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Kimbara S, Imamura Y, Yakushijin K, Higashime A, Koyama T, Fujishima Y, Funakoshi Y, Toyoda M, Kiyota N, Matsuoka H, Minami H. Regorafenib-induced exacerbation of chronic immune thrombocytopenic purpura in remission: A case report. Mol Clin Oncol 2021; 14:30. [PMID: 33414911 PMCID: PMC7783712 DOI: 10.3892/mco.2020.2192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 11/12/2020] [Indexed: 12/03/2022] Open
Abstract
Regorafenib is an oral multi-kinase inhibitor which targets tumor angiogenesis, the tumor microenvironment and oncogenesis. Based on this mode of action, regorafenib has a broad spectrum of toxicities. However, at present, few reports have focused on autoimmune adverse events. We report a first case of regorafenib-induced exacerbation of chronic immune thrombocytopenic purpura in remission during treatment for the patients with heavily treated advanced colorectal cancer. This case report highlights the need for caution with regard to regorafenib treatment in patients with cancer with concomitant immune thrombocytopenic purpura.
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Affiliation(s)
- Shiro Kimbara
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Yoshinori Imamura
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Kimikazu Yakushijin
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Ako Higashime
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Taiji Koyama
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Yoshimi Fujishima
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Yohei Funakoshi
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Masanori Toyoda
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Naomi Kiyota
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan.,Cancer Center, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Hiroshi Matsuoka
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
| | - Hironobu Minami
- Department of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan.,Cancer Center, Kobe University Hospital, Kobe, Hyogo 650-0017, Japan
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52
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Marini I, Zlamal J, Faul C, Holzer U, Hammer S, Pelzl L, Bethge W, Althaus K, Bakchoul T. Autoantibody-mediated desialylation impairs human thrombopoiesis and platelet lifespan. Haematologica 2021; 106:196-207. [PMID: 31857361 PMCID: PMC7776251 DOI: 10.3324/haematol.2019.236117] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/11/2019] [Indexed: 11/09/2022] Open
Abstract
Immune thrombocytopenia is a common bleeding disease caused by autoantibody-mediated accelerated platelet clearance and impaired thrombopoiesis. Accumulating evidence suggests that desialylation affects platelet life span in immune thrombocytopenia. Herein, we report on novel effector functions of autoantibodies from immune thrombocytopenic patients which might interfere with the clinical picture of the disease. Data from our study show that a subgroup of autoantibodies is able to induce cleave of sialic acid residues from the surface of human platelets and megakaryocytes. Moreover, autoantibody-mediated desialylation interferes with the interaction between cells and extracellular matrix proteins leading to impaired platelet adhesion and megakaryocyte differentiation. Using a combination of ex vivo model of thrombopoiesis, a humanized animal model, and a clinical cohort study, we demonstrate that cleavage of sialic acid induces significant impairment in production, survival as well as function of human platelets. These data may indicate that prevention of desialylation should be investigated in the future in clinical studies as a potential therapeutic approach to treat bleeding in immune thrombocytopenia.
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Affiliation(s)
- Irene Marini
- Transfusion Medicine, Medical Faculty of Tübingen, University Hospital Tübingen
| | - Jan Zlamal
- Transfusion Medicine, Medical Faculty of Tübingen, University Hospital Tübingen
| | - Christoph Faul
- Department of Internal Medicine II, University Hospital of Tübingen
| | - Ursula Holzer
- Dept. of Pediatric Hematology-Oncology, University Children's Hospital of Tübingen, Germany
| | - Stefanie Hammer
- Center for Clinical Transfusion Medicine, University Hospital of Tübingen, Germany
| | - Lisann Pelzl
- Transfusion Medicine, Medical Faculty of Tübingen, University Hospital Tübingen
| | - Wolfgang Bethge
- Department of Internal Medicine II, University Hospital of Tübingen
| | - Karina Althaus
- Transfusion Medicine, Medical Faculty of Tübingen, University Hospital Tübingen, Germany
| | - Tamam Bakchoul
- Transfusion Medicine, Medical Faculty of Tübingen, University Hospital Tübingen
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Althaus K, Faul C, Bakchoul T. New Developments in the Pathophysiology and Management of Primary Immune Thrombocytopenia. Hamostaseologie 2020; 41:275-282. [PMID: 33348391 DOI: 10.1055/a-1311-8264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease that is characterized by a significant reduction in the number of circulating platelets and frequently associated with bleeding. Although the pathogenesis of ITP is still not completely elucidated, it is largely recognized that the low platelet count observed in ITP patients is due to multiple alterations of the immune system leading to increased platelet destruction as well as impaired thrombopoiesis. The clinical manifestations and patients' response to different treatments are very heterogeneous suggesting that ITP is a group of disorders sharing common characteristics, namely, loss of immune tolerance toward platelet (and megakaryocyte) antigens and dysfunctional primary hemostasis. Management of ITP is challenging and requires intensive communication between patients and caregivers. The decision to initiate treatment should be based on the platelet count level, age of the patient, bleeding manifestation, and other factors that influence the bleeding risk in individual patients. In this review, we present recent data on the mechanisms that lead to platelet destruction in ITP with a particular focus on current findings concerning alterations of thrombopoiesis. In addition, we give an insight into the efficacy and safety of current therapies and management of ITP bleeding emergencies.
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Affiliation(s)
- Karina Althaus
- Transfusion Medicine, Medical Faculty of Tübingen, University Hospital of Tübingen, Tübingen, Germany.,Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Christoph Faul
- Internal Medicine II, University Hospital of Tübingen, Tübingen, Germany
| | - Tamam Bakchoul
- Transfusion Medicine, Medical Faculty of Tübingen, University Hospital of Tübingen, Tübingen, Germany.,Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
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54
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Newland A, McDonald V. Fostamatinib: a review of its clinical efficacy and safety in the management of chronic adult immune thrombocytopenia. Immunotherapy 2020; 12:1325-1340. [DOI: 10.2217/imt-2020-0215] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Management of chronic immune thrombocytopenia (ITP) is going through a transition, with the main driving forces being a better understanding of the disease, recognition that platelet count is less important than bleeding symptoms, and the availability of new therapies. The heterogeneity of chronic ITP makes treatment challenging, and highlights the need for a personalized approach. A key aspect of tailored treatment is the availability of agents to target specific underlying pathophysiological mechanisms. In this review, we examine the evidence for orally bioavailable fostamatinib and its active moiety, tamatinib (R406), which has been approved for the treatment of chronic adult ITP. Fostamatinib inhibits FcR-triggered, Syk-dependent cytoskeletal rearrangement during phagocytosis and, as such, represents an active therapy targeting a previously unexplored mechanism of ITP pathogenesis.
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Affiliation(s)
- Adrian Newland
- Academic Haematology Unit, Blizard Institute, Barts & The London School of Medicine & Dentistry, Queen Mary Institute of London, London, UK
| | - Vickie McDonald
- Department of Haematology, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Chakraborty S, Alam S, Sayem M, Sanyal M, Das T, Saha P, Sayem M, Byapari BK, Tabassum CT, Kabir A, Amin M, Nabi AN. Investigation of the efficacy and safety of eltrombopag to correct thrombocytopenia in moderate to severe dengue patients - a phase II randomized controlled clinical trial. EClinicalMedicine 2020; 29-30:100624. [PMID: 33294822 PMCID: PMC7691733 DOI: 10.1016/j.eclinm.2020.100624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/17/2020] [Accepted: 10/21/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The dengue-infected patients with or without hemorrhagic manifestations, typically exhibit moderate to severe thrombocytopenia. A thrombopoietin receptor agonist - eltrombopag has been efficacious in correcting thrombocytopenia in patients with various pathological conditions including immune thrombocytopenia, chronic liver disease, and severe aplastic anemia. This study investigated the efficacy and safety of eltrombopag to correct dengue-mediated thrombocytopenia. METHODS In this open-label, randomized controlled phase-II trial, patients with dengue fever (DF) and dengue hemorrhagic fever (DHF) having platelet (PLT) count lower than 100 × 109/L without comorbidity, pregnancy, and liver abnormalities were enrolled in Dhaka Medical College Hospital, Better Life Hospital and AMZ hospital, Dhaka, Bangladesh. Between October 10, 2019, and December 30, 2019, 123 DF and DHF patients were assessed for eligibility to be enrolled in the trial. Fourteen patients were excluded as they failed to fulfill the inclusion criteria (N = 6) or refused to participate in the trial (N = 8). Finally, 109 patients were randomly assigned to either Group 1, (N = 36), Group 2 (N = 37), or Control-group (N = 36) in a 1:1:1 ratio. Two doses of eltrombopag - 25 mg/day and 50 mg/day were administered to Group-1 and Group-2 patients, respectively whereas the control-group patients received standard dengue treatment without eltrombopag. The management of all enrolled patients was according to WHO guidelines. The randomization procedure was performed by using a computerized system (STATA Inc.). CBC and immature platelet fraction (IPF) were monitored from Day-0 to Day-7. Absolute immature platelet count (A-IPC) was calculated from PLT count and IPF for each patient. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were measured on Day-0 and Day-4 and an Ultrasonogram (USG) of the abdomen was performed on Day-4 and Day-7 for each patient. The efficacy of eltrombopag as the primary outcome of the trial was investigated by the proportion of patients with recovered platelet count receiving eltrombopag with corrected platelet count (platelet count above the lower normal limit: 150 × 109/L) on Day-7 of the enrollment as compared to the Control-group. As the secondary outcomes, the reduction of bleeding tendency in response to eltrombopag as well as the safety of eltrombopag in dengue patients were assessed. The safety was evaluated in case of adverse events, liver function enzymes AST/ALT levels and USG. This trial is registered with the international clinical trial registry, number SLCTR/2019/037. RESULTS A total of 101 patients including 77 DF and 24 DHF patients completed the trial as eight patients left the trial without completing the follow-up. Patients of the different groups were compared with respect to mean age (26±8, 30±10 and 30±9 years for, Group-1,-2 and Control-group, respectively) (p-value= 0.23) and basal PLT count (Group-1: 58±24 × 109; Group-2: 52±29 × 109 and control-group: 55±30 × 109) (p-value= 0.63). The mean PLT counts for Group-1 (332 × 109/L ± 92) and Group-2 (371 × 109/L ± 111) were significantly higher than control-group (194 × 109/L ± 96) on Day-7 (adjusted p-value= 1.15 × 10-06 for Group-1 vs. Control-group, and adjusted p-value= 1.82 × 10-08 for Group-2 vs. Control-group).). On Day-7, 91% of Group-1 (N = 30) and Group-2 (N = 32) patients who received eltrombopag achieved primary endpoint of PLT count above than lower normal limit (150 × 109/L) (Group-1: 91%, OR: 8.33, 95% CI: 2.11 to 32.80, p-value: 0.0024 and Group-2: 91%, OR: 8.89, 95% CI: 2.26 to 34.89, p-value: 0.0017) compared to 55% (N = 18) of control-group patients who did not receive eltrombopag. The bleeding manifestations for thirteen out of fourteen grade-II DHF patients were subsided within Day-7 who received eltrombopag, whereas four out of ten grade-II DHF patients with PLT counts lower than the lower normal limit in the control group showed intermittent bleeding symptoms throughout the trial period. Mean A-IPC but not IPF was significantly higher for eltrombopag-treated groups in comparison to the Control-group. The frequency of the most common adverse events (vomiting and diarrheal tendencies) was similar in the treated-and control-groups (N = 5, 15%, and N = 3, 9% for Group-1 and -2, respectively vs. N = 4, 12% in the Control-group). Ten (30%) patients of Group-1 and, fourteen (40%) patients of Group-2 showed increased AST (U/L) as opposed to nine patients (27%) in the Control-group. Increased ALT levels were observed for three (9%), nine (26%), and seven (21%) patients belonging to the Group-1, -2, and Control-group, respectively. PLT counts higher than the upper normal limit (450 × 109/L) on Day-7 were observed for seven patients who were administered the higher dose (50 mg/day) in contrast to the three patients receiving the lower dose (25 mg/day). USG reports did not show thrombosis events in any of the patients. INTERPRETATION The trial revealed that the administration of eltrombopag in a short regimen for three days was efficacious to restore the PLT count in DF and DHF patients. The higher number of A-IPCs in eltrombopag treated patients underscored the possible mode of action of eltrombopag through stimulating megakaryopoiesis in dengue patients. The trial hints toward the positive effect of eltrombopag in the cessation of bleeding manifestation. Administration of the lower dose (25 mg/day) of eltrombopag was shown to be safer and equally efficacious to the higher dose (50 mg/day) in treating dengue-infected patients.
