Religious Limitations Likely Not to Preclude Successful TTP Therapy

Patients with thrombotic thrombocytopenic purpura (TTP) who have religious objections to standard-of-care plasma exchange therapy can still be successfully managed, according to a new report.

A new analysis recently examined the existing scientific literature regarding Jehovah’s Witnesses with TTP in a review article in the journal Transfusion and Apheresis Science.

The study author explained that patients who are Jehovah’s Witnesses reject transfusions of white blood cells, red blood cells, plasma, and platelets on religious grounds. However, he added that it is left up to “the conscience of the individual believer” whether to accept fractions of those components.

Such beliefs can pose a challenge for physicians treating patients with TTP, since therapeutic plasma exchange is the first-line therapy for TTP and considered a cornerstone of treatment. There are about 8.6 million Jehovah’s Witnesses worldwide.

“Given an annual prevalence and incidence of around 10 immune TTP cases per million individuals and 1 new case per million, it is possible that clinicians may encounter a Jehovah’s Witness patient with iTTP during their careers,” he said.

He continued that he has previously encountered patients who were Jehovah’s Witnesses, and generally found them accepting of other therapies, such as albumin, clotting factor concentrates, intravenous immune globulin (IVIG), hemoglobin-based oxygen carriers, and recombinant proteins.

Still he wanted to gain a broader view of the outcomes of patients with TTP who were treated within the parameters of the Jehovah’s Witness guidelines, and so he conducted a literature search seeking reports of cases of such patients. He found 13 reports describing 15 episodes of iTTP. The median age of the patients in the studies was 45.5 years, and all but 1 of the patients included was a female. In about half of the episodes (7 of 15), neurological symptoms were present. In 11 cases, ADAMTS13 testing was performed to confirm the presence of TTP.

Most episodes were treated with corticosteroids (13 episodes) and rituximab (Rituxan; 12 episodes). Nine episodes were treated with apheresis-based therapy. In 5 cases, the von Willebrand factor–directed antibody caplacizumab (Cablivi) was an option, and the therapy was used in 4 of those cases. Those cases had the shortest used time to platelet response, he noted. Exogenous sources of ADAMTS13 were also accepted in many cases. Sources utilized included cryo-poor plasma, factor VIII concentrate, and cryoprecipitate.

The cases in the study spanned 23 years, and the investigator noted that the therapeutic options for patients shifted significantly in that time frame. For instance, the earliest cases in the data set did not yet have access to rituximab, and caplacizumab was only available for the most recent cases. Moreover, he said a clinical trial is currently ongoing to see whether iTTP can be treated with immunosuppression and caplacizumab without upfront plasma exchange.

Although treatment of iTTP may change over time, the author said there is already significant evidence that the religious restrictions associated with being a Jehovah’s Witness do not preclude successful treatment of iTTP.

“Jehovah’s Witnesses have been successfully (or unsuccessfully) treated worldwide, but this case series supports the notion that treatment of iTTP can be successfully carried out among those who do not accept transfusion of standard blood components,” he concluded.

Reference

Tran MH. Therapeutic modalities in thrombotic thrombocytopenic purpura management among Jehovah's Witness patients: a review of reported cases. Transfus Apher Sci. Published online March 21, 2023. doi:10.1016/j.transci.2023.103706