201
|
Chong BH, Choi PYI, Khachigian L, Perdomo J. Drug-induced immune thrombocytopenia. Hematol Oncol Clin North Am 2013; 27:521-40. [PMID: 23714310 DOI: 10.1016/j.hoc.2013.02.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Thrombocytopenia is caused by immune reactions elicited by diverse drugs in clinical practice. The activity of the drug-dependent antibodies produces a marked decrease in blood platelets and a risk of serious bleeding. Understanding of the cellular mechanisms that drive drug-induced thrombocytopenia has advanced recently but there is still a need for improved laboratory tests and treatment options. This article provides an overview of the different types of drug-induced thrombocytopenia, discusses potential pathologic mechanisms, and considers diagnostic methods and treatment options.
Collapse
Affiliation(s)
- Beng H Chong
- Haematology Department, St George Hospital, Kogarah, NSW 2217, Australia.
| | | | | | | |
Collapse
|
202
|
Cheng G. Eltrombopag, a thrombopoietin- receptor agonist in the treatment of adult chronic immune thrombocytopenia: a review of the efficacy and safety profile. Ther Adv Hematol 2013; 3:155-64. [PMID: 23556122 DOI: 10.1177/2040620712442525] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Chronic immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a low platelet count that has persisted for more than 12 months. Patients may be asymptomatic but those with severe disease may have significant morbidity and require treatment. Corticosteroids and intravenous immunoglobulin are recommended as first-line treatments. Recently, two thrombopoietin-receptor agonists, romiplostim and eltrombopag have been licensed for the treatment of chronic ITP. The current indications for thrombopoietin-receptor agonists are for splenectomized adult patients with chronic ITP who are refractory to other treatments and adult nonsplenectomized patients in whom splenectomy is contraindicated. This article reviews data on the pharmacology, clinical efficacy and safety profile of eltrombopag in the treatment of ITP.
Collapse
Affiliation(s)
- Gregory Cheng
- Dr Stanley Ho Medical Development Foundation, 9/F ICBC Tower, Macau Landmark, 555 Avenida da Amizade, Macau
| |
Collapse
|
203
|
Bockow B, Kaplan TB. Refractory immune thrombocytopenia successfully treated with high-dose vitamin D supplementation and hydroxychloroquine: two case reports. J Med Case Rep 2013; 7:91. [PMID: 23556539 PMCID: PMC3623781 DOI: 10.1186/1752-1947-7-91] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 02/28/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Immune thrombocytopenic purpura is thought to be characterized by an immune response against the host's own platelets. If the thrombocytopenia is severe, patients are initially treated with high-dose steroids. Other more toxic second line treatments are considered if steroids fail. Here, we report the case of two patients in whom conventional treatment was unsuccessful but who responded to hydroxychloroquine and high-dose vitamin D replacement therapy. To the best of our knowledge, this is the first description of successful treatment for immune thrombocytopenia with high-dose vitamin D and hydroxychloroquine. CASE PRESENTATION Case 1: We report the case of a 79-year-old Caucasian man who presented with high titer antinuclear antibodies, positive anti-SSA/Ro autoantibodies and clinically was felt to have an overlap of systemic lupus erythematosus and/or Sjögren's syndrome with profound life-threatening thrombocytopenia. There was no evidence of underlying malignancy. The patient's platelet count significantly increased with vitamin D and hydroxychloroquine treatment, but upon vitamin D discontinuation his platelet levels plummeted. Hydroxychloroquine therapy was maintained throughout treatment. With reinstitution of high-dose vitamin D therapy, platelet counts were restored to normal levels.Case 2: We also report the case of an 87-year-old Caucasian woman who presented with high titer antinuclear antibodies, positive anti-SSA/Ro autoantibodies and was felt to have an overlap of systemic lupus erythematosus and/or Sjögren's syndrome with immune thrombocytopenia; she also had severely low levels of 25-hydroxy vitamin D (17ng/mL). There was no evidence of underlying malignancy. She responded to high-dose vitamin D replacement and hydroxychloroquine treatment, thereby alleviating the need for high-dose steroid treatment. She remains in remission while taking vitamin D, hydroxychloroquine and very low-dose prednisone. No untoward side effects were observed in either patient. CONCLUSIONS In our two case reports, we found an association between vitamin D deficiency and immune thrombocytopenia where platelet levels responded to vitamin D treatment and hydroxychloroquine but not to prednisone. We believe there may be synergism between vitamin D supplementation and hydroxychloroquine. The mechanism by which high-dose vitamin D results in increased platelet counts in immune thrombocytopenia patients is unknown. However, vitamin D has long been thought to play an immunomodulatory role, which may include a dampened immune response in patients with immune thrombocytopenia or other autoimmune diseases.
Collapse
Affiliation(s)
- Barry Bockow
- Arthritis Northwest, 16122 8th Ave SW, Seattle, WA, 98166, USA.
| | | |
Collapse
|
204
|
|
205
|
|
206
|
Khellaf M, Viallard JF, Hamidou M, Cheze S, Roudot-Thoraval F, Lefrere F, Fain O, Audia S, Abgrall JF, Michot JM, Dauriac C, Lefort S, Gyan E, Niault M, Durand JM, Languille L, Boutboul D, Bierling P, Michel M, Godeau B. A retrospective pilot evaluation of switching thrombopoietic receptor-agonists in immune thrombocytopenia. Haematologica 2013; 98:881-7. [PMID: 23445876 DOI: 10.3324/haematol.2012.074633] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Romiplostim and eltrombopag, the first thrombopoietic receptor-agonists with demonstrated efficacy against immune thrombocytopenia in prospective controlled studies, were recently authorized in most countries for adults with chronic immune thrombocytopenia. So far, no data are available about the potential contribution of switching from romiplostim to eltrombopag or vice versa in terms of efficacy or tolerance. Efficacies and tolerance profiles were evaluated for 46 patients who sequentially received both drugs, switching from one to the other. The reasons for switching were: lack of efficacy for 23 patients, platelet-count fluctuations for 11, side effects for 4, and 8 patients' preferences. For 50-80% of the patients, switching from romiplostim to eltrombopag or eltrombopag to romiplostim effectively impacted the platelet count, with fluctuations disappearing in 54% and side effects resolved in 100%. In 80% of the patients, the 2 thrombopoietic receptor-agonists achieved similar response patterns. Our results confirmed that switching from one thrombopoietic receptor-agonist to the other could be beneficial in clinical practice for patients with severe chronic immune thrombopenia who failed to respond or experienced adverse events to the first. (Clinical Trials.gov identifier: NCT01618734).