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Affiliation(s)
- Sajib Chakraborty
- Translational Systems Biology Laboratory, Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka 1000, Bangladesh
| | - Saruar Alam
- Translational Systems Biology Laboratory, Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka 1000, Bangladesh
| | - Mohammad Sayem
- Laboratory of Population Genetics, Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka 1000, Bangladesh
| | - Mousumi Sanyal
- Department of Medicine, Dhaka Medical College, Dhaka, Bangladesh
| | - Tonmoy Das
- Translational Systems Biology Laboratory, Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka 1000, Bangladesh
| | - Piyal Saha
- Laboratory of Population Genetics, Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka 1000, Bangladesh
| | - Mohammad Sayem
- Department of Medicine, Aichi Medical College, Dhaka, Bangladesh
| | | | | | - Ahmedul Kabir
- Department of Medicine, Dhaka Medical College, Dhaka, Bangladesh
| | - Md.Robed Amin
- Department of Medicine, Dhaka Medical College, Dhaka, Bangladesh
| | - A.H.M. Nurun Nabi
- Laboratory of Population Genetics, Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka 1000, Bangladesh
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Yu Y, Wang M, Hou Y, Qin P, Zeng Q, Yu W, Guo X, Wang J, Wang X, Liu G, Chu X, Yang L, Feng Y, Zhou F, Sun Z, Zhang M, Wang X, Wang Z, Ran X, Zhao H, Wang L, Zhang H, Bi K, Li D, Yuan C, Xu R, Wang Y, Zhou Y, Peng J, Liu X, Hou M. High-dose dexamethasone plus recombinant human thrombopoietin vs high-dose dexamethasone alone as frontline treatment for newly diagnosed adult primary immune thrombocytopenia: A prospective, multicenter, randomized trial. Am J Hematol 2020; 95:1542-1552. [PMID: 32871029 DOI: 10.1002/ajh.25989] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 08/19/2020] [Accepted: 08/29/2020] [Indexed: 12/24/2022]
Abstract
We conducted a prospective, multicenter, randomized, controlled clinical trial to compare the efficacy and safety of high-dose dexamethasone (HD-DXM) plus recombinant human thrombopoietin (rhTPO), vs HD-DXM alone in newly diagnosed adult immune thrombocytopenia (ITP) patients. Enrolled patients were randomly assigned to receive DXM plus rhTPO or DXM monotherapy. Another 4-day course of DXM was repeated if response was not achieved by day 10 in both arms. One hundred patients in the HD-DXM plus rhTPO arm and 96 patients in the HD-DXM monotherapy arm were included in the full analysis set. So, HD-DXM plus rhTPO resulted in a higher incidence of initial response (89.0% vs 66.7%, P < .001) and complete response (CR, 75.0% vs 42.7%, P < .001) compared with HD-DXM monotherapy. Response rate at 6 months was also higher in the HD-DXM plus rhTPO arm than that in the HD-DXM monotherapy arm (51.0% vs 36.5%, P = .02; sustained CR: 46.0% vs 32.3%, P = .043). Throughout the follow-up period, the overall duration of response was greater in the HD-DXM plus rhTPO arm compared to the HD-DXM monotherapy arm (P = .04), as estimated by the Kaplan-Meier analysis. The study drugs were generally well tolerated. In conclusion, the combination of HD-DXM with rhTPO significantly improved the initial response and yielded favorable SR in newly diagnosed ITP patients, thus could be further validated as a frontline treatment for ITP. This study is registered as clinicaltrials.gov identifier: NCT01734044.
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Affiliation(s)
- Yafei Yu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Miaomiao Wang
- Department of Pediatrics The Second Hospital, Cheeloo College of Medicine, Shandong University Jinan China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Ping Qin
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Qingshu Zeng
- Department of Hematology The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Wenzheng Yu
- Department of Hematology Binzhou Medical University Hospital Binzhou China
| | - Xinhong Guo
- Department of Hematology The First Affiliated Hospital of Xinjiang Medical University Urumqi China
| | - Jingxia Wang
- Department of Hematology Liaocheng People’s Hospital Liaocheng China
| | - Xiaomin Wang
- Department of Hematology Xinjiang Uiger Municipal People’s Hospital Urumqi China
| | - Guoqiang Liu
- Department of Hematology Shengli Oilfield Central Hospital Dongying China
| | - Xiaoxia Chu
- Department of Hematology Yantai Yuhuangding Hospital Yantai China
| | - Lan Yang
- Department of Hematology Xijing Hospital, Fourth Military Medical University Xi’an China
| | - Ying Feng
- Department of Hematology The Second Affiliated Hospital of Guangzhou Medical University Guangdong China
| | - Fang Zhou
- Department of Hematology Military General Hospital Jinan China
| | - Zhaogang Sun
- Department of Hematology Taian City Central Hospital Taian China
| | - Mei Zhang
- Department of Hematology The First Affiliated Hospital of Xi’an Jiaotong University Xi’an China
| | - Xin Wang
- Department of Hematology Shandong Provincial Hospital Affiliated to Shandong University Jinan China
| | - Zhencheng Wang
- Department of Hematology Zibo Central Hospital Zibo China
| | - Xuehong Ran
- Department of Hematology Weifang People’s Hospital Weifang China
| | - Hongguo Zhao
- Department of Hematology The Affiliated Hospital of Qingdao University Qingdao China
| | - Lei Wang
- Department of Hematology Qingdao Municipal Hospital Qingdao China
| | - Haiyan Zhang
- Department of Hematology Linyi People’s Hospital Linyi China
| | - Kehong Bi
- Department of Hematology Shandong Provincial Qianfoshan Hospital Jinan China
| | - Daqi Li
- Department of Hematology Jinan Central Hospital Jinan China
| | - Chenglu Yuan
- Department of Hematology Qilu Hospital (Qingdao), Shandong University Qingdao China
| | - Ruirong Xu
- Department of Hematology Shandong Provincial Hospital of Traditional Chinese Medicine Jinan China
| | - Yili Wang
- Department of Hematology Weihai Municipal Hospital Weihai China
| | - Yuhong Zhou
- Department of Hematology Zhejiang Provincial Hospital of TCM Hangzhou China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Xin‐guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
- Shandong Province Key Laboratory of Hematology/Immunology, Creative Studio of Scientific and Technologic Leading Talents Qilu Hospital, Shandong University Jinan China
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Zhu JJ, Yuan D, Sun RJ, Liu SY, Shan NN. Mucin mutations and aberrant expression are associated with the pathogenesis of immune thrombocytopenia. Thromb Res 2020; 194:222-228. [PMID: 33213847 DOI: 10.1016/j.thromres.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/23/2020] [Accepted: 08/03/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE Primary immune thrombocytopenia (ITP) is an acquired autoimmune disease of unknown aetiology. In this study, we aimed to identify the mutations and aberrant expression of mucins associated with ITP pathogenesis. METHODS First, we investigated the DNA mutation profile of bone marrow samples from patients with ITP (n = 20) by using next-generation sequencing (NGS). In addition, MUC3A, MUC5B and MUC6 were mutated in all patients with ITP. ELISA (enzyme-linked immunoassay) was used to measure MUC3A, MUC5B and MUC6 levels in the plasma of bone marrow fluid mononuclear cells (BMMCs) and peripheral blood mononuclear cells (PBMCs). Real-time quantitative PCR was used to study the mRNA expression levels of MUC3A, MUC5B and MUC6 in BMMCs and PBMCs. RESULTS The results indicated that there were 3998 missense mutations involving 2269 genes in more than 10 individuals. MUC3A levels were not significantly different among the three groups, whereas MUC5B and MUC6 expression were significantly down-regulated in patients with ITP compared with healthy controls. In addition, serum MUC5B and MUC6 levels were significantly higher in patients with ITP in clinical remission than in patients with active ITP. CONCLUSIONS Taken together, these results suggest that genetic alterations and the aberrant serum expression of mucins might be involved in the pathogenesis of ITP.
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Affiliation(s)
- Jing-Jing Zhu
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People's Republic of China
| | - Dai Yuan
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People's Republic of China; Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, People's Republic of China
| | - Rui-Jie Sun
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, People's Republic of China
| | - Shu-Yan Liu
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, People's Republic of China
| | - Ning-Ning Shan
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, People's Republic of China; Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, People's Republic of China.
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Porcelijn L, Schmidt DE, Oldert G, Hofstede-van Egmond S, Kapur R, Zwaginga JJ, de Haas M. Evolution and Utility of Antiplatelet Autoantibody Testing in Patients with Immune Thrombocytopenia. Transfus Med Rev 2020; 34:258-269. [PMID: 33046350 DOI: 10.1016/j.tmrv.2020.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 01/01/2023]
Abstract
To this day, immune thrombocytopenia (ITP) remains a clinical diagnosis made by exclusion of other causes for thrombocytopenia. Reliable detection of platelet autoantibodies would support the clinical diagnosis, but the lack of specificity and sensitivity of the available methods for platelet autoantibody testing limits their value in the diagnostic workup of thrombocytopenia. The introduction of methods for glycoprotein-specific autoantibody detection has improved the specificity of testing and is acceptable for ruling in ITP but not ruling it out as a diagnosis. The sensitivity of these assays varies widely, even between studies using comparable assays. A review of the relevant literature combined with our own laboratory's experience of testing large number of serum and platelet samples makes it clear that this variation can be explained by variations in the characteristics of the tests, including in the glycoprotein-specific monoclonal antibodies, the glycoproteins that are tested, the platelet numbers used in the assay and the cutoff levels for positive and negative results, as well as differences in the tested patient populations. In our opinion, further standardization and optimization of the direct autoantibody detection methods to increase sensitivity without compromising specificity seem possible but will still likely be insufficient to distinguish the often very weak specific autoantibody signals from background signals. Further developments of autoantibody detection methods will therefore be necessary to increase sensitivity to a level acceptable to provide laboratory confirmation of a diagnosis of ITP.
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Affiliation(s)
- Leendert Porcelijn
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands.
| | - David E Schmidt
- Sanquin Research, Department of Experimental Immunohematology, Amsterdam and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gonda Oldert
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | | | - Rick Kapur
- Sanquin Research, Department of Experimental Immunohematology, Amsterdam and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jaap Jan Zwaginga
- Department of Immuno-hematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands; Sanquin Research, Center for Clinical Transfusion Research, Leiden, the Netherlands; Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Masja de Haas
- Department of Immunohematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands; Sanquin Research, Center for Clinical Transfusion Research, Leiden, the Netherlands; Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
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59
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Markers of autoimmunity in immune thrombocytopenia: prevalence and prognostic significance. Blood Adv 2020; 3:3515-3521. [PMID: 31730698 DOI: 10.1182/bloodadvances.2019000400] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 10/29/2019] [Indexed: 01/19/2023] Open
Abstract
Prior studies have demonstrated an increased prevalence of autoimmune markers in patients with immune thrombocytopenia (ITP). Clinical experience has suggested that there may be an association between autoimmune markers and poor outcomes in ITP, but current guidelines do not encourage routine testing in these patients. We retrospectively assessed the prevalence of autoimmune markers in adult patients with ITP from our institutional database and used multiple logistic regression analyses to test for an association between autoimmune marker positivity and thrombotic events or clinical remission. We also assessed whether positivity for common autoimmune markers was associated with positivity for platelet autoantibodies. There was a high rate of autoimmune marker positivity in this population, with antinuclear antibody (65%), antithyroid peroxidase antibody (31%), and direct antiglobulin (29%) the most commonly found. Antithyroid peroxidase antibody positivity was associated with a lower probability of remission (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.09-0.79; P = .017). Lupus anticoagulant positivity was associated with a higher rate of thrombosis (OR, 8.92; 95% CI, 1.94-40.95; P = .005), and antinuclear antibody was strongly associated with thrombosis (P = .001). There was no relation between platelet autoantibody positivity and the presence of autoimmune markers. These results suggest that many patients with ITP have a state of immune dysregulation that extends beyond platelet autoantibodies and that certain autoimmune markers may be prognostically useful in this disorder.
