in European Union in 2011. Ultra violet (UV) detection mode and isocratic elution of the mobile phase were set and made the analytical procedure fast and widely applicable. Chromatographic determination was performed on a Purospher® RP-18 column. The mobile phase consisted of 0.1% trifluoroacetic acid in water and acetonitrile in the ratio 42:58 v/v and the flow rate was 1.0 ml/min. All analyses were carried at a room temperature and the detector was set at 280 nm. Calibration curve over a range of 1.00-10.00 μM was constructed for the purposes of linearity method validation. The specificity and effectiveness of the developed method made it suitable for observation of patients' plasma Tafamidis concentration with time and drug therapy monitoring.
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Affiliation(s)
- Miglena Smerikarova
- Department of Chemistry, Faculty of Pharmacy, Medical University, Dunav Str. no. 2, Sofia 1000, Bulgaria
| | - Stanislav Bozhanov
- Department of Chemistry, Faculty of Pharmacy, Medical University, Dunav Str. no. 2, Sofia 1000, Bulgaria
| | - Vania Maslarska
- Department of Chemistry, Faculty of Pharmacy, Medical University, Dunav Str. no. 2, Sofia 1000, Bulgaria
| | - Ivailo Tournev
- Clinic of Nervous Diseases, UMBAL Aleksandrovska, Department of Neurology, Medical University, Sv. Georgi Sofiiski Str. no. 1, Sofia 1431, Bulgaria
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12
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Rettl R, Mann C, Duca F, Dachs TM, Binder C, Ligios LC, Schrutka L, Dalos D, Koschutnik M, Donà C, Kammerlander A, Beitzke D, Loewe C, Charwat-Resl S, Hengstenberg C, Kastner J, Eslam RB, Bonderman D. Tafamidis treatment delays structural and functional changes of the left ventricle in patients with transthyretin amyloid cardiomyopathy. Eur Heart J Cardiovasc Imaging 2021; 23:767-780. [PMID: 34788394 DOI: 10.1093/ehjci/jeab226] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS Tafamidis improves outcomes in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). However, it is not yet known whether tafamidis affects cardiac amyloid deposition and structural changes in the myocardium. We aimed to determine disease-modifying effects on myocardial amyloid progression and to identify imaging parameters that could be applied for specific therapy monitoring. METHODS AND RESULTS ATTR-CM patients underwent serial cardiac magnetic resonance (CMR) imaging using T1 mapping techniques to derive extracellular volume (ECV). Patients receiving tafamidis 61 mg (n = 35) or 20 mg (n = 15) once daily showed stable measurements at follow-up (FU) {61 mg: 9.0 [interquartile range (IQR) 7.0-11.0] months, 20 mg: 11.0 (IQR 8.0-18.0) months} in left ventricular (LV) ejection fraction (LVEF; 61 mg: 47.6% vs. 47.5%, P = 0.935; 20 mg: 52.4% vs. 52.1%, P = 0.930), LV mass index (LVMI; 61 mg: 110.2 vs. 106.2 g/m2, P = 0.304; 20 mg: 114.5 vs. 115.4 g/m2, P = 0.900), and ECV (61 mg: 47.5% vs. 47.7%, P = 0.861; 20 mg: 56.7% vs. 57.5%, P = 0.759), whereas treatment-naïve ATTR-CM patients (n = 19) had clear signs of disease progression at the end of the observation period [12.0 (IQR 10.0-21.0) months; LVEF: 53.3% vs. 45.7%, P = 0.031; LVMI: 98.9 vs. 106.9 g/m2, P = 0.027; ECV: 49.3% vs. 54.6%, P = 0.023]. Between-group comparison at FU revealed positive effects in tafamidis 61 mg-treated compared to treatment-naïve patients (LVEF: P = 0.035, LVMI: P = 0.036, ECV: P = 0.030), while those treated with 20 mg showed no difference in the above LV measurements when compared with treatment-naïve (P = 0.120, P = 0.287, P = 0.158). However, both treatment groups showed clinically beneficial effects compared to the natural course [61 mg, 6-min walk distance (6-MWD): P = 0.005, N-terminal prohormone of brain natriuretic peptide (NT-proBNP): P = 0.002; 20 mg, 6-MWD: P = 0.023, NT-proBNP: P = 0.003]. CONCLUSION Tafamidis delays myocardial amyloid progression in ATTR-CM patients, resulting in structural, functional, and clinical benefits compared to the natural course. Serial CMR including measurement of ECV may be appropriate for disease-specific therapy monitoring.