Collapse
Affiliation(s)
- Mehdi Khellaf
- Department of Internal Medicine, Centre Hospitalier Universitaire (CHU) Henri-Mondor, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris-Est Créteil (UPEC), Créteil, France
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
207
|
Kuter DJ, Bussel JB, Newland A, Baker RI, Lyons RM, Wasser J, Viallard JF, Macik G, Rummel M, Nie K, Jun S. Long-term treatment with romiplostim in patients with chronic immune thrombocytopenia: safety and efficacy. Br J Haematol 2013; 161:411-23. [DOI: 10.1111/bjh.12260] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 01/09/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - James B. Bussel
- Division of Hematology; Departments of Pediatrics and Medicine; Weill Medical College of Cornell University; New York; NY; USA
| | - Adrian Newland
- Department of Haematology; The Royal London Hospital; Whitechapel; London; UK
| | - Ross I. Baker
- Centre for Thrombosis and Haemophilia; Royal Perth Hospital; Murdoch University; Perth; WA; Australia
| | - Roger M. Lyons
- Cancer Care Centers South Texas/US Oncology; San Antonio; TX; USA
| | - Jeffrey Wasser
- Division of Hematology-Oncology; Department of Medicine; University of Connecticut School of Medicine; Farmington; CT; USA
| | - Jean-Francois Viallard
- Université Victor Segalen Bordeaux 2; Hôpital Haut-Lévêque; CHU de Bordeaux; Pessac; France
| | - Gail Macik
- University of Virginia; Charlottesville; VA; USA
| | - Mathias Rummel
- Klinikum der Justus-Liebig-Universität; Giessen; Germany
| | - Kun Nie
- Amgen Inc.; Thousand Oaks; CA; USA
| | | |
Collapse
|
208
|
Wang Y, Huang R, Song C, Hu H, Zhang M. Some viral microRNAs were up-regulated in megakaryocytes incubated with immune thrombocytopenia plasma. Eur J Haematol 2013; 90:220-7. [PMID: 23282244 DOI: 10.1111/ejh.12063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2012] [Indexed: 12/24/2022]
Affiliation(s)
- Ya Wang
- Department of Hematology; Zhujiang Hospital; Southern Medical University; Guangzhou; China
| | - Rui Huang
- Department of Hematology; Zhujiang Hospital; Southern Medical University; Guangzhou; China
| | - Chaoyang Song
- Department of Hematology; Zhujiang Hospital; Southern Medical University; Guangzhou; China
| | - Haiyan Hu
- Department of Oncology; The Sixth People's Hospital; Shanghai JiaoTong University; Shanghai; China
| | | |
Collapse
|
209
|
No cross-resistance after sequential use of romiplostim and eltrombopag in chronic immune thrombocytopenic purpura. Blood 2013; 121:1240-2. [DOI: 10.1182/blood-2012-11-465575] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
|
210
|
Chen JF, Yang LH, Chang LX, Feng JJ, Liu JQ. The clinical significance of circulating B cells secreting anti-glycoprotein IIb/IIIa antibody and platelet glycoprotein IIb/IIIa in patients with primary immune thrombocytopenia. ACTA ACUST UNITED AC 2013; 17:283-90. [PMID: 22971534 DOI: 10.1179/1607845412y.0000000014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The objective of the study is to evaluate the possible roles of the detection of circulating B cells secreting anti-glycoprotein IIb/IIIa antibody, platelet glycoprotein IIb/IIIa, and anti-glycoprotein IIb/IIIa antibody in the diagnosis of primary immune thrombocytopenia (ITP) patients. METHODS Circulating B cells secreting anti-glycoprotein IIb/IIIa antibody, platelet glycoprotein IIb/IIIa and anti-glycoprotein IIb/IIIa antibody in 64 patients with ITP, 33 non-ITP patients, and 32 controls were measured with enzyme-linked immunospot assay (ELISPOT), monoclonal antibody immobilization of platelet antigens assay (MAIPA) and flow cytometic analysis (FCM), respectively. RESULTS Compared with the controls and non-ITP patients, the frequency of circulating B cells secreting anti-glycoprotein IIb/IIIa antibody was significantly increased, whereas the positive rate of platelet glycoprotein IIb/IIIa was significantly decreased (P < 0.05) in ITP patients, respectively. The sensitivities for the diagnosis of ITP of ELISPOT and FCM were 68.8% and 57.8%, and the specificities of 90.9% and 90.9%, respectively. The sensitivities of ELISPOT and FCM were higher than MAIPA's sensitivity (39.1%) (P < 0.05). However, there was no apparent difference of the sensitivities of ELISPOT and FCM and the specificities of those three detections (MAIPA's specificity was 81.8%) (P > 0.05). DISCUSSION ELISPOT and FCM for detecting the circulating B cells secreting anti-glycoprotein IIb/IIIa antibody and the platelet glycoprotein IIb/IIIa were as specific as that of MAIPA for assay of anti-glycoprotein IIb/IIIa antibody, but ELISPOT and FCM had higher sensitivities. So ELISPOT and FCM were sensitive and specific for identifying patients with autoantibody-mediated thrombocytopenia and these should be used as diagnostic tests in clinic.