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Koca Yozgat A, Leblebisatan G, Akbayram S, Çınar Özel S, Karakaş Z, Erduran E, Yılmaz Ş, Koçak Ü, Ünal Ş, Özdemir GN, Albayrak M, Zengin E, Oymak Y, Bör Ö, Çakmaklı HF, Söker M, Gürlek Gökçebay D, Tokgöz H, Malbora B, Karaman S, Celkan T, Şaşmaz İ, Yaralı N, Ören H, Ünüvar A, Özbek NY. Outcomes of Eltrombopag Treatment and Development of Iron Deficiency in Children with Immune Thrombocytopenia in Turkey. Turk J Haematol 2020; 37:139-144. [PMID: 32181630 PMCID: PMC7463208 DOI: 10.4274/tjh.galenos.2020.2019.0380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective Immune thrombocytopenia (ITP) is a rare autoimmune disease and hematologic disorder characterized by reduced platelet counts that can result in significant symptoms, such as bleeding, bruising, epistaxis, or petechiae. The thrombopoietin receptor agonist eltrombopag (EPAG) is a second-line agent used to treat chronic ITP purpura in adults and children. Materials and Methods The present retrospective study evaluated the efficacy, safety, and side effects of EPAG treatment in pediatric patients with acute refractory and chronic immune thrombocytopenia, particularly focusing on iron-deficiency anemia. Results The diagnosis was chronic ITP in 89 patients and acute refractory ITP in 16 patients. The mean age of patients was 9.5±4.5 years (minimum-maximum: 1.2-18 years) at the beginning of EPAG treatment. The overall response rate was 74.3% (n=78). The mean time for platelet count of ≥50x109/L was 11.6±8 weeks (range: 1-34 weeks). The treatment was stopped for 27 patients (25.7%) at an average of 6.8±9 months (range: 1-38 months). The reason for discontinuation was lack of response in 18 patients, nonadherence in 4 patients, and hepatotoxicity in 2 patients. Response to treatment continued for an average of 4 months after cessation of EPAG in 3 patients. Conclusion Results of the current study imply that EPAG is an effective therapeutic option in pediatric patients with acute refractory and chronic ITP. However, patients must be closely monitored for response and side effects during treatment, and especially for iron deficiency.
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Affiliation(s)
- Ayça Koca Yozgat
- Ankara City Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
| | - Göksel Leblebisatan
- Çukurova University Faculty of Medicine, Department of Pediatric Hematology, Adana, Turkey
| | - Sinan Akbayram
- Gaziantep University Faculty of Medicine, Department of Pediatric Hematology, Gaziantep, Turkey
| | - Simge Çınar Özel
- İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - Zeynep Karakaş
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - Erol Erduran
- Karadeniz Technical University Faculty of Medicine, Department of Pediatric Hematology, Trabzon, Turkey
| | - Şebnem Yılmaz
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Hematology, İzmir, Turkey
| | - Ülker Koçak
- Gazi University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Şule Ünal
- Hacettepe University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Gül Nihal Özdemir
- Kanuni Sultan Süleyman Training and Research Hospital, Clinic of Pediatric Hematology, İstanbul, Turkey
| | - Meryem Albayrak
- Kırıkkale University Faculty of Medicine, Department of Pediatric Hematology, Kırıkkale, Turkey
| | - Emine Zengin
- Kocaeli University Faculty of Medicine, Department of Pediatric Hematology, Kocaeli, Turkey
| | - Yeşim Oymak
- Dr. Behçet Uz Children’s Training and Research Hospital, Clinic of Pediatric Hematology, İzmir, Turkey
| | - Özcan Bör
- Eskişehir University Faculty of Medicine, Department of Pediatric Hematology, Eskişehir, Turkey
| | - Hasan Fatih Çakmaklı
- Ankara University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Murat Söker
- Dicle University Faculty of Medicine, Department of Pediatric Hematology, Diyarbakır, Turkey
| | - Dilek Gürlek Gökçebay
- Ankara Keçiören Training and Research Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
| | - Hüseyin Tokgöz
- Necmettin Erbakan University Meram Faculty of Medicine, Department of Pediatric Hematology, Konya, Turkey
| | - Barış Malbora
- Yeni Yüzyıl University, Gaziosmanpaşa Hospital, Clinic of Pediatric Hematology, İstanbul, Turkey
| | - Serap Karaman
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - Tiraje Celkan
- İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - İlgen Şaşmaz
- Çukurova University Faculty of Medicine, Department of Pediatric Hematology, Adana, Turkey
| | - Neşe Yaralı
- Ankara City Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
| | - Hale Ören
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Hematology, İzmir, Turkey
| | - Ayşegül Ünüvar
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - Namık Yaşar Özbek
- Ankara City Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
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Ebbo M, Rivière E, Godeau B. [Adult immune thrombocytopenia and thrombopoietin receptor agonist: Ten years later]. Rev Med Interne 2020; 42:38-45. [PMID: 32712041 DOI: 10.1016/j.revmed.2020.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/22/2020] [Indexed: 12/24/2022]
Abstract
Ten years after their licence in France, the use of the two thrombopoietin receptor agonists (TPO-RA), eltrombopag and romiplostim, has deeply modified the landscape of immune thrombocytopenia (ITP) treatment. In this review, we summarise data on efficacy and safety of these treatments during ITP, as well as their use in clinical practice. Their place in therapeutic strategy, the recent description of persistant remission after discontinuation of TPO-RA, and future new thrombopoietic agents are also discussed. Their use has progressively increased and early use at a newly diagnosed stage of the disease is under evaluation. However physician have to keep in mind that thromboembolism rates appear to be higher with TPO-RA treatment in ITP patients at high risk of thrombosis, and that data from "real-life" studies with very long term follow up are not available. Finally, the cost of these treatments should also be evaluated in future therapeutic strategies comparisons.
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Affiliation(s)
- M Ebbo
- Département de Médecine Interne, Hôpital de la Timone, AP-HM, Marseille, France; Aix Marseille Université, CNRS, INSERM, Centre d'Immunologie de Marseille Luminy, Marseille, France
| | - E Rivière
- Université de Bordeaux, Faculté de Médecine, 232 rue Léo Saignat, 33000 Bordeaux, France; CHU de Bordeaux, Service de Médecine Interne et Maladies Infectieuses, Hôpital Haut-Lévêque, 33604 Pessac, France
| | - B Godeau
- Service de médecine interne, Centre de référence des cytopénies autoimmunes de l'adulte, CHU Henri Mondor, APHP, UPEC, 94010 Créteil, France.
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62
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Thadchanamoorthy V, Dayasiri K. Dengue hemorrhagic fever as a rare cause of chronic immune thrombocytopenic purpura-a pediatric case report. Trop Med Health 2020; 48:59. [PMID: 32699523 PMCID: PMC7370471 DOI: 10.1186/s41182-020-00248-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/14/2020] [Indexed: 11/19/2022] Open
Abstract
Background Dengue is a common mosquito-borne infection in tropical countries. Dengue incidence in Sri Lanka is generally showing a rising trend. Both chronic immune thrombocytopenia purpura (ITP) children and chronic ITP triggered by dengue fever in the pediatric age group are rarely reported. This unusual presentation is a diagnostic challenge to clinicians. The authors have reported a pediatric patient who presented with chronic ITP following recovery from dengue hemorrhagic fever. Case presentation A 14-year-old previously healthy boy was initially managed as for dengue hemorrhagic fever. Following initial detection of persistent thrombocytopenia at 2 weeks post-discharge, his parents defaulted follow-up for 1 year as he remained asymptomatic. However, 1 year after initial admission, the child re-presented with ecchymotic patches and a platelet count of 30 × 103/cumm. Review of serial blood counts performed during previous hospital admission and by his parents themselves revealed persistent thrombocytopenia over preceding 12 months. Subsequently, the child had an in-depth evaluation. The diagnosis of ITP was confirmed by ruling out differential diagnosis and he was managed as for chronic ITP. His platelet counts showed good response to oral corticosteroids and he is currently being followed up at the pediatric hematology clinic. Conclusion While reporting, a 14-year-old boy who developed chronic ITP following dengue hemorrhagic fever, this report highlights importance of frequent monitoring of blood counts to accurately detect and manage critical phase of dengue fever. The report also highlights the value of monitoring platelet counts in post-recovery phase to ensure they have normalized.
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Affiliation(s)
- V Thadchanamoorthy
- Faculty of Health Care Sciences, Eastern University, Chenkalady, Sri Lanka
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63
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Rituximab and immune thrombocytopenia in adults: The state of knowledge 20 years later. Rev Med Interne 2020; 42:32-37. [PMID: 32680716 DOI: 10.1016/j.revmed.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/23/2020] [Indexed: 01/19/2023]
Abstract
Rituximab has been used for immune thrombocytopenia (ITP) for almost 20 years and is now considered a valid off-label second-line treatment. About 60% to 70% of patients with ITP show initial response to rituximab, but in half of these patients, the disease will eventually relapse. Therefore, in 30% of patients with persistent or chronic ITP, one course of rituximab at 375 mg/m2/week for 4 weeks or 2 fixed 1000-mg rituximab infusions allows for a sustained response rate at 5 years. Unfortunately, to date, no robust predictor of long-term sustained response has been found to assist the physician in deciding to treat with rituximab on an individual basis, and the choice of rituximab or another second-line treatment must be individualized and shared with the patient. Retreatment with rituximab has been found efficient, with a similar or higher magnitude and duration of response in most patients. Rituximab is usually well tolerated, with mainly mild and easily manageable infusion-related adverse events. Severe infections are uncommon, including in the long-term, and occur in patients with at least another contributing factor in more than two thirds. Several issues remain to be resolved. Indeed, head-to-head comparisons with other and new treatments in ITP and robust predictors of long-term response are urgently needed to better determine the position of rituximab in the therapeutic armamentarium for adult ITP. Additionally, the place of combination therapies, maintenance therapy with rituximab and rituximab in newly-diagnosed ITP deserve additional studies.
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Vayne C, Guéry EA, Rollin J, Baglo T, Petermann R, Gruel Y. Pathophysiology and Diagnosis of Drug-Induced Immune Thrombocytopenia. J Clin Med 2020; 9:jcm9072212. [PMID: 32668640 PMCID: PMC7408966 DOI: 10.3390/jcm9072212] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 12/12/2022] Open
Abstract
Drug-induced immune thrombocytopenia (DITP) is a life-threatening clinical syndrome that is under-recognized and difficult to diagnose. Many drugs can cause immune-mediated thrombocytopenia, but the most commonly implicated are abciximab, carbamazepine, ceftriaxone, eptifibatide, heparin, ibuprofen, mirtazapine, oxaliplatin, penicillin, quinine, quinidine, rifampicin, suramin, tirofiban, trimethoprim-sulfamethoxazole, and vancomycin. Several different mechanisms have been identified in typical DITP, which is most commonly characterized by severe thrombocytopenia due to clearance and/or destruction of platelets sensitized by a drug-dependent antibody. Patients with typical DITP usually bleed when symptomatic, and biological confirmation of the diagnosis is often difficult because detection of drug-dependent antibodies (DDabs) in the patient’s serum or plasma is frequently not possible. This is in contrast to heparin-induced thrombocytopenia (HIT), which is a particular DITP caused in most cases by heparin-dependent antibodies specific for platelet factor 4, which can strongly activate platelets in vitro and in vivo, explaining why affected patients usually have thrombotic complications but do not bleed. In addition, laboratory tests are readily available to diagnose HIT, unlike the methods used to detect DDabs associated with other DITP that are mostly reserved for laboratories specialized in platelet immunology.
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Affiliation(s)
- Caroline Vayne
- EA 7501-Groupe Innovation et Ciblage Cellulaire (GICC), Université François Rabelais, CEDEX 01, 37032 Tours, France; (C.V.); (J.R.)
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
| | - Eve-Anne Guéry
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
| | - Jérôme Rollin
- EA 7501-Groupe Innovation et Ciblage Cellulaire (GICC), Université François Rabelais, CEDEX 01, 37032 Tours, France; (C.V.); (J.R.)
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
| | - Tatiana Baglo
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
- Laboratoire d’Hématologie, CNHU de Cotonou, Cotonou 01 BP 386, Benin
| | - Rachel Petermann
- Département d’Immunologie plaquettaire, Institut National de la Transfusion Sanguine (INTS), 75015 Paris, France;
- Equipe ETRES (Ethics, Research, Translations), Centre de Recherche des Cordeliers, UMRS 1138, INSERM, Sorbonne Université, Université de Paris, 75006 Paris, France
| | - Yves Gruel
- EA 7501-Groupe Innovation et Ciblage Cellulaire (GICC), Université François Rabelais, CEDEX 01, 37032 Tours, France; (C.V.); (J.R.)