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Affiliation(s)
- René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christopher Mann
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Theresa-Marie Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Lore Schrutka
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Carolina Donà
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Andreas Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Dietrich Beitzke
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Christian Loewe
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Silvia Charwat-Resl
- Department of Cardiology, Clinic Favoriten, Kundratstraße 3, 1100 Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Roza Badr Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.,Department of Cardiology, Clinic Favoriten, Kundratstraße 3, 1100 Vienna, Austria
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13
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Griffin JM, Rosenthal JL, Grodin JL, Maurer MS, Grogan M, Cheng RK. ATTR Amyloidosis: Current and Emerging Management Strategies: JACC: CardioOncology State-of-the-Art Review. JACC: CARDIOONCOLOGY 2021; 3:488-505. [PMID: 34729521 PMCID: PMC8543085 DOI: 10.1016/j.jaccao.2021.06.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 12/15/2022]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is increasingly diagnosed owing to the emergence of noninvasive imaging and improved awareness. Clinical penetrance of pathogenic alleles is not complete and therefore there is a large cohort of asymptomatic transthyretin variant carriers. Screening strategies, monitoring, and treatment of subclinical ATTR-CA requires further study. Perhaps the most important translational triumph has been the development of effective therapies that have emerged from a biological understanding of ATTR-CA pathophysiology. These include recently proven strategies of transthyretin protein stabilization and silencing of transthyretin production. Data on neurohormonal blockade in ATTR-CA are limited, with the primary focus of medical therapy on judicious fluid management. Atrial fibrillation is common and requires anticoagulation owing to the propensity for thrombus formation. Although conduction disease and ventricular arrhythmias frequently occur, little is known regarding optimal management. Finally, aortic stenosis and ATTR-CA frequently coexist, and transcatheter valve replacement is the preferred treatment approach.
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Key Words
- 6MWT, 6-minute walk test
- AF, atrial fibrillation
- AL, light chain amyloid
- AS, aortic stenosis
- ASO, antisense oligonucleotide
- ATTR-CA, transthyretin cardiac amyloidosis
- ATTRv, variant transthyretin cardiac amyloidosis
- ATTRwt, wild-type transthyretin cardiac amyloidosis
- CMR, cardiac magnetic resonance
- DCCV, direct current cardioversion
- HF, heart failure
- LVEF, left ventricular ejection fraction
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- SAP, serum amyloid P component
- TAVR, transcatheter aortic valve replacement
- amyloidosis
- cardiomyopathy
- heart failure
- siRNA, small interfering RNA
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Affiliation(s)
- Jan M Griffin
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mathew S Maurer
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Richard K Cheng
- University of Washington Medical Center, Seattle, Washington, USA
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14
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Falk RH, Haddad M, Walker CR, Dorbala S, Cuddy SAM. Effect of Tafamidis on Serum Transthyretin Levels in Non-Trial Patients With Transthyretin Amyloid Cardiomyopathy. JACC: CARDIOONCOLOGY 2021; 3:580-586. [PMID: 34729530 PMCID: PMC8543137 DOI: 10.1016/j.jaccao.2021.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 11/28/2022]
Abstract
Background Transthyretin amyloid (ATTR) cardiomyopathy is slowed by tafamidis, which stabilizes the TTR molecule and reduces the formation of amyloidogenic oligomers. Stabilizers in clinical doses raise serum TTR, which may be a surrogate for the degree of stabilization. Objectives This study aims to determine, in a non-trial, unselected population of patients with ATTR cardiomyopathy, the effect of tafamidis on serum levels of TTR, and to compare these with published data of changes in TTR. Methods TTR levels were measured before therapy and 3 to 12 months following initiation of tafamidis therapy in all patients seen between May 20, 2019, and March 1, 2021, who had a follow-up visits within 12 months of therapy initiation. Results Among 72 patients with ATTR cardiomyopathy (67 patients with wild-type and 5 patients with variant TTR), administration of tafamidis increased serum TTR from 21.8 mg ± 0.7 mg/dL to 29.3 ± 0.86 mg/dL, an increase of 34.5%. In 5 patients with variant TTR, the increase was 70.9%, compared to 32.0% in the wild-type patients. Mean N-terminal pro-brain natriuretic peptide increased over a mean follow-up of 21 ± 1.2 weeks, but the change was not statistically significant. Over the same period there was a small increase in high-sensitivity troponin T that was of borderline statistical significance (P = 0.057). Conclusions Tafamidis consistently increases serum TTR levels in patients with ATTR cardiomyopathy, consistent with its effect on stabilizing TTR. Measurement of TTR level change post-TTR stabilizing therapy might be a surrogate for stabilization and could be a more accurate measure of drug efficacy than an in vitro nonphysiologic test of stabilization.