Collapse
Affiliation(s)
- Jian-fang Chen
- The Second Hospital of Shanxi Medical University, Taiyuan, People's Republic of China
| | | | | | | | | |
Collapse
|
211
|
Kühne T. Update on the Intercontinental Cooperative ITP Study Group (ICIS) and on the Pediatric and Adult Registry on Chronic ITP (PARC ITP). Pediatr Blood Cancer 2013; 60 Suppl 1:S15-8. [PMID: 23109493 DOI: 10.1002/pbc.24342] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 08/30/2012] [Indexed: 01/19/2023]
Abstract
The Intercontinental Cooperative ITP Study Group (ICIS) was founded in 1997, when the American practice guidelines demonstrated that there is a substantial lack of clinical data. The aim of the group was to promote basic science and clinical research in the field of ITP. Clinical data and more recently DNA is collected to investigate children and adults with ITP. ICIS organizes regular meetings and opened several registries, the most recent being the Pediatric and Adult Registry on Chronic ITP (PARC-ITP), all of which will be briefly discussed. There are many unanswered questions in basic science and clinical research in ITP which need large collaborative studies. The international network of ICIS may be of value in better understanding ITP.
Collapse
Affiliation(s)
- Thomas Kühne
- Division of Oncology/Hematology, University Children's Hospital, Basel, Switzerland.
| |
Collapse
|
212
|
Immunohematologic disorders. Clin Immunol 2013. [DOI: 10.1016/b978-0-7234-3691-1.00075-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
213
|
McCrae KR. Thrombocytopenia in Pregnancy. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00044-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
214
|
Neunert CE. Current management of immune thrombocytopenia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:276-282. [PMID: 24319191 DOI: 10.1182/asheducation-2013.1.276] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune-mediated condition that results from antibody-mediated destruction of platelets and impaired megakaryocyte platelet production. ITP patients exhibit severe thrombocytopenia and are at risk for significant hemorrhage. Few randomized trials exist to guide management of patients with ITP. Ultimately, each patient requires an individualized treatment plan that takes into consideration the platelet count, bleeding symptoms, health-related quality of life, and medication side effects. This article provides an up-to-date review of management strategies drawing on links between the expanding amounts of clinical trial data and associated biology studies to enhance understanding of the disease heterogeneity with regard to the complex pathogenesis and response to treatment.
Collapse
Affiliation(s)
- Cindy E Neunert
- 1Department of Pediatrics and Cancer Center, Georgia Regents University, Augusta, GA
| |
Collapse
|
215
|
von Gunten S, Wehrli M, Simon HU. Cell Death in Immune Thrombocytopenia: Novel Insights and Perspectives. Semin Hematol 2013; 50 Suppl 1:S109-15. [DOI: 10.1053/j.seminhematol.2013.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
216
|
Abstract
Primary immune thrombocytopenia (ITP) is one of the most common bleeding disorders of childhood. In most cases, it presents with sudden widespread bruising and petechiae in an otherwise well child. Thought to be mainly a disorder of antibody-mediated platelet destruction, ITP can be self-limited or develop into a chronic condition. In this review, we discuss current concepts of the pathophysiology and treatment approaches to pediatric ITP.
Collapse
|
217
|
Arnold DM. Positioning new treatments in the management of immune thrombocytopenia. Pediatr Blood Cancer 2013; 60 Suppl 1:S19-22. [PMID: 23109488 PMCID: PMC4854632 DOI: 10.1002/pbc.24341] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 08/30/2012] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a syndrome characterized by low platelet counts and an increased risk of bleeding. For most children, ITP is a self-limiting disease; however, for some children and most adults, thrombocytopenia can become chronic. Newer therapies for ITP include rituximab and thrombopoietin (TPO) receptor agonists. Rituximab is a useful second-line therapy and may be splenectomy-sparing. Thrombopoeitin receptor agonists have demonstrated large treatment effects with respect to increasing platelet levels; however, they require maintenance dosing. This review summarizes how these new agents might be positioned in the management of patients with chronic ITP.
