What is the recommended treatment approach for a patient with Transthyretin (TTR) amyloidosis?

Treatment of Transthyretin (TTR) Amyloidosis

For patients with wild-type or variant TTR cardiac amyloidosis and NYHA class I-III heart failure symptoms, tafamidis (61 mg or 80 mg daily) is the indicated disease-modifying therapy to reduce cardiovascular morbidity and mortality. 1

Disease-Modifying Therapies by Clinical Presentation

For TTR Cardiac Amyloidosis (ATTR-CM)

TTR Stabilizer Therapy:

• Tafamidis is the only FDA-approved therapy for ATTR-CM and should be initiated immediately upon diagnosis in patients with NYHA class I-III symptoms 1
• Tafamidis reduced all-cause mortality from 42.9% to 29.5% and decreased hospitalizations from 0.7/year to 0.48/year compared to placebo 2
• Treatment is most effective when administered early in the disease course before irreversible organ damage occurs 1, 2

For Variant TTR with Polyneuropathy (ATTRv-PN)

Gene Silencing Therapies (FDA-approved for ATTRv polyneuropathy only):

• Patisiran: 0.3 mg/kg IV every 3 weeks (30 mg for patients ≥100 kg) 1, 3

  • Requires premedication with dexamethasone 10 mg IV, acetaminophen 500 mg, diphenhydramine 50 mg, and famotidine 20 mg 1
  • Mandatory vitamin A supplementation 3,000 IU daily 1, 3

• Inotersen: 284 mg subcutaneously once weekly 1, 4

  • Requires weekly platelet monitoring and biweekly serum creatinine/eGFR/UPCR monitoring due to risk of thrombocytopenia and glomerulonephritis 1, 4
  • Mandatory vitamin A supplementation 3,000 IU daily 1

• Vutrisiran: 25 mg subcutaneously every 3 months 1

  • Mandatory vitamin A supplementation 3,000 IU daily 1
  • Reduces mean steady-state serum vitamin A by 62% over 9 months 5

Important Note: These gene silencing therapies are FDA-approved only for ATTRv polyneuropathy, not for cardiac manifestations or wild-type ATTR 1, 3

Genetic Testing Requirements

• All patients diagnosed with TTR cardiac amyloidosis must undergo TTR gene sequencing to differentiate hereditary variant (ATTRv) from wild-type (ATTRwt) disease 1
• This distinction is critical because it determines eligibility for gene silencing therapies and has implications for family screening 1

Supportive Cardiac Management

Diuretic Therapy:

• Loop diuretics are the primary treatment for fluid overload and symptomatic relief 1, 2
• Use cautiously to avoid overdiuresis and volume contraction leading to hypotension 1

Beta-Blockers:

• Can be useful to increase diastolic filling time and control heart rate in atrial fibrillation 1
• Use with caution due to risk of hypotension 1

Anticoagulation:

• Warfarin (INR goal 2-3) or direct thrombin inhibitors are indicated for all patients with cardiac amyloidosis and atrial fibrillation or history of embolic stroke/TIA 1
• Anticoagulation is reasonable regardless of CHA₂DS₂-VASc score due to high thromboembolic risk 1

Critical Medications to AVOID

The following medications bind to amyloid fibrils and cause harm:

• Digoxin: Binds to amyloid fibrils causing toxicity even with normal serum levels 1, 6
• Calcium channel blockers (nifedipine, verapamil): Bind to amyloid fibrils causing exaggerated hypotensive and negative inotropic responses 1, 6

Management of Neurologic Manifestations

Neuropathic Pain:

• First-line: Pregabalin 75 mg twice daily, titrate to 300-600 mg/day 1
• Alternative: Gabapentin 300 mg at bedtime, titrate to 1,800-3,600 mg/day 1
• Alternative: Duloxetine 20-30 mg daily, titrate to 60-120 mg/day 1
• Avoid tricyclic antidepressants in patients with autonomic dysfunction due to risk of worsening orthostatic hypotension, urinary retention, and constipation 1

Orthostatic Hypotension:

• Non-pharmacologic: Increased fluid intake, salt tablets, compression stockings 1
• Pharmacologic: Midodrine 2.5 mg three times daily, fludrocortisone, or droxidopa 1
• Pyridostigmine is an option without risks of fluid retention or supine hypertension 1
• These interventions may be poorly tolerated in patients with heart failure 1

Transplantation Considerations

For Hereditary TTR Amyloidosis:

• Combined cardiac and liver transplantation may be considered in selected patients with 5-year survival rates of 50-80% 1
• Liver transplantation cures the disease process because TTR protein is synthesized in the liver 1

For AL Amyloidosis (to differentiate):

• Cardiac transplantation alone has poor prognosis with 5-year survival of only 20-30% 1
• Cardiac transplantation followed by bone marrow transplantation may achieve 5-year survival of 35-55% 1

Diagnostic Algorithm Before Treatment

Step 1: Screen for monoclonal light chains to exclude AL amyloidosis 1, 6, 7

• Serum and urine immunofixation electrophoresis 1
• Serum free light chain assay 1, 2

Step 2: If no monoclonal protein detected, perform bone scintigraphy (technetium-pyrophosphate scan) 1

• Cardiac uptake confirms ATTR-CM without need for biopsy 1

Step 3: TTR gene sequencing to differentiate ATTRv from ATTRwt 1

Treatment Monitoring and Expectations

• Tafamidis and gene silencing therapies slow but do not halt disease progression 5
• Early treatment produces superior outcomes compared to delayed therapy 5
• Patients should be followed every 6-12 months depending on disease severity and treatment response 8
• Treatment should demonstrate beneficial response compared to baseline; disease progression despite therapy requires reassessment 5
• Device-based therapy for cardiac rhythm abnormalities should be performed with consideration for life expectancy 1