- Laboratoire d’Hématologie-Hémostase, Hôpital Trousseau, CHRU Tours, CEDEX 09, 37044 Tours, France; (E.-A.G.); (T.B.)
- Correspondence: ; Tel.: +33-2-4747-4672; Fax: +33-2-4747-5904
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65
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Romiplostim for the management of pediatric immune thrombocytopenia: drug development and current practice. Blood Adv 2020; 3:1907-1915. [PMID: 31239245 DOI: 10.1182/bloodadvances.2019000279] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/29/2019] [Indexed: 12/13/2022] Open
Abstract
Since successful cloning of thrombopoietin (TPO) in 1994, significant advances have been made in the development of recombinant TPO receptor agonists. The US Food and Drug Administration (FDA) has approved 2 agents for use in patients with immune thrombocytopenia (ITP): eltrombopag and romiplostim. Romiplostim is a once-weekly subcutaneous injection that has been shown to increase the platelet count, lessen bleeding, and reduce concurrent medication use in adults with ITP. In December 2018, the US FDA approved romiplostim for use in pediatric patients ≥1 year of age with ITP of >6 months' duration and insufficient response to corticosteroids, immunoglobulins, or splenectomy, based on similarly favorable clinical trial data. In addition, romiplostim is well tolerated, making it an attractive option for the treatment of children. Expansion of off-label romiplostim use is being reported in children for ITP <6 months, neonatal thrombocytopenia, hereditary thrombocytopenias, and chemotherapy- and bone marrow transplant-associated thrombocytopenia. We review here the development of romiplostim with a focus on pediatric use.
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66
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Al-Samkari H, Grace RF, Kuter DJ. The role of romiplostim for pediatric patients with immune thrombocytopenia. Ther Adv Hematol 2020; 11:2040620720912992. [PMID: 32523658 PMCID: PMC7236573 DOI: 10.1177/2040620720912992] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/18/2020] [Indexed: 01/19/2023] Open
Abstract
The thrombopoietin receptor agonists (TPO-RAs) are a class of platelet growth factors used to treat immune thrombocytopenia (ITP) in children and adults. Romiplostim is a peptide TPO-RA approved for over a decade to treat adults with ITP but was just recently US Food and Drug Administration approved to manage ITP in children 1 year of age and older who have had an inadequate response to corticosteroids, intravenous immunoglobulin, or splenectomy. Like the small molecule TPO-RA eltrombopag, romiplostim offers a high clinical response rate in pediatric patients with ITP, but requires use over an extended, and possibly indefinite, duration. This review is a critical appraisal of the role of romiplostim in pediatric ITP, discussing the safety and efficacy of this agent in clinical trials of children and adults and defining the patients most likely to benefit from romiplostim treatment. The treating hematologist is additionally provided guidance with treatment goals, dosing strategies, toxicity management, and indications for discontinuation.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical chool, Suite 118, Room 112, Zero Emerson Place, Boston, MA 02114, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - David J Kuter
- Division of Hematology, Harvard Medical School, Boston, MA, USA
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67
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Birocchi S, Podda GM, Manzoni M, Casazza G, Cattaneo M. Thrombopoietin receptor agonists for the treatment of primary immune thrombocytopenia: a meta-analysis and systematic review. Platelets 2020; 32:216-226. [PMID: 32281449 DOI: 10.1080/09537104.2020.1745168] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Previous meta-analyses reported discordant results on the efficacy and safety of thrombopoietin receptor agonists (TPO-RA) as second-line treatment in patients with immune thrombocytopenia (ITP). We conducted a meta-analysis of primary ITP treatment with the TPO-RA Romiplostim, Eltrombopag and Avatrombopag, including additional studies and relevant endpoints. We searched MEDLINE, EMBASE and CENTRAL for randomized clinical trials (RCTs) and cohort studies on TPO-RA in ITP published until December 31, 2018. The primary endpoints were: risk ratio (RR) of treatment failure and bleeding of WHO grade ≥2; rate of remission after discontinuation of treatment. The principal safety outcome was RR and incidence of thrombotic events and liver damage. From 1044 identified records we selected 16 RCTs and 19 cohort studies. RCTs included 909 patients assigned to TPO-RA and 427 to the control arm. Treatment failure was observed in 21% TPO-RA-treated patients and 47% control arm patients (RR = 0.42, 95% CI 0.33-0.53) in RCTs during a median follow-up of 13 weeks, and in 29% TPO-RA-treated patients in cohort studies, during a median follow-up of 69 weeks. The incidence of remission after TPO discontinuation was 18% (5-36%). RR of WHO grade ≥2 bleeding was 0.58 (0.38-0.86) in TPO-RA-treated patients, compared to control arm patients. Adverse events were rare and not significantly different in the two groups of patients. All-cause mortality was significantly lower with TPO-RA (RR 0.21, 95% CI, 0.06-0.68). In conclusion, TPO-RA are effective and safe in patients with ITP, even in the long term.
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Affiliation(s)
- Simone Birocchi
- Unità di Medicina II, ASST Santi Paolo e Carlo - Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
| | - Gian Marco Podda
- Unità di Medicina II, ASST Santi Paolo e Carlo - Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
| | - Marco Manzoni
- Unità di Medicina II, ASST Santi Paolo e Carlo - Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco", Università degli Studi di Milano, Milano, Italy
| | - Marco Cattaneo
- Unità di Medicina II, ASST Santi Paolo e Carlo - Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
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Sun T, Han SM, Wu WJ, Gao BL. Femoral pseudotumor secondary to injury in a patient with idiopathic thrombocytopenic purpura: Case report. Medicine (Baltimore) 2020; 99:e19788. [PMID: 32282742 PMCID: PMC7220076 DOI: 10.1097/md.0000000000019788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Idiopathic thrombocytopenic purpura (ITP) is the condition of having a low platelet count of unknown causes and is a poorly understood acquired hemorrhagic disease involving destruction of platelets in the reticuloendothelial system induced by antiplatelet antibodies. Patients with ITP can have traumatic intra-articular, intraosseous or soft tissue hemorrhage which may present as a rare intraosseous pseudotumor on medical imaging. PATIENT CONCERNS A 30-year old male patient had complaint of pain in the right leg for 1 year. Laboratory test revealed a much lower platelet count (3-12 × 10/L). DIAGNOSES Radiography and computed tomography showed expansive bone destruction in the distal segment of the right femur, and magnetic resonance imaging revealed heterogeneous signal intensity in the lesion. Lesion curettage and pathology showed an expansion cyst with a really thin cortical bone shell containing serum-like red liquid and some sediment-like deposit. Consequently, the diagnosis of a pseudotumor was confirmed. INTERVENTIONS Lesion curettage and bone graft surgery were performed, and 8 units of platelet were transfused to the patient. Giant cell reaction was found on the shell of the lesion, but no tumor cell was found on pathological examination. OUTCOMES The platelet count was 308 × 10/L 5 days after operation, and the clotting time was normal. At 6 month follow-up after lesion curettage, the patient remained normal with no deterioration in the lesion site. CONCLUSION The diagnosis of a pseudotumor of ITP relies mainly on imaging findings of the lesion and, in particular, knowledge of the underlying bleeding disorders. Radiologist and pathologist should be aware of the characteristics of this rare complication of ITP and other bleeding disorders like hemophilia in order to avoid misinterpretation of the lesion as a tumor or infection disease.
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Affiliation(s)
- Tao Sun
- Department of Orthopaedic Surgery
| | - Shu-Man Han
- Department of Radiology, The Third Hospital of Hebei Medical University, Shijiazhuang Hebei Province, China
| | - Wen-Juan Wu
- Department of Radiology, The Third Hospital of Hebei Medical University, Shijiazhuang Hebei Province, China
| | - Bu-Lang Gao
- Department of Radiology, The Third Hospital of Hebei Medical University, Shijiazhuang Hebei Province, China
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Wyman B, Perl A. Metabolic pathways mediate pathogenesis and offer targets for treatment in rheumatic diseases. Curr Opin Rheumatol 2020; 32:184-191. [PMID: 31895126 PMCID: PMC9204384 DOI: 10.1097/bor.0000000000000687] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW The cause of autoimmune diseases remains incompletely understood. Here, we highlight recent advances in the role of proinflammatory metabolic pathways in autoimmune disease, including treatment with antioxidants and mechanistic target of rapamycin (mTOR) inhibitors. RECENT FINDINGS Recent studies show that mTOR pathway activation, glucose utilization, mitochondrial oxidative phosphorylation, and antioxidant defenses play critical roles in the pathogenesis of autoimmune diseases, including rheumatoid arthritis, immune thrombocytopenia, Sjögren's syndrome, large vessel vasculitis, and systemic lupus erythematosus. mTOR activity leads to Th1 and Th17 cell proliferation, Treg depletion, plasma cell differentiation, macrophage dysfunction, and increased antibody and immune complex production, ultimately resulting in tissue inflammation. mTOR also affects the function of connective tissue cells, including fibroblast-like synoviocytes, endothelial cells, and podocytes. mTOR inhibition via rapamycin and N-acetylcysteine, and blockade of glucose utilization show clinical efficacy in both mouse models and clinical trials, such as systemic lupus erythematosus. SUMMARY The mTOR pathway is a central regulator of growth and survival signals, integrating environmental cues to control cell proliferation and differentiation. Activation of mTOR underlies inflammatory lineage specification, and mTOR blockade-based therapies show promising efficacy in several autoimmune diseases.
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Affiliation(s)
- Brandon Wyman
- Division of Rheumatology, Department of Medicine
- Department of Biochemistry and Molecular Biology, State University of New York, Upstate Medical University, College of Medicine, Syracuse, New York, USA
| | - Andras Perl
- Division of Rheumatology, Department of Medicine
- Department of Microbiology and Immunology
- Department of Biochemistry and Molecular Biology, State University of New York, Upstate Medical University, College of Medicine, Syracuse, New York, USA
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Hicks SM, Coupland LA, Jahangiri A, Choi PY, Gardiner EE. Novel scientific approaches and future research directions in understanding ITP. Platelets 2020; 31:315-321. [PMID: 32054377 DOI: 10.1080/09537104.2020.1727871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diagnosis of immune thrombocytopenia (ITP) and prediction of response to therapy remain significant and constant challenges in hematology. In patients who present with ITP, the platelet count is frequently used as a surrogate marker for disease severity, and so often determines the need for therapy. Although there is a clear link between thrombocytopenia and hemostasis, a direct correlation between the extent of thrombocytopenia and bleeding symptoms, especially at lower platelet counts is lacking. Thus, bleeding in ITP is heterogeneous, unpredictable, and nearly always based on a multitude of risk factors, beyond the platelet count. The development of an evidence-based, validated risk stratification model for ITP treatment is a major goal in the ITP community and this review discusses new laboratory approaches to evaluate the various pathobiologies of ITP that may inform such a model.
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Affiliation(s)
- Sarah M Hicks
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia
| | - Lucy A Coupland
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia
| | - Anila Jahangiri
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia
| | - Philip Y Choi
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia.,Haematology Department, The Canberra Hospital, Canberra, Australia
| | - Elizabeth E Gardiner
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia
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Abstract
Abstract
Reticulated platelets are immature platelets freshly released from the bone marrow into the circulation and contain vestigial amounts of ribonucleic acid. Thus, they can serve as an indicator for the activity of thrombopoiesis. Despite the current lack of a standardized reference method, two types of hematology analyzers have incorporated a fully automated measurement of reticulated platelets. The “immature platelet fraction” (IPF; Sysmex XE-/XN-series) has some clinical utility in the differential diagnosis of thrombocytopenia. This is less clear for “reticulated platelets” (retPLT; Abbott CELL-DYN Sapphire/Alinity HQ). The usefulness of these parameters in the prediction of platelet recovery after chemotherapy or stem cell transplantation and as a decision aid for platelet transfusions has not been unequivocally confirmed. Recent findings have shown an association of reticulated platelets with an adverse risk in patients with coronary artery disease and stroke as well as resistance to anti-platelet therapy. Furthermore, a role of reticulated platelets for the prediction of sepsis was indicated. However, validation in larger prospective trials is necessary to establish the clinical benefit of reticulated platelets in these conditions. This review gives an overview of the available analytical methods and summarizes the current knowledge regarding the clinical application of reticulated platelets.
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Affiliation(s)
- Lisa Meintker
- Department of Medicine 5 for Hematology and Oncology , University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg , Erlangen , Germany
| | - Stefan W. Krause
- Department of Medicine 5 for Hematology and Oncology , University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg , Erlangen , Germany
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Newland AC, Sánchez‐González B, Rejtő L, Egyed M, Romanyuk N, Godar M, Verschueren K, Gandini D, Ulrichts P, Beauchamp J, Dreier T, Ward ES, Michel M, Liebman HA, Haard H, Leupin N, Kuter DJ. Phase 2 study of efgartigimod, a novel FcRn antagonist, in adult patients with primary immune thrombocytopenia. Am J Hematol 2020; 95:178-187. [PMID: 31821591 PMCID: PMC7004056 DOI: 10.1002/ajh.25680] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022]
Abstract
Primary immune thrombocytopenia (ITP) is an acquired autoimmune bleeding disorder, characterized by a low platelet count (<100 × 109/L) in the absence of other causes associated with thrombocytopenia. In most patients, IgG autoantibodies directed against platelet receptors can be detected. They accelerate platelet clearance and destruction, inhibit platelet production, and impair platelet function, resulting in increased risk of bleeding and impaired quality of life. Efgartigimod is a human IgG1 antibody Fc‐fragment, a natural ligand of the neonatal Fc receptor (FcRn), engineered for increased affinity to FcRn, while preserving its characteristic pH‐dependent binding. Efgartigimod blocks FcRn, preventing IgG recycling, and causing targeted IgG degradation. In this Phase 2 study, 38 patients were randomized 1:1:1 to receive four weekly intravenous infusions of either placebo (N = 12) or efgartigimod at a dose of 5 mg/kg (N = 13) or 10 mg/kg (N = 13). This short treatment cycle of efgartigimod in patients with ITP, predominantly refractory to previous lines of therapy, was shown to be well tolerated, and demonstrated a favorable safety profile consistent with Phase 1 data. Efgartigimod induced a rapid reduction of total IgG levels (up to 63.7% mean change from baseline), which was associated with clinically relevant increases in platelet counts (46% patients on efgartigimod vs 25% on placebo achieved a platelet count of ≥50 × 109/L on at least two occasions, and 38% vs 0% achieved ≥50 × 109/L for at least 10 cumulative days), and a reduced proportion of patients with bleeding. Taken together, these data warrant further evaluation of FcRn antagonism as a novel therapeutic approach in ITP.
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Affiliation(s)
- Adrian C. Newland
- Department of Haematology, Centre for HaematologyThe Royal London Hospital London UK
| | | | - László Rejtő
- Department of HematologyJósa András Teaching Hospital Nyíregyháza Hungary
| | - Miklos Egyed
- Department of HematologyKaposi Mor Teaching Hospital Kaposvar Hungary
| | | | - Marie Godar
- argenx BVBAIndustriepark‐Zwijnaarde 7 Zwijnaarde Belgium
| | | | | | - Peter Ulrichts
- argenx BVBAIndustriepark‐Zwijnaarde 7 Zwijnaarde Belgium
| | - Jon Beauchamp
- argenx BVBAIndustriepark‐Zwijnaarde 7 Zwijnaarde Belgium
| | - Torsten Dreier
- argenx BVBAIndustriepark‐Zwijnaarde 7 Zwijnaarde Belgium
| | - E. Sally Ward
- Department of Molecular and Cellular MedicineTexas A&M University Health Science Center College Station Texas
- Centre for Cancer ImmunologyUniversity of Southampton Southampton UK
| | - Marc Michel
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'AdulteCentre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris, Université Paris Est Créteil Créteil France
| | - Howard A. Liebman
- Jane Anne Nohl Division of Hematology, Department of MedicineUniversity of Southern California Los Angeles California
| | - Hans Haard
- argenx BVBAIndustriepark‐Zwijnaarde 7 Zwijnaarde Belgium
| | - Nicolas Leupin
- argenx BVBAIndustriepark‐Zwijnaarde 7 Zwijnaarde Belgium
| | - David J. Kuter
- Department of HematologyMassachusetts General Hospital and Harvard Medical School Boston Massachusetts
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Reference guide for management of adult immune thrombocytopenia in Japan: 2019 Revision. Int J Hematol 2020; 111:329-351. [PMID: 31897887 PMCID: PMC7223085 DOI: 10.1007/s12185-019-02790-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/28/2019] [Accepted: 12/02/2019] [Indexed: 02/08/2023]
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Zhu J, Chen R, Zhao S, Zhu L, Li X, Xie M, Ye X. A megakaryocyte morphological classification-based predictive model for steroid sensitivity in primary immune thrombocytopenia. Platelets 2019; 31:939-944. [PMID: 31875757 DOI: 10.1080/09537104.2019.1708300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The first-line therapy for primary immune thrombocytopenia (ITP) is steroids, but about one-third of patients do not respond to steroids. Recent studies have shown megakaryocyte (MK) growth and development abnormalities and poorly compensated thrombopoiesis. Here, we attempted to determine the impact of MK morphological classification on steroid response. We enrolled 170 adult patients with primary ITP and divided them into steroid-sensitive ITP (109/170) and non-steroid-sensitive ITP (61/170) groups. In the univariate logistic model, female, reduced thrombocytogenic MK count (TMC), increased granular MK count to total MK count ratio (GMC/TM ratio), and elevated naked nucleus MK count to TM count ratio were significantly associated with steroid-sensitive ITP. In the multivariate logistic model, sex, reduced TMC, and increased GMC/TM ratio were independent predictors of steroid-sensitive ITP diagnosis. Based on the regression parameters, we established a predictive index with weighted risk score of 1 assigned each to sex, TMC, and GMC/TM ratio. A predictive index ≥2 points had the best area under the curve value (0.63) with 47.7% sensitivity and 78.7% specificity for predicting steroid sensitivity. These findings may help guide early treatment strategies in ITP.
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Affiliation(s)
- Jingjing Zhu
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Rongrong Chen
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Shuqi Zhao
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Lixia Zhu
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Xueying Li
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Mixue Xie
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Xiujin Ye
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
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Deshayes S, Khellaf M, Zarour A, Layese R, Fain O, Terriou L, Viallard J, Cheze S, Graveleau J, Slama B, Audia S, Cliquennois M, Ebbo M, Le Guenno G, Salles G, Bonmati C, Teillet F, Galicier L, Lambotte O, Hot A, Lefrère F, Mahévas M, Canoui‐Poitrine F, Michel M, Godeau B. Long-term safety and efficacy of rituximab in 248 adults with immune thrombocytopenia: Results at 5 years from the French prospective registry ITP-ritux. Am J Hematol 2019; 94:1314-1324. [PMID: 31489694 DOI: 10.1002/ajh.25632] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/29/2019] [Accepted: 09/03/2019] [Indexed: 01/19/2023]
Abstract
Rituximab is a second-line option in adults with immune thrombocytopenia (ITP), but the estimated 5-year response rate, only based on pooled retrospective data, is about 20%, and no studies have focused on long-term safety. We conducted a prospective multicenter registry of 248 adults with ITP treated with rituximab with 5 years of follow-up to assess its long-term safety and efficacy. The median follow-up was 68.4 [53.7-78.5] months. The incidence of severe infections was only 2/100 patient-years. Profound hypogammaglobulinemia (<5 g/L) developed in five patients at 15 to 31 months after the last rituximab infusion. In total, 25 patients died at a median age of 80 [69.5-83.9] years, corresponding to a mortality rate of 2.3/100 patient-years. Only three deaths related to infection that occurred 12 to 14 months after rituximab infusions could be due in part to rituximab. At 60 months of follow-up, 73 (29.4%) patients had a sustained response. On univariate and multivariate analysis, the only factor significantly associated with sustained response was a previous transient response to corticosteroids (P = .022). Overall, 24 patients with an initial response and then relapse received retreatment with rituximab, which gave a response in 92%, with a higher duration of response in 54%. As a result of its safety profile and its sustained response rate, rituximab remains an important option in the current therapeutic armamentarium for adult ITP. Retreatment could be an effective and safe option.
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Affiliation(s)
- Samuel Deshayes
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
- Service de Médecine Interne Normandie Univ, UNICAEN, CHU de Caen Normandie Caen France
| | - Mehdi Khellaf
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Anissa Zarour
- Unité de Recherche Clinique, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Richard Layese
- Unité de Recherche Clinique, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
- Service de Santé Publique CHU Henri‐Mondor, EA 7376 CEpiA, UPEC Créteil France
| | - Olivier Fain
- Service de Médecine Interne, Hôpital Saint‐Antoine, Assistance Publique‐Hôpitaux de Paris Sorbonne Université Paris France
| | - Louis Terriou
- Service de Médecine Interne Centre Hospitalier Régional Universitaire de Lille Lille France
| | - Jean‐François Viallard
- Département de Médecine Interne et Maladies Infectieuses Centre Hospitalier Universitaire Haut Lévêque, Université de Bordeaux Pessac France
| | - Stéphane Cheze
- Service d'Hématologie Clinique Normandie Univ, UNICAEN, CHU de Caen Normandie Caen France
| | - Julie Graveleau
- Service de Médecine Interne Centre Hospitalier Universitaire de Nantes Nantes France
| | - Borhane Slama
- Service d'Hématologie Centre Hospitalier d'Avignon Avignon France
| | | | - Manuel Cliquennois
- Département d'Hématologie Groupe Hospitalier de l'Institut Catholique de Lille Lille France
| | - Mikael Ebbo
- Service de Médecine Interne Hôpital de la Timone, Assistance Publique‐Hôpitaux de Marseille, Université Aix‐Marseille Marseille France
| | - Guillaume Le Guenno
- Service de Médecine Interne Centre Hospitalier Universitaire Estaing Clermont Ferrand France
| | - Gilles Salles
- Service d'Hématologie Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre‐Bénite, University Claude Bernard Lyon 1 Lyon France
| | - Caroline Bonmati
- Service d'Hématologie Centre Hospitalier Universitaire de Nancy Nancy France
| | - France Teillet
- Département d'Immuno‐Hématologie Centre Hospitalier Universitaire Louis Mourier, Assistance Publique‐Hôpitaux de Paris Colombes France
| | - Lionel Galicier
- Service d'Immuno‐Pathologie Centre Hospitalier Universitaire Saint‐Louis, Assistance Publique‐Hôpitaux de Paris Paris France
| | - Olivier Lambotte
- Service de Médecine Interne Centre Hospitalier Universitaire Bicêtre, Assistance Publique‐Hôpitaux de Paris Paris France
| | - Arnaud Hot
- Service de Médecine Interne Groupement Hospitalier Edouard Herriot Lyon France
| | - François Lefrère
- Service d'Hématologie Centre Hospitalier Universitaire Necker, Assistance Publique‐ Hôpitaux de Paris Paris France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Florence Canoui‐Poitrine
- Unité de Recherche Clinique, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
- Service de Santé Publique CHU Henri‐Mondor, EA 7376 CEpiA, UPEC Créteil France
| | - Marc Michel
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre National de Référence des Cytopénies Auto‐Immunes de l'Adulte, Centre Hospitalier Universitaire Henri‐Mondor, Assistance Publique‐Hôpitaux de Paris Université Paris Est Créteil Créteil France
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The Use of High Dose Eltrombopag in the Management of Sepsis-Associated Thrombocytopenia in Critically Ill Patients. ACTA ACUST UNITED AC 2019; 5:123-129. [PMID: 31915717 PMCID: PMC6942450 DOI: 10.2478/jccm-2019-0019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/05/2019] [Indexed: 12/19/2022]
Abstract
Introduction Sepsis is a life-threatening condition, and sepsis-associated thrombocytopenia (SAT) is a common consequence of the disease where platelet count falls drastically within a very short time. Multiple key factors may cause platelet over-activation, destruction and reduction in platelet production during the sepsis. Eltrombopag is a thrombopoietin receptor agonist and is the second-line drug of choice in the treatment of chronic immune thrombocytopenia (ITP). Aim of the study The objective of this study was to observe the therapeutic outcome of high dose eltrombopag in SAT management in critically ill patients. Material and Methods This 6-month-long single group, observational study was conducted on seventeen ICU patients with SAT. Eltrombopag 100 mg/day in two divided doses was given to each patient. Platelet counts were monitored. A low platelet blood count returning to 150 K/μL or above, is taken as indicative of a successful reversal of a thrombocytopenia event. Results The mean Apache II score of patients (n= 17) was 18.71 (p-value: >0.05). No eltrombopag-induced adverse event was observed among the patients during the study period. Thrombocytopenia events were reversed successfully in 64.71% of patients (11; n= 17) within eight days of eltrombopag therapy. Conclusions The therapeutic potentiality of high dose eltrombopag regime in the management of sepsis-associated thrombocytopenia was found clinically significant in over two-thirds of critically ill adult patients enrolled in the study. These data may point to a new strategy in the management of acute type of thrombocytopenia in septic patients.
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77
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Immune thrombocytopenic purpura increased risk of subsequent pancreatitis: A Nationwide population cohort study. Sci Rep 2019; 9:16923. [PMID: 31729447 PMCID: PMC6858306 DOI: 10.1038/s41598-019-53165-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 10/29/2019] [Indexed: 11/26/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is characterized by thrombocytopenia and bleeding diathesis. Pancreatitis is a very rare complication but may be fatal. We analyzed data of newly diagnosed ITP patients, excluding those with a history of splenectomy, unknown sex or date of birth, or preexisting pancreatitis at the time of ITP diagnosis, and compared these with selected age-, gender-, and index-year-matched controls, using the Taiwan National Health Insurance Research Database from 1996 to 2013. The study enrolled 100,177 ITP patients and 100,177 controls. We found that pancreatitis risk was higher in secondary ITP patients, regardless of age group, gender, baseline Charlson comorbidity index (CCI) score, history of biliary stone, hyperlipidemia, or alcoholism, than in the control population. Primary ITP patients with CCI score 1 and without biliary tract stone history also showed a higher pancreatitis risk than the controls. The incidence rate and cumulative incidence of pancreatitis were increased in primary, secondary, and unspecified ITP cases. These phenomena may be related to the presence of autoantibodies against glycoprotein IIb/IIIa, or to IgG4, microparticle obstruction, or sclerosis. We noted a direct association between ITP and the development of pancreatitis in Taiwan population.
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78
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Bussel J, Kulasekararaj A, Cooper N, Verma A, Steidl U, Semple JW, Will B. Mechanisms and therapeutic prospects of thrombopoietin receptor agonists. Semin Hematol 2019; 56:262-278. [PMID: 31836033 DOI: 10.1053/j.seminhematol.2019.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
The second-generation thrombopoietin (TPO) receptor agonists eltrombopag and romiplostim are potent activators of megakaryopoiesis and represent a growing treatment option for patients with thrombocytopenic hematological disorders. Both TPO receptor agonists have been approved worldwide for the treatment of children and adults with chronic immune thrombocytopenia. In the EU and USA, eltrombopag is approved for the treatment of patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy and in the USA for the first-line treatment of severe aplastic anemia in combination with immunosuppressive therapy. Eltrombopag has also shown efficacy in several other disease settings, for example, chemotherapy-induced thrombocytopenia, selected inherited thrombocytopenias, and myelodysplastic syndromes. While both TPO receptor agonists stimulate TPO receptor signaling and enhance megakaryopoiesis, their vastly different biochemical structures bestow upon them markedly different molecular and functional properties. Here, we review and discuss results from preclinical and clinical studies on the functional and molecular mechanisms of action of this new class of drug.
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Affiliation(s)
- James Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY.
| | | | | | - Amit Verma
- Albert Einstein College of Medicine, New York, NY
| | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Britta Will
- Albert Einstein College of Medicine, New York, NY.
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79
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Sheng Z, Li J, Wang Y, Li S, Hou M, Peng J, Feng Q. A CARD9 single-nucleotide polymorphism rs4077515 is associated with reduced susceptibility to and severity of primary immune thrombocytopenia. Ann Hematol 2019; 98:2497-2506. [PMID: 31595308 DOI: 10.1007/s00277-019-03796-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 09/08/2019] [Indexed: 12/29/2022]
Abstract
Primary immune thrombocytopenia (ITP) is an acquired autoimmune disease characterized by a low platelet count and consequent increased risk of bleeding. The etiology underlying this condition remains poorly understood. The aim of this study is to evaluate the association of a single nucleotide polymorphism (SNP) rs4077515 in the caspase recruitment domain-containing protein 9 (CARD9) gene with the pathogenesis and therapy of ITP. Two hundred ninety-four patients with ITP and 324 age-matched healthy participants were recruited in this case-control study. Genotyping of CARD9 rs4077515 polymorphism was performed by Sanger sequencing. Our results revealed that a polymorphism rs4077515 in CARD9 gene is associated with decreased risk of susceptibility to and severity of ITP (susceptibility: codominant, AA vs. GG, OR = 0.175, 95% CI = 0.054-0.776, p = 0.001; recessive, GG + AG vs. AA, OR = 6.183, 95% CI = 2.287-16.715, p < 0.001; severity: allele, A vs. G, OR = 0.685, 95% CI = 0.476-0.985, p = 0.041; codominant, AG vs. GG, OR = 0.571, 95% CI = 0.350-0.931, p = 0.025; dominant, AA + AG vs. GG, OR = 0.558, 95% CI = 0.343-0.907, p = 0.019). The existence of the allele A, the mutant AA genotype and the heterozygous AG genotype of CARD9 rs4077515, plays a protective role in ITP. However, CARD9 rs4077515 polymorphism had no effect on corticosteroid sensitivity or refractoriness of ITP.
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Affiliation(s)
- Zi Sheng
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, 250012, China
| | - Ju Li
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, 250012, China
| | - Yuanjian Wang
- Department of Clinical Medicine, West China School of Medicine, Sichuan University, Chengdu, China
| | - Song Li
- Department of Oncology, Qilu Hospital, Shandong University, Jinan, China
| | - Ming Hou
- Key Laboratory of Cardiovascular Remodelling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Jinan, China.,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Shandong University, Jinan, China
| | - Jun Peng
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, 250012, China
| | - Qi Feng
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, 250012, China.
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80
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LeVine DN, Brooks MB. Immune thrombocytopenia (ITP): Pathophysiology update and diagnostic dilemmas. Vet Clin Pathol 2019; 48 Suppl 1:17-28. [PMID: 31538353 DOI: 10.1111/vcp.12774] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/28/2019] [Accepted: 05/20/2019] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a common autoimmune bleeding disorder. The understanding of ITP pathogenesis is rapidly evolving. We now recognize ITP as a complex and heterogeneous syndrome that results from a combination of humoral and cell-mediated attacks on platelets peripherally and megakaryocytes in the bone marrow. Autoantibody-mediated ITP also varies in the pathway used to clear platelets, which depends on the platelet glycoprotein being targeted. Moreover, ITP patients present with variable bleeding severities and treatment responses that do not closely correlate with platelet count. A gold standard diagnostic test for ITP is lacking, and biomarkers to assess disease severity are in their infancy. This review provides an update on the immunopathogenesis of ITP and summarizes currently available tests for ITP diagnosis, prediction of disease severity, and treatment responses. Given the heterogeneous pathogenesis and clinical presentation of ITP, we highlight the need for the development of diagnostic and prognostic tests that would allow for the individualized management of a complex disease.
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Affiliation(s)
- Dana N LeVine
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Iowa State University, Ames, Iowa
| | - Marjory B Brooks
- Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York
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Affiliation(s)
- Nichola Cooper
- From the Department of Medicine, Hammersmith Hospital, Imperial College, London (N.C.); and the Departments of Medicine, Hematology-Oncology, and Research, Østfold Hospital Trust, Kalnes, and the Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo (W.G.) - both in Norway
| | - Waleed Ghanima
- From the Department of Medicine, Hammersmith Hospital, Imperial College, London (N.C.); and the Departments of Medicine, Hematology-Oncology, and Research, Østfold Hospital Trust, Kalnes, and the Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo (W.G.) - both in Norway
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82
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Zain MA, Zafar F, Ashfaq A, Jamil AR, Ahmad A. Helicobacter pylori: An Underrated Cause of Immune Thrombocytopenic Purpura. A Comprehensive Review. Cureus 2019; 11:e5551. [PMID: 31695974 PMCID: PMC6820323 DOI: 10.7759/cureus.5551] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP) is the autoimmune-mediated destruction of platelets. ITP is a diagnosis of exclusion after other identifiable etiologies have been ruled out. After the first report by Gasbarrini et al. (1998) showing rising platelet counts in ITP patients following Helicobacter pylori (HP) eradication therapy, there is growing evidence that highlights the role of HP in triggering ITP. However, the exact pathophysiology of HP-associated ITP is still unclear, but many theories have been implicated in this regard. According to various reports, the postulated mechanisms for the role of HP in cITP include molecular mimicry, increased plasmacytoid dendritic cell numbers, phagocytic perturbation, and variable host immune response to HP virulence factors. One famous theory suggested molecular mimicry between platelet surface antigen and bacterial virulence factor, i.e. cytotoxin-associated gene A (CagA). It is thought that a chronic inflammatory response following an HP infection induces the host autoantibodies' response against CagA, which cross-reacts with platelet surface glycoproteins; therefore, it may accelerate platelet destruction in the host reticuloendothelial system. However, further studies are mandated to better understand the causal link between ITP and HP and study the role of biogeography. Nowadays, it is recommended that every patient with ITP should undergo HP diagnostic testing and triple therapy should be administered in all those candidates who test positive for HP infection. In our review, there were a few pregnant female ITP patients who took HP eradication therapy mainly after 20 weeks of gestation without maternal or fetal worst outcomes. However, large-scale studies are advisable to study the adverse fetal outcomes following triple therapy use.
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Affiliation(s)
- Muhammad A Zain
- Internal Medicine, Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, PAK
| | - Fahad Zafar
- Internal Medicine, Maimonides Medical Center, Brooklyn, USA
| | - Ammar Ashfaq
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, USA
| | - Abdur R Jamil
- Internal Medicine, Central Michigan University, Saginaw, USA
| | - Asrar Ahmad
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, USA
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Lucchini E, Zaja F, Bussel J. Rituximab in the treatment of immune thrombocytopenia: what is the role of this agent in 2019? Haematologica 2019; 104:1124-1135. [PMID: 31126963 PMCID: PMC6545833 DOI: 10.3324/haematol.2019.218883] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/09/2019] [Indexed: 01/19/2023] Open
Abstract
The use of rituximab for the treatment of immune thrombocytopenia was greeted enthusiastically: it led to up to 60% response rates, making it, nearly 20 years ago, the main alternative to splenectomy, with far fewer side effects. However, long-term follow-up data showed that only 20-30% of patients maintained the remission. No significant changes have been registered using different dose schedules and timing of administration, while the combination with other drugs seemed promising. Higher response rates have been observed in young women before the chronic phase, but apart from that, other clinical factors or biomarkers predictive of response are still lacking. In this review we examine the historical and current role of rituximab in the management of immune thrombocytopenia, 20 years after its first use for the treatment of autoimmune diseases.
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Affiliation(s)
- Elisa Lucchini
- SC Ematologia, Azienda Sanitaria Universitaria Integrata Trieste, Italy
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata Trieste, Italy
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Hall LS, Lennon CS, Hall AM, Urbaniak SJ, Vickers MA, Barker RN. Combination peptide immunotherapy suppresses antibody and helper T-cell responses to the major human platelet autoantigen glycoprotein IIb/IIIa in HLA-transgenic mice. Haematologica 2019; 104:1074-1082. [PMID: 30514805 PMCID: PMC6518892 DOI: 10.3324/haematol.2017.179424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 11/29/2018] [Indexed: 12/19/2022] Open
Abstract
Platelet destruction in immune thrombocytopenia is caused by autoreactive antibody and T-cell responses, most commonly directed against platelet glycoprotein IIb/IIIa. Loss of self-tolerance in the disease is also associated with deficient activity of regulatory T cells. Having previously mapped seven major epitopes on platelet glycoprotein IIIa that are recognized by helper T cells from patients with immune thrombocytopenia, the aim was to test whether peptide therapy with any of these sequences, alone or in combination, could inhibit responses to the antigen in humanized mice expressing HLA-DR15. None of the individual peptides, delivered by a putative tolerogenic regimen, consistently suppressed the antibody response to subsequent immunization with human platelet glycoprotein IIb/IIIa. However, the combination of glycoprotein IIIa peptides aa6-20 and aa711-725, which contain the predominant helper epitopes in patients and elicited the strongest trends to suppress when used individually, did abrogate this response. The peptide combination also blunted, but did not reverse, the ongoing antibody response when given after immunization. Suppression of antibody was associated with reduced splenocyte T-cell responsiveness to the antigen, and with the induction of a regulatory T-cell population that is more responsive to the peptides than to purified platelet glycoprotein IIb/IIIa. Overall, these data demonstrate that combinations of peptides containing helper epitopes, such as platelet glycoprotein IIIa aa6-20 and aa711-725, can promote in vivo suppression of responses to the major antigen implicated in immune thrombocytopenia. The approach offers a promising therapeutic option to boost T-cell regulation, which should be taken forward to clinical trials.
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Affiliation(s)
- Lindsay S Hall
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
- Scottish National Blood Transfusion Service, Foresterhill Road, Aberdeen, UK
| | - Charlotte S Lennon
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
| | - Andrew M Hall
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
| | - Stanislaw J Urbaniak
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
- Scottish National Blood Transfusion Service, Foresterhill Road, Aberdeen, UK
| | - Mark A Vickers
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
- Scottish National Blood Transfusion Service, Foresterhill Road, Aberdeen, UK
| | - Robert N Barker
- Institute of Medical Sciences, Ashgrove Road West, University of Aberdeen
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85
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Vrbensky JR, Moore JE, Arnold DM, Smith JW, Kelton JG, Nazy I. The sensitivity and specificity of platelet autoantibody testing in immune thrombocytopenia: a systematic review and meta-analysis of a diagnostic test. J Thromb Haemost 2019; 17:787-794. [PMID: 30801909 DOI: 10.1111/jth.14419] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/15/2019] [Indexed: 11/30/2022]
Abstract
Essentials The diagnosis of ITP is based on a platelet count < 100 × 109 L-1 and exclusion of other causes. There are no standard tests or biomarkers to diagnose ITP. The sensitivity of platelet autoantibody testing is low (53%). The specificity is high (> 90%). A positive autoantibody test can be useful to rule in ITP but a negative does not rule out ITP. SUMMARY: Background Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a low platelet count and an increased risk of bleeding. The sensitivity and specificity of platelet autoantibody tests is variable and their utility is uncertain. Objective The purpose of this study was to perform a systematic review and meta-analysis of platelet autoantibody tests in the diagnosis of ITP. Methods Ovid Medline, PubMed, and Web of Science were searched from inception until 31 May 2018. Two reviewers independently assessed studies for eligibility and extracted data. Studies that reported testing results for antiplatelet autoantibodies on platelets (direct tests) or in plasma/serum (indirect tests) for 20 or more ITP patients were included. Results Pooled estimates for sensitivity and specificity were calculated using a random effects model. Pooled estimates for the sensitivity and specificity of direct anti-platelet autoantibody testing for either anti-glycoprotein IIbIIIa or anti-glycoprotein IbIX were 53% (95% confidence interval [CI], 44-61%) and 93% (95% CI, 81-99%), respectively. For indirect testing, the pooled estimates for the sensitivity and specificity were 18% (95% CI, 12-24%) and 96% (95% CI, 87-100%), respectively. Conclusions Autoantibody testing in ITP patients has a high specificity but low sensitivity. A positive autoantibody test can be useful for ruling in ITP, but a negative test does not rule out ITP.
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Affiliation(s)
- John R Vrbensky
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Joyce E Moore
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
- Canadian Blood Services, Hamilton, Ontario, Canada
| | - James W Smith
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John G Kelton
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada
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86
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Kuter DJ, Newland A, Chong BH, Rodeghiero F, Romero MT, Pabinger I, Chen Y, Wang K, Mehta B, Eisen M. Romiplostim in adult patients with newly diagnosed or persistent immune thrombocytopenia (ITP) for up to 1 year and in those with chronic ITP for more than 1 year: a subgroup analysis of integrated data from completed romiplostim studies. Br J Haematol 2019; 185:503-513. [PMID: 30793285 PMCID: PMC6593696 DOI: 10.1111/bjh.15803] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 12/18/2018] [Indexed: 12/14/2022]
Abstract
The thrombopoietin receptor agonist romiplostim is approved for second-line use in chronic immune thrombocytopenia (ITP), but its effects in patients with ITP for ≤1 year are not well characterized. This analysis of pooled data from 9 studies included patients with ITP for ≤1 year (n = 311) or >1 year (n = 726) who failed first-line treatments and received romiplostim, placebo or standard of care. In subgroup analysis by ITP duration, patient incidences for platelet response at ≥75% of measurements were higher for romiplostim [ITP ≤1 year: 74% (204/277); ITP >1 year: 71% (450/634)] than for placebo/standard of care [ITP ≤1 year: 18% (6/34); ITP >1 year: 9% (8/92)]. Of patients with ≥9 months on study, 16% with ITP ≤1 year and 6% with ITP >1 year discontinued romiplostim and maintained platelet counts ≥50 × 109 /l for ≥6 months without ITP treatment (treatment-free remission). Independent of ITP duration, rates of serious adverse events and bleeding were lower with romiplostim than placebo/standard of care and thrombotic events occurred at similar rates. In this analysis, romiplostim and placebo/standard of care had similar safety profiles and romiplostim increased platelet counts in patients with either ITP ≤1 year or ITP >1 year, with more treatment-free remission in those with ITP ≤1 year.
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Affiliation(s)
- David J. Kuter
- Department of HematologyMassachusetts General HospitalBostonMAUSA
| | - Adrian Newland
- The Pathology Clinical Academic Groupthe Royal London HospitalLondonUK
| | - Beng H. Chong
- University of New South Wales and St. George HospitalSydneyAustralia
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87
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Al-Samkari H, Kuter DJ. Optimal use of thrombopoietin receptor agonists in immune thrombocytopenia. Ther Adv Hematol 2019; 10:2040620719841735. [PMID: 31007886 PMCID: PMC6460888 DOI: 10.1177/2040620719841735] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/11/2019] [Indexed: 12/11/2022] Open
Abstract
The thrombopoietin receptor agonists (TPO-RAs) are a class of platelet growth factors commonly used to treat immune thrombocytopenia (ITP). There are three agents that have been investigated for the treatment of chronic ITP: the peptide agent romiplostim and the small molecule agents eltrombopag and avatrombopag. These agents offer a higher clinical response rate than most other ITP therapies but may require indefinite use. This review is a critical appraisal of the TPO-RAs in adult ITP, defining the optimal patient groups to receive these agents and assisting the hematologist with agent choice, goals of treatment, dosing strategies, and toxicity management. Use of endogenous thrombopoietin levels to predict response to eltrombopag and romiplostim treatment is discussed and alternative dosing protocols suited for certain patient subgroups are described. Finally, indications for discontinuation and combination therapy with other agents are considered.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Suite 118, Room 112, Zero Emerson Place, Boston, MA 02114, USA
| | - David J. Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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88
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[Efficacy and safety of recombinant human thrombopoietin in adult patients with primary immune thrombocytopenia during the perioperative period]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:191-194. [PMID: 30929384 PMCID: PMC7342530 DOI: 10.3760/cma.j.issn.0253-2727.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
目的 观察成人原发免疫性血小板减少症(ITP)患者围手术期应用rhTPO的疗效和安全性。 方法 对拟接受择期手术的一线糖皮质激素治疗无效的ITP患者在围手术期应用重组人血小板生成素(rhTPO)1.5×104 U/d皮下注射,直至符合下列任何一个条件则停止:①血小板计数达到手术要求;②PLT≥100×109/L;③疗程达14 d。 结果 ①2016年1月1日至2018年6月30日共入组42例患者,男14例,女28例,中位年龄60(25~73)岁,持续性ITP 5例,慢性ITP 37例。②中位rhTPO疗程7(3~14)d。完全反应24例,有效7例,无效11例。达到完全反应的中位时间为7(3~16)d,血小板计数达峰值中位时间为10(3~21)d。③27例(64.3%)完成手术(全麻手术14例,局麻手术13例)。④手术患者rhTPO治疗前、手术前、手术后第7天中位血小板计数分别为33(20~89)×109/L、125(78~245)×109/L、72(30~250)×109/L,中位峰值血小板计数为149(101~466)×109/L。⑤未发生感染、出血、血栓和rhTPO相关不良事件。 结论 rhTPO可作为ITP患者择期手术围手术期提升血小板水平的备选方案。
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89
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Nurden AT. Acquired Glanzmann thrombasthenia: From antibodies to anti-platelet drugs. Blood Rev 2019; 36:10-22. [PMID: 31010659 DOI: 10.1016/j.blre.2019.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 02/06/2023]
Abstract
In contrast to the inherited platelet disorder given by mutations in the ITGA2B and ITGB3 genes, mucocutaneous bleeding from a spontaneous inhibition of normally expressed αIIbβ3 characterizes acquired Glanzmann thrombasthenia (GT). Classically, it is associated with autoantibodies or paraproteins that block platelet aggregation without causing a fall in platelet count. However, inhibitory antibodies to αIIbβ3 are widely associated with primary immune thrombocytopenia (ITP), occur in secondary ITP associated with leukemia and related disorders, solid cancers and myeloma, other autoimmune diseases, following organ transplantation while cytoplasmic dysregulation of αIIbβ3 function features in myeloproliferative and myelodysplastic syndromes. Antibodies to αIIbβ3 occur during viral and bacterial infections, while drug-dependent antibodies reacting with αIIbβ3 are a special case. Direct induction of acquired GT is a feature of therapies that block platelets in coronary artery disease. This review looks at these conditions, emphasizing molecular mechanisms, therapy, patient management and future directions for research.
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Affiliation(s)
- Alan T Nurden
- Institut de Rhythmologie et de Modélisation Cardiaque, Plateforme Technologique d'Innovation Biomédicale, Hôpital Xavier Arnozan, Pessac, France.
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90
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Sun RJ, Shan NN. Megakaryocytic dysfunction in immune thrombocytopenia is linked to autophagy. Cancer Cell Int 2019; 19:59. [PMID: 30923461 PMCID: PMC6419848 DOI: 10.1186/s12935-019-0779-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 03/11/2019] [Indexed: 01/07/2023] Open
Abstract
Immune thrombocytopenic purpura (ITP) is a multifactorial autoimmune disease characterized by both increased platelet destruction and/or reduced platelet production. Even though they are detected in ≤ 50% of ITP patients, auto-antibodies play a pivotal role in the pathogenesis of ITP. Recent experimental and clinical observations have revealed abnormal autophagy in ITP patients. Autophagy is a catabolic process responsible for the elimination and recycling of cytoplasmic constituents, such as organelles and macromolecules, in eukaryotic cells. Additionally, it triggers cell death or promotes cell survival following various forms of stress, and maintains the microenvironment and stemness of haematopoietic stem cells. The role of autophagy in megakaryopoiesis, thrombopoiesis, and platelet function is slowly being uncovered. The abnormal autophagy in ITP patients may be caused by deletion of autophagy-related genes such as ATG7 and abnormal signalling due to overexpression of mTOR. These changes are thought to affect markers of haematopoietic stem cells, such as CD41 and CD61, and differentiation of megakaryocytes, ultimately decreasing the function and quantity of platelets and leading to the onset of ITP. This review highlights recent evidence on the essential role played by autophagy in megakaryopoiesis, megakaryocyte differentiation, thrombopoiesis, and platelet production. It also discusses the potential of targeting the autophagy pathway as a novel therapeutic approach against ITP.