Collapse
Affiliation(s)
- Donald M. Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada,Canadian Blood Services, Hamilton, Ontario, Canada,Correspondence to: Donald M. Arnold, MDCM, MSc, Department of Medicine, McMaster University, 1280 Main Street West HSC 3V50, Hamilton, Ontario, Canada L8N 4K1.
| |
Collapse
|
218
|
|
219
|
Mahabir VK, Ross C, Popovic S, Sur ML, Bourgeois J, Lim W, George JN, Wang G, Cook RJ, Toltl LJ, Nazi I, Kelton JG, Arnold DM. A blinded study of bone marrow examinations in patients with primary immune thrombocytopenia. Eur J Haematol 2012; 90:121-6. [PMID: 23140198 DOI: 10.1111/ejh.12041] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The role of bone marrow examinations in patients with primary immune thrombocytopenia (ITP) is uncertain. The objectives of this study were to determine the inter-rater reliability of bone marrow examinations and to identify distinguishing morphological features of ITP bone marrows under controlled conditions. METHODS Histological slides of bone marrow biopsy specimens and aspirates from 32 adult patients with severe primary ITP who had failed a median of two treatments, and 51 non-thrombocytopenic controls were retrieved from hospital archives. Slides were arranged in random order in a slide box and coded. Blinded to the diagnosis and platelet counts, three independent hematopathologists were asked to identify the ITP bone marrows and to evaluate megakaryocyte number, morphology, and distribution. RESULTS Overall chance-corrected agreement on ITP classification among the three raters was poor [kappa (κ) = 0.30; 95% confidence interval 0.22-0.38]. Raters were generally unable to correctly identify the ITP bone marrows from controls. Increased number of megakaryocytes, while an uncommon finding, was more frequent among ITP patients compared with controls (6/32, 18.8%; vs. 2/51, 3.9%; P = 0.05), and abnormal megakaryocyte morphology often led individual raters to reach a diagnosis of ITP. Overall sensitivity and specificity of bone marrow examinations were 24% and 90%, respectively. CONCLUSIONS This study confirms methodologically that bone marrow examinations are unreliable and frequently non-diagnostic in ITP. Thus, they are not useful for patients with typical disease. Rare subsets of patients with severe ITP demonstrated unique features such as increased number of megakaryocytes.
Collapse
Affiliation(s)
- Vishwanath K Mahabir
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
220
|
Ku FC, Tsai CR, Der Wang J, Wang CH, Chang TK, Hwang WL. Stromal-derived factor-1 gene variations in pediatric patients with primary immune thrombocytopenia. Eur J Haematol 2012; 90:25-30. [DOI: 10.1111/ejh.12025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2012] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Chih Hsiang Wang
- Institute of Molecular Biology; National Chung Hsing University; Taichung; Taiwan
| | - Te-Kau Chang
- Department of Pediatrics; Taichung Veterans General Hospital; Taichung; Taiwan
| | - Wen-Li Hwang
- Division of Hematology and Medical Oncology; Taichung Veterans General Hospital; Taichung; Taiwan
| |
Collapse
|
221
|
Ji L, Zhan Y, Hua F, Li F, Zou S, Wang W, Song D, Min Z, Chen H, Cheng Y. The ratio of Treg/Th17 cells correlates with the disease activity of primary immune thrombocytopenia. PLoS One 2012; 7:e50909. [PMID: 23226546 PMCID: PMC3513316 DOI: 10.1371/journal.pone.0050909] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 10/26/2012] [Indexed: 11/18/2022] Open
Abstract
