On Location 2018 ASH Annual Meeting
Age, Blood Type, and Rituximab Use Associated With Relapse Risk in TTP
For patients with thrombotic thrombocyto-
penic purpura (TTP), rituximab prevented
relapse in the first year after administration,
but the protective effect waned over time,
according to results from a study presented
at the 2018 ASH Annual Meeting. The
authors, led by Lova Sun, MD, from Mas-
sachusetts General Hospital, also found that
younger age, prior episodes of TTP at
presentation, and a non-O blood type
predicted a higher risk of relapse.
“Rituximab has been increasingly
incorporated into the treatment of TTP,
but the exact nature and duration of its
impact on relapse has not yet been fully
established,” Dr. Sun said during her
presentation. “The goal of our study was
to identify risk factors at presentation for
subsequent TTP relapse and to charac-
terize the impact of rituximab on relapse
in the setting of increased use of this
drug for TTP in the past decade or so.”
The study consecutively enrolled 124
patients who presented with acute TTP
at one of five academic medical centers
between 2004 and 2017. The median age
at presentation was 42 years (range = 31-
52 years), and most patients (104; 84%)
presented with de novo disease.
Of the 124 patients enrolled, 60
(48%) received rituximab, and the au-
thors observed an “unsurprisingly steady
increase” in the proportion of patients
who were treated with rituximab during
the study period. The drug was admin-
istered at a median of 12 days (range =
7-24 days) after presentation.
Thirty-four patients in the entire
cohort (27%) experienced disease
relapse at a median of 1.96 years (range
= 1.05-4.07 years) after presentation.
Eight patients (7.3%) died within 90
days of presentation, most frequently
due to infections or cardiac arrest. Dr.
Sun noted that these patients had a
delay to diagnosis and start of plasma
exchange therapy.
The baseline characteristics between
patients who did and did not receive
rituximab were similar, she reported,
“with the exception that patients who
received rituximab had a more severe
and refractory disease course, lower
platelet count at day 4 [after presenta-
tion], a higher reticulocyte count, and
more plasma exchange procedures.” (P
values for these comparisons were not
reported.)
In a Kaplan-Meier survival analysis,
the researchers found that patients
treated with rituximab had a signifi-
cantly lower relapse risk at one year
after presentation, compared with
patients who did not receive ritux-
imab (p=0.01). However, at five years
of follow-up, the relapse-free survival
curves converged, with no difference
over time (p=0.45).
The median time to relapse among all
patients was 1.96 years (range = 1.08-4.06
years) and was nearly three times longer in
the rituximab-treated group than the non-
rituximab-treated group (3.71 years [range
= 1.75-4.93 years] vs. 1.33 years [0.43-2.35
years]; p value not reported).
After adjusting for follow-up time, time
• presenting with TTP relapse (hazard
ratio [HR] = 3.05; 95% CI 1.4-6.6;
p=0.005)
ASH Clinical News
• non-O blood group (HR=2.11;
95% CI 1.03-4.3; p=0.041)
While rituximab on the day of administra-
tion was associated with a decreased relapse
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34
• age <25 years (HR=2.94;
95% CI 1.2-7.2; p=0.018)
from presentation to rituximab administra-
tion, and the waning effect of rituximab over
time, the researchers identified the following
factors as predictors of relapse: