title: Rituximab for treatment of refractory/relapsing thrombotic thrombocytopenic purpura (TTP).
abstract: Plasma exchange is the standard treatment for thrombotic thrombocytopenic purpura (TTP). For patients refractory to plasma exchange, treatment options are limited and often unsuccessful. The platelet thrombi that form in acquired TTP are believed to result from the presence of procoagulant ultralarge multimers of von Willebrand factor (VWF) in the circulation due to autoantibody inhibition of VWF cleaving protease (ADAMTS-13), the enzyme that normally cleaves the ultralarge multimers. Rituximab, a chimeric monoclonal antibody against CD20, has been recognized as a useful therapy for antibody-mediated autoimmune disease. We therefore treated four patients with recurrent TTP with 2 or 4 weekly doses of rituximab in addition to corticosteroids, vincristine, plasma, or continuing plasma exchange. Three patients responded with prompt improvement in microangiopathic hemolytic anemia and thrombocytopenia, which allowed plasma exchange to be discontinued or avoided and prednisone to be rapidly discontinued. Two of the 3 responders have remained in unmaintained complete remission for 13+ months. The third patient relapsed at 13 months; a second course of rituximab and prednisone resulted in an unmaintained remission for 6+ months. All four patients were tested for ADAMTS-13 activity and its inhibitor at a point in their course when samples were available. Low ADAMTS-13 activity was noted in 3 patients tested at relapse, and the inhibitor activity was detectable in 2 patients. ADAMTS-13 activity increased during remission in one of these 2 patients although the patient had a persistence of the inhibitor. One patient tested only during remission had a normal ADAMTS-13 level. We conclude that rituximab may have a role and deserves further study in the treatment of patients with relapsing TTP.
authors.affiliation: Hematology/Oncology, Washington Hospital Center, Washington, DC 20010, USA.
authors.forename: Afaq
authors.initials: A
authors.lastname: Ahmad
authors.forename: Anita
authors.initials: A
authors.lastname: Aggarwal
authors.forename: Daya
authors.initials: D
authors.lastname: Sharma
authors.forename: Harish P
authors.initials: HP
authors.lastname: Dave
authors.forename: Virginia
authors.initials: V
authors.lastname: Kinsella
authors.forename: Margaret E
authors.initials: ME
authors.lastname: Rick
authors.forename: Geraldine P
authors.initials: GP
authors.lastname: Schechter
mesh_terms: D051722:ADAM Proteins; D000071120:ADAMTS13 Protein; D000911:Antibodies, Monoclonal / Q000008:administration & dosage / Q000627:therapeutic use*; D058846:Antibodies, Monoclonal, Murine-Derived; D003131:Combined Modality Therapy; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D008666:Metalloendopeptidases / Q000378:metabolism; D008875:Middle Aged; D010951:Plasma Exchange; D011697:Purpura, Thrombotic Thrombocytopenic / Q000097:blood / Q000188:drug therapy* / Q000201:enzymology; D012008:Recurrence; D000069283:Rituximab; D016896:Treatment Outcome; D014841:von Willebrand Factor / Q000378:metabolism
chemical_list: D000911:Antibodies, Monoclonal; D058846:Antibodies, Monoclonal, Murine-Derived; D014841:von Willebrand Factor; D000069283:Rituximab; D051722:ADAM Proteins; D008666:Metalloendopeptidases; D000071120:ADAMTS13 Protein; C099604:ADAMTS13 protein, human