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Affiliation(s)
- Rodney H Falk
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mia Haddad
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Crystal R Walker
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah A M Cuddy
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,CV Imaging Program, Cardiovascular Division, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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15
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Obici L, Mussinelli R. Current and Emerging Therapies for Hereditary Transthyretin Amyloidosis: Strides Towards a Brighter Future. Neurotherapeutics 2021; 18:2286-2302. [PMID: 34850359 PMCID: PMC8804119 DOI: 10.1007/s13311-021-01154-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 12/19/2022] Open
Abstract
The past few years have witnessed an unprecedented acceleration in the clinical development of novel therapeutic options for hereditary transthyretin amyloidosis. Recently approved agents and drugs currently under investigation not only represent a major breakthrough in this field but also provide validation of the therapeutic potential of innovative approaches, like RNA interference and CRISPR-Cas9-mediated gene editing, in rare inherited disorders. In this review, we describe the evolving therapeutic landscape for hereditary transthyretin amyloidosis and discuss how this highly disabling and fatal condition is turning into a treatable disease. We also provide an overview of the molecular mechanisms involved in transthyretin (TTR) amyloid formation and regression, to highlight how a deeper understanding of these processes has contributed to the identification of novel treatment targets. Finally, we focus on major areas of uncertainty and unmet needs that deserve further efforts to improve long-term patients' outcomes and allow for a brighter future.
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Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy.
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy
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16
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Plumadore E, Lombardo L, Cabral KP. Pharmacotherapy review: Emerging treatment modalities in transthyretin cardiac amyloidosis. Am J Health Syst Pharm 2021; 79:52-62. [PMID: 34491302 DOI: 10.1093/ajhp/zxab356] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE This review aims to summarize the evidence and pharmacological characteristics of treatment options for transthyretin amyloid cardiomyopathy (ATTR-CM). Additionally, this review highlights the role of clinical pharmacists in helping to secure newly introduced therapies. SUMMARY ATTR-CM, a disease characterized by misfolded protein that is deposited in the myocardium and disrupts cardiac functioning, has historically been underdiagnosed due to the need for invasive biopsy and an illusion of rarity. Once diagnosed, limited treatment modalities for ATTR-CM have led providers to rely on nonpharmacological remedies or off-label use of medications with limited evidence of benefit. However, recent noninvasive diagnostic advancements and heightened disease state awareness have revealed increased prevalence of ATTR-CM. This has led to the introduction of several first-in-class pharmaceuticals with actions targeted at inhibiting the various phases of amyloidosis: TTR stabilizers include diflunisal and first-in-class, Food and Drug Administration (FDA)-approved tafamidis; TTR silencers include patisiran and inotersen; fibril disrupters include doxycycline with tauroursodeoxycholic acid; and alternative agents include green tea extract and curcumin. CONCLUSION ATTR-CM treatments have emerged and, despite current limited data, are continuing to evolve. Tafamidis, the only agent approved by FDA for ATTR-CM, shows promise to improve survival and quality of life in patients with ATTR-CM. Pharmacists can play a key role in assisting with agent selection for this disease state, as well as providing knowledge about current and future clinical trials evaluating the safety and efficacy of the available treatment modalities.