Background Primary immune thrombocytopenia (ITP) is an autoimmune heterogeneous disorder that is characterized by decreased platelet count. Regulatory T (Treg) cells and T helper type 17 (Th17) cells are two subtypes of CD4+ T helper (Th) cells. They play opposite roles in immune tolerance and autoimmune diseases, while they share a common differentiation pathway. The imbalance of Treg/Th17 has been demonstrated in several autoimmune diseases. In this study, we aimed to investigate the ratio of the number of Treg cells to the number of Th17 cells in ITP patients and evaluate the clinical implications of the alterations in this ratio. Methods Thirty adult patients with newly diagnosed ITP enrolled in this study. Twelve patients had been clinically followed up for 12 months. The percentages of CD4+CD25hiFoxp3+ Treg cells and CD3+CD4+IL-17-producing Th17 cells in these patients and healthy controls (n = 17) were longitudinally analyzed by flow cytometry. Results The percentage of Treg cells in ITP patients was significantly lower than that of healthy controls, and the percentage of Th17 cells increased significantly at disease onset. The ratio of Treg/Th17 correlated with the disease activity. Conclusion The ratio of Treg/Th17 might be relevant to the clinical diversity of ITP patients, and this Treg/Th17 ratio might have prognostic role in ITP patients.
Collapse
Affiliation(s)
- Lili Ji
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yanxia Zhan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fanli Hua
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Hematology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shanhua Zou
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguang Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dongli Song
- Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Min
- Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao Chen
- Department of Surgery, Huadong Hospital, Fudan University, Shanghai, China
| | - Yunfeng Cheng
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Biomedical Research Center, Zhongshan Hospital, Fudan University, Shanghai, China
- * E-mail:
| |
Collapse
|
222
|
Abstract
With increasing recognition of the complications related to coagulopathies, it is of paramount importance for all orthopedic surgeons to possess a basic knowledge of common bleeding disorders. The evaluation of the coagulopathic patient requires a careful history, physical examination, and laboratory evaluation. Bleeding disorders commonly include quantitative and qualitative platelet and coagulation factor disorders and coagulation inhibitors. The management of these coagulopathies that can be encountered in elective and nonelective practice is often ignored. With appropriate knowledge and a multidisciplinary approach with hematologists and cardiologists, surgeons can perform minor and major orthopedic procedures safely and effectively.
Collapse
Affiliation(s)
- John Mansour
- Department of Orthopaedic Trauma, Cooper University Hospital, Camden, New Jersey, USA.
| | | | | |
Collapse
|
223
|
Abstract
PURPOSE OF REVIEW Thrombopoietin-receptor agonists (TPO-RAs) have been approved for use in immune thrombocytopenia (ITP) after showing safety and efficacy. There is increasing interest to expand the role of TPO-RAs, both in ITP as well as in other thrombocytopenic disorders. RECENT FINDINGS In ITP, more studies are providing evidence of TPO-RA efficacy and safety, as well as their applicability to various patient groups, including children. Use of TPO-RAs in hepatitis C has shown early success in allowing treatments in patients who would otherwise be excluded due to thrombocytopenia. Use in congenital thrombocytopenias has also shown early success. The use of TPO-RAs in myelodysplastic syndrome (MDS) is questionable after reports of increasing blasts and leukemic transformation, whereas in other chemotherapy-induced thrombocytopenias (C-ITs) reports are few. Bone marrow fibrosis remains an area of active study, although the data to date suggest this is seen in a small minority of patients, and is reversible and of questionable clinical relevance. Thrombotic complications are also an area of concern and need further close follow-up. SUMMARY The use of TPO-RAs continues to grow as more evidence of safety and efficacy is found. More studies are needed to determine their utility in other diseases as well as to better characterize adverse events observed to date.
