Ravulizumab as an alternative for gemcitabine related trombotic microangiopathy: A case report

Thrombotic microangiopathy (TMA) is characterized by endotelial damage, microangiopathic hemolytic anemia, thrombocytopenia and organ damage, particularly renal. In Oncology, TMA can be secondary to the cancer itself or related to oncological treatments. TMA associated with gemcitabine has a poor prognosis, with high mortality and complement activation plays a central role in its pathophisiology. While eculizumab has shown efficacy and improved outcomes in this condition, evidence regarding the use of ravulizumab remains scarce. We present the case of an 81-year-old woman with arterial hypertension and a history of left breast cancer treated with surgery and radiotherapy, currently diagnosed with stage IV left breast angiosarcoma treated with gemcitabine after progression on paclitaxel. She developed a hypertensive emergency, anemia (Hb 6.9 g/dL), thrombocytopenia (68,000 platelets), impaired renal function (creatinine 1.64 mg/dL) and elevated LDH (1126 U/L). Suspecting gemcitabine-induced TMA, the treatment was discontinued and ravulizumab was initiated, resulting in rapid renal and hematological response. Oncological treatment with pazopanib was reintroduced, leading to recurrence of TMA. That treatment was suspended and another dose of ravulizumab was administered, with good response. TMA is a significant cause of morbidity and mortality in cancer patients, contributing to progression to chronic kidney disease and the discontinuation of oncological treatment. This case highlights the role of ravulizumab in gemcitabine-associated TMA, offering advantages in frail patients due to its longer half-life, reduced administration frequency and favorable outcomes.