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Affiliation(s)
| | | | - Katherine P Cabral
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA.,Capital Cardiology Associates, Albany, NY, USA
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17
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Carvalho RL, de Miranda AS, Nunes MP, Gomes RS, Jardim GAM, Júnior ENDS. On the application of 3d metals for C-H activation toward bioactive compounds: The key step for the synthesis of silver bullets. Beilstein J Org Chem 2021; 17:1849-1938. [PMID: 34386103 PMCID: PMC8329403 DOI: 10.3762/bjoc.17.126] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/28/2021] [Indexed: 01/24/2023] Open
Abstract
Several valuable biologically active molecules can be obtained through C-H activation processes. However, the use of expensive and not readily accessible catalysts complicates the process of pharmacological application of these compounds. A plausible way to overcome this issue is developing and using cheaper, more accessible, and equally effective catalysts. First-row transition (3d) metals have shown to be important catalysts in this matter. This review summarizes the use of 3d metal catalysts in C-H activation processes to obtain potentially (or proved) biologically active compounds.
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Affiliation(s)
- Renato L Carvalho
- Institute of Exact Sciences, Department of Chemistry, Federal University of Minas Gerais - UFMG, CEP 31270-901, Belo Horizonte, MG, Brazil
| | - Amanda S de Miranda
- Institute of Exact Sciences, Department of Chemistry, Federal University of Minas Gerais - UFMG, CEP 31270-901, Belo Horizonte, MG, Brazil
| | - Mateus P Nunes
- Institute of Exact Sciences, Department of Chemistry, Federal University of Minas Gerais - UFMG, CEP 31270-901, Belo Horizonte, MG, Brazil
| | - Roberto S Gomes
- Department of Pharmaceutical Sciences, North Dakota State University, Fargo, ND, United States
| | - Guilherme A M Jardim
- Institute of Exact Sciences, Department of Chemistry, Federal University of Minas Gerais - UFMG, CEP 31270-901, Belo Horizonte, MG, Brazil
- Centre for Excellence for Research in Sustainable Chemistry (CERSusChem), Department of Chemistry, Federal University of São Carlos – UFSCar, CEP 13565-905, São Carlos, SP, Brazil
| | - Eufrânio N da Silva Júnior
- Institute of Exact Sciences, Department of Chemistry, Federal University of Minas Gerais - UFMG, CEP 31270-901, Belo Horizonte, MG, Brazil
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18
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Kelly J, Powers E. Response. Amyloid 2021; 28:140-141. [PMID: 33274653 DOI: 10.1080/13506129.2020.1853094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Jeffery Kelly
- Department of Chemistry, The Skaggs Institute for Chemical Biology, The Scripps Research Institute Scripps, La Jolla, CA, USA
| | - Evan Powers
- Department of Chemistry, The Skaggs Institute for Chemical Biology, The Scripps Research Institute Scripps, La Jolla, CA, USA
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19
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Obici L, Adams D. Acquired and inherited amyloidosis: Knowledge driving patients' care. J Peripher Nerv Syst 2021; 25:85-101. [PMID: 32378274 DOI: 10.1111/jns.12381] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/19/2022]
Abstract
Until recently, systemic amyloidoses were regarded as ineluctably disabling and life-threatening diseases. However, this field has witnessed major advances in the last decade, with significant improvements in therapeutic options and in the availability of accurate and non-invasive diagnostic tools. Outstanding progress includes unprecedented hematological response rates provided by risk-adapted regimens in light chain (AL) amyloidosis and the approval of innovative pharmacological agents for both hereditary and wild-type transthyretin amyloidosis (ATTR). Moreover, the incidence of secondary (AA) amyloidosis has continuously reduced, reflecting advances in therapeutics and overall management of several chronic inflammatory diseases. The identification and validation of novel therapeutic targets has grounded on a better knowledge of key molecular events underlying protein misfolding and aggregation and on the increasing availability of diagnostic, prognostic and predictive markers of organ damage and response to treatment. In this review, we focus on these recent advancements and discuss how they are translating into improved outcomes. Neurological involvement dominates the clinical picture in transthyretin and gelsolin inherited amyloidosis and has a significant impact on disease course and management in all patients. Neurologists, therefore, play a major role in improving patients' journey to diagnosis and in providing early access to treatment in order to prevent significant disability and extend survival.