Collapse
|
224
|
Basciano PA, Bussel J, Hafeez Z, Christos PJ, Giannakakou P. The beta 1 tubulin R307H single nucleotide polymorphism is associated with treatment failures in immune thrombocytopenia (ITP). Br J Haematol 2012; 160:237-43. [PMID: 23157319 DOI: 10.1111/bjh.12124] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 09/20/2012] [Indexed: 01/19/2023]
Abstract
Predictive biomarkers are needed in immune thrombocytopenia (ITP). Single nucleotide polymorphisms (SNPs) in beta 1 tubulin are potential candidates, as beta 1 tubulin is integral for platelet production and function, and SNPs in beta 1 tubulin have been associated with distinct phenotypes in platelets. We investigated the most prevalent beta 1 tubulin SNP (R307H) as a biomarker in patients with ITP via a retrospective chart review. Allelic frequencies between a group of 191 ITP patients and a healthy control group showed no difference, suggesting no direct aetiological role for the SNP in ITP. However, over similar periods of follow-up, both heterozygote and homozygote minor allele ITP patients were treated with significantly more treatment modalities and had significantly higher risk of failure to immune-modulatory therapies [relative risk (RR) = 1·5, 95% confidence interval (CI) = 1·1-2·1; P = 0·01]; with rituximab, in particular, ITP patients with the SNP experienced a 58% failure rate (RR = 1·6, 95%CI = 1·03-2·5; P = 0·04). Analysis of the absolute immature platelet fraction (A-IPF) as a marker of platelet production showed that SNP patients had significantly higher median A-IPFs compared to non-SNP patients when complete responses were achieved using immune modulatory therapies. The data suggest that the beta 1 tubulin R307H SNP has potential for use as a biomarker in ITP and may affect platelet turnover.
Collapse
Affiliation(s)
- Paul A Basciano
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medical College, New York, NY 10065, USA.
| | | | | | | | | |
Collapse
|
225
|
Abstract
Immune thrombocytopenia (ITP) comprises a syndrome of diverse disorders that have in common immune-mediated thrombocytopenia, but that differ with respect to pathogenesis, natural history and response to therapy. ITP may occur in the absence of an evident predisposing etiology (primary ITP) or as a sequela of a growing list of associated conditions (secondary ITP). Primary ITP remains a diagnosis of exclusion and must be differentiated from non-autoimmune etiologies of thrombocytopenia and secondary causes of ITP. The traditional objective of management is to provide a hemostatic platelet count (> 20-30 × 10(9) L(-1) in most cases) while minimizing treatment-related toxicity, although treatment goals should be tailored to the individual patient and clinical setting. Corticosteroids, supplemented with either intravenous immune globulin G or anti-Rh(D) as needed, are used as upfront therapy to stop bleeding and raise the platelet count acutely in patients with newly diagnosed or newly relapsed disease. Although most adults with primary ITP respond to first-line therapy, the majority relapse after treatment is tapered and require a second-line approach to maintain a hemostatic platelet count. Standard second-line options include splenectomy, rituximab and the thrombopoietin receptor agonists, romiplostim and eltrombopag. Studies that directly compare the efficacy, safety and cost-effectiveness of these approaches are lacking. In the absence of such data, we do not favor a single second-line approach for all patients. Rather, we consider the pros and cons of each option with our patients and engage them in the decision-making process.
