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Thrombotic microangiopathy as a cause of cardiovascular toxicity from the BCR-ABL1 tyrosine kinase inhibitor ponatinib.

Latifi Y, Moccetti F, Wu M, Xie A, Packwood W, Qi Y, Ozawa K, Shentu W, Brown E, Shirai T, McCarty OJ, Ruggeri Z, Moslehi J, Chen J, Druker BJ, López JA, Lindner JR
Blood. 2019 133 (14): 1597-1606

PMID: 30692122 · PMCID: PMC6450432 · DOI:10.1182/blood-2018-10-881557

The third-generation tyrosine kinase inhibitor (TKI) ponatinib has been associated with high rates of acute ischemic events. The pathophysiology responsible for these events is unknown. We hypothesized that ponatinib produces an endothelial angiopathy involving excessive endothelial-associated von Willebrand factor (VWF) and secondary platelet adhesion. In wild-type mice and ApoE mice on a Western diet, ultrasound molecular imaging of the thoracic aorta for VWF A1-domain and glycoprotein-Ibα was performed to quantify endothelial-associated VWF and platelet adhesion. After treatment of wild-type mice for 7 days, aortic molecular signal for endothelial-associated VWF and platelet adhesion were five- to sixfold higher in ponatinib vs sham therapy ( < .001), whereas dasatinib had no effect. In ApoE mice, aortic VWF and platelet signals were two- to fourfold higher for ponatinib-treated compared with sham-treated mice ( < .05) and were significantly higher than in treated wild-type mice ( < .05). Platelet and VWF signals in ponatinib-treated mice were significantly reduced by -acetylcysteine and completely eliminated by recombinant ADAMTS13. Ponatinib produced segmental left ventricular wall motion abnormalities in 33% of wild-type and 45% of ApoE mice and corresponding patchy perfusion defects, yet coronary arteries were normal on angiography. Instead, a global microvascular angiopathy was detected by immunohistochemistry and by intravital microscopy observation of platelet aggregates and nets associated with endothelial cells and leukocytes. Our findings reveal a new form of vascular toxicity for the TKI ponatinib that involves VWF-mediated platelet adhesion and a secondary microvascular angiopathy that produces ischemic wall motion abnormalities. These processes can be mitigated by interventions known to reduce VWF multimer size.

© 2019 by The American Society of Hematology.

MeSH Terms (16)

Animals Aorta Cardiovascular Diseases Endothelium Fusion Proteins, bcr-abl Humans Imidazoles Ischemia Mice Mice, Knockout Platelet Adhesiveness Protein Kinase Inhibitors Pyridazines Thrombotic Microangiopathies Ventricular Dysfunction von Willebrand Factor

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