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Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - David Adams
- National Reference Center for Familial Amyloid Polyneuropathy and Other Rare Neuropathies, APHP, Université Paris Saclay, INSERM U1195, Le Kremlin Bicêtre, France
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20
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Abstract
Often considered a rare disease, cardiac amyloidosis is increasingly recognized by practicing clinicians. The increased rate of diagnosis is in part due the aging of the population and increasing incidence and prevalence of cardiac amyloidosis with advancing age, as well as the advent of noninvasive methods using nuclear scintigraphy to diagnose transthyretin cardiac amyloidosis due to either variant or wild type transthyretin without a biopsy. Perhaps the most important driver of the increased awareness is the elucidation of the biologic mechanisms underlying the pathogenesis of cardiac amyloidosis which have led to the development of several effective therapies with differing mechanisms of actions. In this review, the mechanisms underlying the pathogenesis of cardiac amyloidosis due to light chain (AL) or transthyretin (ATTR) amyloidosis are delineated as well as the rapidly evolving therapeutic landscape that has emerged from a better pathophysiologic understanding of disease development.
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Affiliation(s)
- Jan M. Griffin
- Division of Cardiology, Cardiovascular Research Laboratory
for the Elderly, Columbia University Irving Medical Center, New York, NY
| | - Hannah Rosenblum
- Division of Cardiology, Cardiovascular Research Laboratory
for the Elderly, Columbia University Irving Medical Center, New York, NY
| | - Mathew S. Maurer
- Division of Cardiology, Cardiovascular Research Laboratory
for the Elderly, Columbia University Irving Medical Center, New York, NY
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21
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Benbrahim M, Norman K, Sanchorawala V, Siddiqi OK, Hughes D. A Review of Novel Agents and Clinical Considerations in Patients With ATTR Cardiac Amyloidosis. J Cardiovasc Pharmacol 2021; 77:544-548. [PMID: 33657048 DOI: 10.1097/fjc.0000000000001004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/04/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Transthyretin (ATTR) amyloidosis is a multisystem disease caused by organ deposition of amyloid fibrils derived from the misfolded transthyretin (TTR) protein. The purpose of this article is to provide an overview of current treatment regimens and summarize important considerations for each agent. A literature search was performed with the PubMed database for articles published through October 2020. Search criteria included therapies available on the market and investigational therapies used for ATTR amyloidosis treatment. Both prospective clinical trials and retrospective studies have been included in this review. Available therapies discussed in this review article are tafamidis, diflunisal, patisiran, and inotersen. Tafamidis is FDA approved for treatment of wild-type ATTR (ATTRwt) and hereditary ATTR (ATTRv) cardiomyopathy, and patisiran and inotersen are FDA approved for ATTRv polyneuropathy. Diflunisal does not have an FDA-labeled indication for amyloidosis but has been studied in ATTRv polyneuropathy and ATTRwt cardiomyopathy. Investigational therapies include a TTR stabilizer, AG10; 2 antifibril agents, PRX004 and doxycycline/tauroursodeoxycholic acid; and 2 gene silencers, vutrisiran and AKCEA-TTR-LRx; and clinical trials are ongoing. ATTR amyloidosis treatment selection is based on subtype and presence of cardiac or neurological manifestations. Additional considerations such as side effects, monitoring, and administration are outlined in this review.
