Bring a pot of salted water to a boil. Once boiling, cook the pasta according to the directions. Be sure to reserve 1 ½ to 2 cups of pasta water for the sauce.
While the water is boiling, heat the butter in a saucepan over medium heat. Once melted, stir in the shallots and garlic with a big pinch of salt and pepper. Cook, stirring often, until the onions soften. Add in the tomato paste and stir, cooking for 5 minutes. The color will darken - this is where the flavor is. Stir in the pumpkin puree. Cook for another 1 to 2 minutes until combined.
Stream in the vodka and stir, scraping the brown bits and flavor from the bottom. Stir in ½ cup of the reserved pasta water. Stir in more pasta water if the mixture is super thick. Stir in the heavy cream and parmesan, stirring until the cheese melts. Add in the nutmeg.
Taste and season the sauce with more salt and pepper if needed.
Add the cooked pasta to the sauce and toss well. If needed, you can stream in more of the pasta water until it’s creamy and silky. Top with the crispy sage, spicy bread crumbs and a sprinkle of parmesan.
Serve immediately.