di Giampaolo Merlini, Centro per lo Studio e la Cura delle Amiloidosi Sistemiche, Fondazione IRCCS Policlinico San Matteo, Dipartimento di Medicina Molecolare Università di Pavia. Slide per l'intervento tenuto in Fondazione Giannino Bassetti in occasione del primo incontro del ciclo "La medicina di precisione", primo progetto dalla convenzione tra Università di Pavia e Fondazione Bassetti. 12 marzo 2018

1. La struttura della
medicina di precisione
Giampaolo Merlini
Centro per lo Studio e la Cura delle Amiloidosi Sistemiche
Fondazione IRCCS Policlinico San Matteo
Dipartimento di Medicina Molecolare
Università di Pavia

2. • Precision medicine would define diseases by
underlying molecular causes and other factors in
addition to traditional signs and symptoms.
• The precision medicine initiative could be worthwhile
if it aids the development of targeted therapeutic
agents and improves clinical outcomes.
Lancet. 2011 Nov 12;378(9804):1678 editorial on Toward precision medicine released by the US
National Research Council on Nov 2, 2011
Precision Medicine and Systemic Amyloidosis

3. The goal of precision medicine is to target the right
treatments to the right patients at the right time.
(source: www.fda.gov)

4. • Define diseases by underlying molecular causes
Precision Medicine and Systemic Amyloidosis
• Development of targeted therapeutic agents
• Improve clinical outcomes
• Target the right patients

5. Systemic amyloidosis: Protein misfolding disease
Merlini & Bellotti, N Engl J Med. 2003
Cross-b fiber
diffraction
pattern
• Mutations
• Increased
concentration
(↑ synthesis,
↓clearance)
• Intrinsic
propensity: aging
36 amyloid
proteins

6. • Define diseases by underlying molecular causes
Precision Medicine and Systemic Amyloidosis
• Development of targeted therapeutic agents
• Improve clinical outcomes
• Target the right patients

7. Amyloid type Organ involvement
Heart Kidney Liver PNS ANS Soft tissues
Light chain amyloidosis 74%
Wild-type TTR amyloidosis 10%
80% men, isolated heart
Hereditary ATTR amyloidosis 7%
Clinical presentation of AL and ATTR amyloidosis overlaps
～25% of patients with wild-type TTR cardiac amyloidosis have a monoclonal LC

8. Wrong typing of
amyloid deposits
can be
catastrophic

9. Avoid Titanic Errors
Merlini & Bellotti. N Engl J Med 2003;349:583–96.
Therapy:
Liver
Transplant
Therapy:
Stem Cells
Transplant

10. Amyloid typing by immunohistochemistry
Strong, false-positive immunostaining for
transthyretin in cardiac amyloid is a
potential pitfall, augmented by the frequent
lack of staining for immunoglobulin light
chains
Patient with AL lambda
anti-kappa
anti-lambda anti-TTR
Am J Surg Pathol, 2011

11.  Male 68 yrs
 IgG (1.3 g/dl) + BJP
 FLC  52.3 mg/L (rif. <26.3), / 0.15 ratio
 NT-proBNP 577 pg/mL; TnI 0.05 ng/mL (rif. <0.06)
 Infiltrative cardiomiopathy on echocardiography (IVS: 15.7 mm; PW: 15
mm; EF:50%), ECG: Q wave in V1 and V2
 Heart MRI: myocardial hypertrophy, late enhancement
 Genetic tests for TTR and Apo-AI: negative
 abdomina fat biopsy: negative  salivary glands biopsy: negative
Diagnosis of systemic amyloidosis: problems and pitfalls
Ctrl S U S S U
EF IFIX
IgG Lambda

12. Endomyocardial biopsy
Green birefringence under polarized
light after Congo red staining
Proteomics: wtTTR
Diagnosis: AL amyloidosis with heart
involvement
Chemotherapy was initiated
Diagnosis: Senile systemic
amyloidosis
Therapy: Doxy-TUDCA
Diagnosis of systemic amyloidosis: problems and pitfalls

13. • Define diseases by underlying molecular causes
Precision Medicine and Systemic Amyloidosis
• Development of targeted therapeutic agents
• Improve clinical outcomes
• Target the right patients

14. ATTR: Treatment targets
Suppression of the synthesis
• Liver transplantation1
• Gene silencing (siRNA2, ASO3)
Redirecting oligomers off-pathway
• EGCG7
Amyloid fibril
degradation/reabsorption
• Anti-SAP therapy9,10
• Anti-amyloid mAb11
• Doxycycline+TUDCA12,13
Amorphous aggregates
Small oligomers
Amyloid fibrils
× Oxidative stress
Inflammation
• Anti-cytokines8
Folded monomer
misfolding
Aggregation
Tetramer stabilizers
• Tafamidis4
• Diflunisal5
• Tolcapone6
1. Ericzon et al, Transplantation 2015; 2. Coelho et al, N Engl J Med. 2013; 3. Ackermann et al, Amyloid
2016; 4. Coelho T, et al. Neurology. 2012; 5. Berk JL, et al. JAMA 2013; 6 Sant’Anna et al, Nat Commun
2016; 7. Ehrnhoefer, et al. Nat SMB. 2008; 8. Gonçalves et al, J Neuropathol Exp Neurol. 2015; 9. Bodin et
al, Nature. 2010; 10. Richards et al, NEJM 2015; 11. Higaki et al, Amyloid 2016; 12. Cardoso et al, J
Transl Med. 2010; 13. Obici et al, Amyloid 2012

15. Targeted therapies in AL amyloidosis: Current and future directions
Kinetically/
thermodynamically
unstable LC
LC stabilizers4
Doxycycline
Metal binding comp.9
p38MAPK inhibitors10
EGCG5-8
Anti-SAP mAb
Anti-amyloid mAbs
1. Rosenzweig et al, Cytotherapy 2017 - 2. Hovey et al, Gene Ther. 2011 – 3. Zhou et al, Blood 2014 – 4. Brumshtein et al. eLife 2015 – 5. Andrich et al, J Biol Chem 2017 – 6. Hunstein et al, Blood 2007 – 7. Mereles et al,
Clin Res Cardiol. 2010 – 8. Meshitsuka et al, Int J Hematol. 2017 – 9. Diomede et al, Antioxid Redox Signal. 2017 – 10. Shi et al, PNAS 2010
siRNA2,3
Anti-plasma cell therapies
• ASCT
• Bortezomib-based
• MDex
• IMiDs
• Daratumumab
• lxazomib
• Carfilzomib
• Bendamustine
• Venetoclax
• T-cell based therapy1

16. • In the near future the treatment of systemic amyloidosis will
include the combination of agents targeting critical steps of the
amyloid cascade
• The cost of drugs for rare diseases is unbearable

17. • Define diseases by underlying molecular causes
Precision Medicine and Systemic Amyloidosis
• Development of targeted therapeutic agents
• Improve clinical outcomes
• Target the right patients

18. Improved outcomes for newly diagnosed AL amyloidosis over the years
2000-2014: Cracking the glass ceiling of early death
Muchtar et al, Blood 2017
6-month mortality from 37% to 24%.
2007-2012 4 year OS 60%
2000-2006 4 year OS 53%
1984-1994 4 year OS 38%
1995-1999 4 year OS 49%
Merlini, Blood 2012 updated – Wechalekar et al, Lancet 2017
Pavia Amyloidosis Center UK National Amyloidosis Center

19. Academia
FDA
EMA
Funding
agencies
Advocacy
ISA, ARC,
Amyloid
foundations
Pharmaceuticals
Ongoing collaborative model for rapid translation from
bench to bedside
GRAZIE !