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Affiliation(s)
| | - Kelsey Norman
- Department of Pharmacy, Boston Medical Center, Boston, MA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA; and
| | - Omar K Siddiqi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA; and
- Section of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA
| | - David Hughes
- Department of Pharmacy, Boston Medical Center, Boston, MA
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22
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Burton A, Castaño A, Bruno M, Riley S, Schumacher J, Sultan MB, See Tai S, Judge DP, Patel JK, Kelly JW. Drug Discovery and Development in Rare Diseases: Taking a Closer Look at the Tafamidis Story. Drug Des Devel Ther 2021; 15:1225-1243. [PMID: 33776421 PMCID: PMC7987260 DOI: 10.2147/dddt.s289772] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/20/2021] [Indexed: 12/25/2022] Open
Abstract
Rare diseases are increasingly recognized as a global public health priority. Governments worldwide currently provide important incentives to stimulate the discovery and development of orphan drugs for the treatment of these conditions, but substantial scientific, clinical, and regulatory challenges remain. Tafamidis is a first-in-class, disease-modifying transthyretin (TTR) kinetic stabilizer that represents a major breakthrough in the treatment of transthyretin amyloidosis (ATTR amyloidosis). ATTR amyloidosis is a rare, progressive, and fatal systemic disorder caused by aggregation of misfolded TTR and extracellular deposition of amyloid fibrils in various tissues and organs, including the heart and nervous systems. In this review, we present the successful development of tafamidis spanning 3 decades, marked by meticulous laboratory research into disease mechanisms and natural history, and innovative clinical study design and implementation. These efforts established the safety and efficacy profile of tafamidis, leading to its regulatory approval, and enabled post-approval initiatives that further support patients with ATTR amyloidosis.
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Affiliation(s)
| | | | | | - Steve Riley
- Clinical Pharmacology, Pfizer Inc, Groton, CT, USA
| | | | - Marla B Sultan
- Global Product Development, Pfizer Inc, New York, NY, USA
| | - Sandi See Tai
- Global Product Development, Pfizer Inc, Collegeville, PA, USA
| | - Daniel P Judge
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Jignesh K Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Jeffery W Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
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23
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Nelson LT, Paxman RJ, Xu J, Webb B, Powers ET, Kelly JW. Blinded potency comparison of transthyretin kinetic stabilisers by subunit exchange in human plasma. Amyloid 2021; 28:24-29. [PMID: 32811187 PMCID: PMC7952025 DOI: 10.1080/13506129.2020.1808783] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Transthyretin (TTR) tetramer dissociation is rate limiting for aggregation and subunit exchange. Slowing of TTR tetramer dissociation via kinetic stabiliser binding slows cardiomyopathy progression. Quadruplicate subunit exchange comparisons of the drug candidate AG10, and the drugs tolcapone, diflunisal, and tafamidis were carried out at 1, 5, 10, 20 and 30 µM concentrations in 4 distinct pooled wild type TTR (TTRwt) human plasma samples. These experiments reveal that the concentration dependence of the efficacy of each compound at inhibiting TTR dissociation was primarily determined by the ratio between the stabiliser's dissociation constants from TTR and albumin, which competes with TTR to bind kinetic stabilisers. The best stabilisers, tafamidis (80 mg QD), AG10 (800 mg BID), and tolcapone (3 x 100 mg over 12 h), exhibit very similar kinetic stabilisation at the plasma concentrations resulting from these doses. At a 10 µM plasma concentration, AG10 is slightly more potent as a kinetic stabiliser vs. tolcapone and tafamidis (which are similar), which are substantially more potent than diflunisal. Dissociation of TTR can be limited to 10% of its normal rate at concentrations of 5.7 µM AG10, 10.3 µM tolcapone, 12.0 µM tafamidis, and 188 µM diflunisal. The potency similarities revealed by our study suggest that differences in safety, adsorption and metabolism, pharmacokinetics, and tissue distribution become important for kinetic stabiliser clinical use decisions.
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Affiliation(s)
- Luke T Nelson
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Ryan J Paxman
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Jin Xu
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Bill Webb
- Center for Metabolomics, The Scripps Research Institute, La Jolla, CA, USA
| | - Evan T Powers
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA
| | - Jeffery W Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA, USA.,The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, CA, USA
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24
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Rapezzi C, Aimo A, Emdin M. Tafamidis is entering the clinical arena for the treatment of transthyretin-related cardiomyopathy: certainties and unmet needs. Eur J Heart Fail 2021; 23:286-289. [PMID: 33443315 DOI: 10.1002/ejhf.2104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Claudio Rapezzi
- Cardiovascular Center, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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25
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Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive, life-threatening disease characterized by the aggregation and deposition of amyloidogenic misfolded transthyretin (TTR) in the myocardium. The gradual accumulation of insoluble TTR amyloid fibrils can result in restrictive cardiomyopathy and heart failure. Tafamidis (Vyndaqel®; Vyndamax®), a TTR stabilizer, has been approved for use in the treatment of adults with ATTR-CM in several countries. Tafamidis stabilizes both wild-type and mutant TTR, inhibiting the formation of TTR amyloid fibrils. In the pivotal phase III ATTR-ACT trial, tafamidis significantly reduced all-cause mortality and frequency of cardiovascular-related hospitalizations relative to placebo in patients with ATTR-CM. In addition, tafamidis recipients experienced significantly less deterioration in 6-minute walk test distance and quality of life than placebo recipients over the 30-month treatment period. Treatment benefits were largely consistent between patients with wild-type TTR and patients with a variant TTR genotype. Tafamidis was generally well tolerated in patients with ATTR-CM and, with a safety profile similar to that of placebo, tafamidis is suitable for long-term use. Given that treatment for this condition has in the past been largely limited to symptom management, tafamidis constitutes a valuable disease-modifying therapy for patients with ATTR-CM.