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Affiliation(s)
- Rui-Jie Sun
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, 325 Jing Wu Rd, Jinan, 250021 Shandong People's Republic of China
| | - Ning-Ning Shan
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, 325 Jing Wu Rd, Jinan, 250021 Shandong People's Republic of China
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91
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Multiple concomitant mechanisms contribute to low platelet count in patients with immune thrombocytopenia. Sci Rep 2019; 9:2208. [PMID: 30778108 PMCID: PMC6379541 DOI: 10.1038/s41598-018-38086-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 12/20/2018] [Indexed: 11/16/2022] Open
Abstract
Mechanisms leading to low platelet count in immune thrombocytopenia (ITP) involves both decreased production and increased destruction of platelet. However, the contribution of these pathologic mechanisms to clinical outcome of individual patients is uncertain. Here we evaluated different pathogenic mechanisms including in vitro megakaryopoiesis, platelet/megakaryocyte (MK) desialylation and MK apoptosis, and compared these effects with thrombopoyesis and platelet apoptosis in the same cohort of ITP patients. Normal umbilical cord blood-CD34+ cells, mature MK derived cells or platelets were incubated with plasma from ITP patients. Despite inhibition of thrombopoiesis previously observed, megakaryopoiesis was normal or even increased. Plasma from ITP patients affected the sialylation pattern of control platelets and this effect occurred concomitantly with apoptosis in 35% ITP samples. However, none of these abnormalities were observed in control MKs incubated with ITP plasma. Addition of mononuclear cells as immune effectors did not lead to phosphatidylserine exposure in MK, ruling out an antibody-mediated cytotoxic effect. These results suggest that both desialylation and apoptosis may be relevant mechanisms leading to platelet destruction although, they do not interfere with MK function. Analysis of these thrombocytopenic factors in individual patients showed no specific distribution pattern. However, the presence of circulating antiplatelet autoantibodies was associated with higher incidence of abnormalities. In conclusion, the causes of thrombocytopenia are multifactorial and may occur together, providing a rational basis for the use of combination therapies targeting concomitant ITP mechanisms in patients with refractory disease.
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92
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93
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Thrombopoietin Receptor Agonists. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00061-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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94
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Asoglu V, Umit EG, Demir M. A biomarker and therapeutical target in immune thrombocytopenia: TNF receptor-associated factor 6. Biomark Med 2019; 13:27-31. [DOI: 10.2217/bmm-2018-0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Immune thrombocytopenia (ITP) is an acquired disease characterized by various pathogenetic mechanisms. We aimed to evaluate the value of TRAF6 as a biomarker of pathogenesis in ITP. Methods: 85 newly diagnosed ITP patients and 85 controls were included. Results: In the patient group, mean TRAF6 level was 2348 pg/ml and in the control group, TRAF6 level was 25.57 pg/ml. In corticosteroid-responding patients, TRAF6 levels were lower than nonresponding patients. Discussion: TRAF6 levels were observed to be higher than healthy controls, which suggest a solid relation with ITP pathogenesis. The observation that in patients who present with high TRAF6 levels, there was a significant corticosteroid refractoriness and responsiveness.
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Affiliation(s)
- Veysi Asoglu
- Department of Hematology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Elif G Umit
- Department of Hematology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Muzaffer Demir
- Department of Hematology, Faculty of Medicine, Trakya University, Edirne, Turkey
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95
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Akuta K, Kashiwagi H, Yujiri T, Nishiura N, Morikawa Y, Kato H, Honda S, Kanakura Y, Tomiyama Y. A unique phenotype of acquired Glanzmann thrombasthenia due to non-function-blocking anti-αIIbβ3 autoantibodies. J Thromb Haemost 2019; 17:206-219. [PMID: 30388316 DOI: 10.1111/jth.14323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 10/27/2018] [Indexed: 11/29/2022]
Abstract
Essentials Acquired Glanzmann thrombasthenia (aGT) is generally caused by function-blocking antibodies (Abs). We demonstrated a unique aGT case due to marked reduction of αIIbβ3 with anti-αIIbβ3 Abs. The anti-αIIbβ3 Abs of the patient did not inhibit platelet function but reduced surface αIIbβ3. Internalization of αIIbβ3 induced by the Abs binding may be responsible for the phenotype. SUMMARY: Background Acquired Glanzmann thrombasthenia (aGT) is a bleeding disorder generally caused by function-blocking anti-αIIbβ3 autoantibodies. Aim We characterize an unusual case of aGT caused by marked reduction of surface αIIbβ3 with non-function-blocking anti-αIIbβ3 antibodies (Abs). Methods A 72-year-old male suffering from immune thrombocytopenia since his 50s showed exacerbation of bleeding symptom despite mild thrombocytopenia. Platelet aggregation was absent with all agonists but ristocetin. Analysis of αIIbβ3 expression and genetic analysis were performed. We also analyzed effects of anti-αIIbβ3 Abs of the patient on platelet function and αIIbβ3 expression. Results Surface αIIbβ3 expression was markedly reduced to around 5% of normal, whereas his platelets contained αIIbβ3 to the amount of 40-50% of normal. A substantial amount of fibrinogen was also detected in his platelets. There were no abnormalities in ITGA2B and ITGB3 cDNA. These results indicated that reduced surface αIIbβ3 expression caused a GT phenotype, and active internalization of αIIbβ3 was suggested. Anti-αIIbβ3 IgG Abs were detected in platelet eluate and plasma. These Abs did not inhibit PAC-1 binding, indicating that the Abs were non-function-blocking. Surface αIIbβ3 expression of a megakaryocytic cell line and cultured megakaryocytes tended to be impaired by incubation with the patient's Abs. After 2 years of aGT diagnosis, his bleeding symptom improved and surface αIIbβ3 expression was recovered to 20% of normal with reduction of anti-αIIbβ3 Abs. Conclusion We demonstrated a unique aGT phenotype due to marked reduction of surface αIIbβ3. Internalization induced by anti-αIIbβ3 Abs may be responsible in part for the phenotype.
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Affiliation(s)
- K Akuta
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - H Kashiwagi
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - T Yujiri
- Third Department of Internal Medicine, Yamaguchi University School of Medicine, Ube, Japan
| | - N Nishiura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Y Morikawa
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - H Kato
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - S Honda
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Y Kanakura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Y Tomiyama
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Blood Transfusion, Osaka University Hospital, Suita, Japan
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96
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Aleem A, Al-Zahrani H, Mohareb F, Ahmed S, Al-Suliman A, Al Saeed H, Al-Ghamdi M, Al-Hashmi H. Management of adult immune thrombocytopenia: Recommendations by an expert Saudi panel. JOURNAL OF APPLIED HEMATOLOGY 2019. [DOI: 10.4103/joah.joah_51_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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97
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Lozier JN, Noel P. Immunohematological Disorders. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00062-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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98
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Liu Y, Wang R, Han P, Zhao Y, Li G, Li G, Nie M, Wang L, Chen J, Liu X, Hou M. Effect of recombinant human thrombopoietin on immune thrombocytopenia in pregnancy in a murine model. Int Immunopharmacol 2018; 67:287-293. [PMID: 30572253 DOI: 10.1016/j.intimp.2018.12.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 12/04/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Abstract
Primary immune thrombocytopenia (ITP) is a serious medical disorder that has the potential for maternal and fetal mortality. Corticosteroids, intravenous immunoglobulin, or both are the first-line treatments for ITP in pregnancy, but choices are limited if patients fail to respond. Recombinant human thrombopoietin (rhTPO) has been proved effective and safe in management of chronic ITP. However, the efficacy and safety of rhTPO for pregnant ITP patients still need to be explored. Here we developed an ideal murine model that simulated human ITP in pregnancy and evaluated the efficacy and safety of rhTPO in management of ITP in pregnancy. Model mice were subcutaneously administered with 0, 150, 1,500 and 15,000 U/kg rhTPO for 14 days. Significant higher platelet counts were noted in rhTPO-treated groups on Day 7, 10 and 14. On Day 20, half the maternal mice were sacrificed. Frequencies of Tregs in CD4+ T cells in rhTPO-treated groups were statistically higher than control. Significant higher plasma levels of TGF-β1 were observed in rhTPO-treated groups than control. There was no significant abnormality in gross or visceral examination of fetuses. The remaining half maternal mice and their pups were observed for at least three weeks to assess vital signs. No abnormal signs were noted. Furthermore, we investigated the underlying mechanisms. Results showed that Tregs were negative for c-Mpl and rhTPO had no direct effect on Tregs. Additionally, the Treg frequency in splenic CD4+ T cells in LY2109761-treated model mice was statistically lower than control. Thus, rhTPO may be a safe and effective option for treatment of pregnant ITP patients.
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Affiliation(s)
- Yang Liu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Rui Wang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Panpan Han
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yajing Zhao
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Guijie Li
- Department of Interventional Diagnosis and Treatment, Shandong Provincial Qianfoshan Hospital Affiliated to Shandong University, Jinan, China
| | - Guosheng Li
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Mu Nie
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Lingjun Wang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Jian Chen
- Department of Hematology, Jining No. 1 People's Hospital, Jining, China
| | - Xuena Liu
- Department of Rheumatology, Qilu Hospital, Shandong University, Jinan, China.
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China; Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Shandong University, Jinan, China; Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province, Qilu Hospital, Shandong University, Jinan, China.
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99
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Zhan FX, Li J, Fang M, Ding J, Wang Q. Importance of Th22 Cell Disequilibrium in Immune Thrombocytopenic Purpura. Med Sci Monit 2018; 24:8767-8772. [PMID: 30510151 PMCID: PMC6289030 DOI: 10.12659/msm.912528] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The disequilibrium of T helper (Th) cells play an important role in the occurrence and development of immune thrombocytopenic purpura (ITP). Th22 cells, as a newly discovered subset of T lymphocytes, plays an important role in autoimmune disorders and inflammatory diseases. MATERIAL AND METHODS This study explored the role of different lymphocyte subsets in chronic ITP. To explore the value of Th22 cells in the diagnosis of ITP, the numbers of Th1, Th17, and Th22 cells were detected by a 4-color flow cytometric in 32 chronic ITP patients and 30 healthy controls. RESULTS Our data showed that, compared with healthy controls, the numbers of circulating Th1, Th17, and Th22 (p<0.05) cells increased significantly in ITP patients, and Th22 cells were correlated positively with Th1 cells (r=0.4041, p<0.01) and Th17 cells (r=0.4637, p<0.05). Moreover, a positive relationship was found between Th1/Th22 cells and Th1 cells (r=0.7696, p<0.001). CONCLUSIONS A disequilibrium expression profile of Th22 cells in peripheral blood was associated with pathogenesis of ITP, possibly through cooperatively working with Th17 and Th1, which may provide a novel approach for diagnosis of ITP.
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Affiliation(s)
- Feng-Xia Zhan
- Department of Clinical Laboratory, Hospital of Shandong University, Jinan, Shandong, China (mainland)
| | - Juan Li
- Department of Clinical Laboratory, Qilu Hospital (Qingdao), Shandong University, Qingdao, Shandong, China (mainland)
| | - Min Fang
- Department of Clinical Laboratory, Qingdao Women's and Children's Hospital, Qingdao, Shandong, China (mainland)
| | - Juan Ding
- Department of Clinical Laboratory, Qilu Hospital, Shandong University, Jinan, Shandong, China (mainland)
| | - Qian Wang
- Department of Clinical Laboratory, Qilu Hospital, Shandong University, Jinan, Shandong, China (mainland)
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100
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Al-Samkari H, Kuter DJ. Thrombopoietin level predicts response to treatment with eltrombopag and romiplostim in immune thrombocytopenia. Am J Hematol 2018; 93:1501-1508. [PMID: 30187942 DOI: 10.1002/ajh.25275] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 11/07/2022]
Abstract
Thrombopoietin receptor agonists (TPO-RAs) are used to treat immune thrombocytopenia (ITP), but predicting clinical response to TPO-RAs before initiation is not possible. To determine whether endogenous TPO levels predict treatment response to TPO-RAs we performed a retrospective analysis of ITP patients with known baseline TPO levels who received TPO-RAs. Data was collected for ITP patients with a baseline TPO level treated with eltrombopag or romiplostim. Multiple logistic regression was used to model the probability of 3 classes of treatment response (overall, moderate, and superior) based on TPO level; receiver operating characteristic (ROC) analysis was performed to identify optimal TPO thresholds for response; correlations between TPO level and various response characteristics were analyzed. A total of 67 patients (37 receiving eltrombopag and 46 receiving romiplostim) were included. Logistic regression models demonstrated a significant predictive relation between TPO level and probability of all classes of response; per 10 pg/mL TPO increase, odds ratio for overall response to eltrombopag was 0.524 (95% CI 0.327, 0.837) and romiplostim was 0.905 (95% CI, 0.844, 0.970). TPO level was inversely correlated with all classes of response; for overall response, r = -0.719 (P < .001) for eltrombopag and r = -0.584 (P < .001) for romiplostim. ROC analysis identified TPO thresholds of ≤136 pg/mL (eltrombopag) and ≤209 pg/mL (romiplostim) as optimally discriminating between responders and nonresponders. Most non-responders had high TPO levels but did respond after addition of low-dose prednisone. In conclusion, TPO levels predict response to eltrombopag and romiplostim in ITP patients, with lower levels predicting improved probability and magnitude of response.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
| | - David J. Kuter
- Division of Hematology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts
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