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26
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Damy T, Garcia‐Pavia P, Hanna M, Judge DP, Merlini G, Gundapaneni B, Patterson TA, Riley S, Schwartz JH, Sultan MB, Witteles R. Efficacy and safety of tafamidis doses in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT) and long-term extension study. Eur J Heart Fail 2020; 23:277-285. [PMID: 33070419 PMCID: PMC8048553 DOI: 10.1002/ejhf.2027] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/10/2020] [Accepted: 10/13/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Tafamidis is an effective treatment for transthyretin amyloid cardiomyopathy (ATTR‐CM) in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR‐ACT). While ATTR‐ACT was not designed for a dose‐specific assessment, further analysis from ATTR‐ACT and its long‐term extension study (LTE) can guide determination of the optimal dose. Methods and results In ATTR‐ACT, patients were randomized (2:1:2) to tafamidis 80 mg, 20 mg, or placebo for 30 months. Patients completing ATTR‐ACT could enrol in the LTE (with placebo‐treated patients randomized to tafamidis 80 or 20 mg; 2:1) and all patients were subsequently switched to high‐dose tafamidis. All‐cause mortality was assessed in ATTR‐ACT combined with the LTE (median follow‐up 51 months). In ATTR‐ACT, the combination of all‐cause mortality and cardiovascular‐related hospitalizations over 30 months was significantly reduced with tafamidis 80 mg (P = 0.0030) and 20 mg (P = 0.0048) vs. placebo. All‐cause mortality vs. placebo was reduced with tafamidis 80 mg [Cox hazards model (95% confidence interval): 0.690 (0.487–0.979), P = 0.0378] and 20 mg [0.715 (0.450–1.137), P = 0.1564]. The mean (standard error) change in N‐terminal pro‐B‐type natriuretic peptide from baseline to Month 30 was −1170.51 (587.31) (P = 0.0468) with tafamidis 80 vs. 20 mg. In ATTR‐ACT combined with the LTE there was a significantly greater survival benefit with tafamidis 80 vs. 20 mg [0.700 (0.501–0.979), P = 0.0374]. Incidence of adverse events in both tafamidis doses were comparable to placebo. Conclusion Tafamidis, both 80 and 20 mg, effectively reduced mortality and cardiovascular‐related hospitalizations in patients with ATTR‐CM. The longer‐term survival data and the lack of dose‐related safety concerns support tafamidis 80 mg as the optimal dose. Clinical Trial Registration: ClinicalTrials.gov NCT01994889; NCT02791230.
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Affiliation(s)
- Thibaud Damy
- French Referral Center for Cardiac Amyloidosis, Amyloidosis Mondor Network, GRC Amyloid Research Institute and Department of Cardiology, all at APHP, CHU Henri Mondor; and INSERM U955, Clinical Investigation Center 006, and DHU ATVBCréteilFrance
| | - Pablo Garcia‐Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, CIBERCVMadridSpain
- Universidad Francisco de Vitoria, Pozuelo de AlarconMadridSpain
| | - Mazen Hanna
- Amyloidosis CentreCleveland ClinicClevelandOHUSA
| | | | - Giampaolo Merlini
- Amyloidosis CenterIRCCS Policlinico San Matteo and University of PaviaPaviaItaly
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