Collapse
MESH Headings
- Adrenal Cortex Hormones/adverse effects
- Adrenal Cortex Hormones/therapeutic use
- Adult
- Decision Support Techniques
- Hematologic Agents/adverse effects
- Hematologic Agents/therapeutic use
- Hemostasis/drug effects
- Humans
- Immunoglobulins, Intravenous/adverse effects
- Immunoglobulins, Intravenous/therapeutic use
- Platelet Count
- Predictive Value of Tests
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/epidemiology
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Recurrence
- Rho(D) Immune Globulin/therapeutic use
- Risk Factors
- Splenectomy/adverse effects
- Treatment Outcome
Collapse
Affiliation(s)
- S Lakshmanan
- Department of Medicine Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | |
Collapse
|
226
|
Crosstalk between Platelets and the Immune System: Old Systems with New Discoveries. Adv Hematol 2012; 2012:384685. [PMID: 23008717 PMCID: PMC3447344 DOI: 10.1155/2012/384685] [Citation(s) in RCA: 170] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 08/15/2012] [Indexed: 11/17/2022] Open
Abstract
Platelets are small anucleate cells circulating in the blood. It has been recognized for more than 100 years that platelet adhesion and aggregation at the site of vascular injury are critical events in hemostasis and thrombosis; however, recent studies demonstrated that, in addition to these classic roles, platelets also have important functions in inflammation and the immune response. Platelets contain many proinflammatory molecules and cytokines (e.g., P-selectin, CD40L, IL-1β, etc.), which support leukocyte trafficking, modulate immunoglobulin class switch, and germinal center formation. Platelets express several functional Toll-like receptors (TLRs), such as TLR-2, TLR-4, and TLR-9, which may potentially link innate immunity with thrombosis. Interestingly, platelets also contain multiple anti-inflammatory molecules and cytokines (e.g., transforming growth factor-β and thrombospondin-1). Emerging evidence also suggests that platelets are involved in lymphatic vessel development by directly interacting with lymphatic endothelial cells through C-type lectin-like receptor 2. Besides the active contributions of platelets to the immune system, platelets are passively targeted in several immune-mediated diseases, such as autoimmune thrombocytopenia, infection-associated thrombocytopenia, and fetal and neonatal alloimmune thrombocytopenia. These data suggest that platelets are important immune cells and may contribute to innate and adaptive immunity under both physiological and pathological conditions.
Collapse
|
227
|
Thymic retention of CD4+CD25+FoxP3+ T regulatory cells is associated with their peripheral deficiency and thrombocytopenia in a murine model of immune thrombocytopenia. Blood 2012; 120:2127-32. [DOI: 10.1182/blood-2012-02-413526] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
AbstractImmune thrombocytopenia (ITP) is a bleeding disorder in which antibodies and/or T cells lead to enhanced peripheral platelet destruction and reduced bone marrow platelet production. Several reports have observed that ITP is associated with a peripheral deficiency of tolerance-inducing CD4+CD25+FoxP3+ T regulatory cells (Tregs). Using a murine model of ITP, we analyzed Tregs in the spleen and thymus. CD61 knockout mice were immunized against wild-type (CD61+) platelets, and their splenocytes were transferred into severe combined immunodeficient (SCID) mice. Compared with SCID mice receiving naive splenocytes, within 2 weeks after transfer, the ITP SCID mice became thrombocytopenic (< 200 × 109 platelets/L) and had increased serum anti-CD61 antibodies. The quantity of thymic Tregs by 2 weeks after transfer was significantly elevated, whereas Tregs in the spleens were significantly reduced. Treatment of the ITP mice with 2 g/kg intravenous immunoglobulin raised the platelet counts, reduced antibody production, and normalized the thymic and splenic Treg populations. Compared with thymocytes from ITP mice treated with intravenous immunoglobulin, thymocytes from untreated ITP mice delayed the onset of ITP when administered before engraftment with immune splenocytes. These results suggest that ITP in mice is associated with a peripheral Treg deficiency because of thymic retention and therapy normalizes the Tregs.
Collapse
|
228
|
Use of the novel thrombopoietin receptor-agonist romiplostim, in combination with steroids and immunoglobulins for the increase of platelets prior to splenectomy, in refractory immune thrombocytopenia: a case report. Blood Coagul Fibrinolysis 2012; 23:331-4. [PMID: 22343685 DOI: 10.1097/mbc.0b013e3283513a97] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This case report describes a patient with relapsed primary immune thrombocytopenic purpura (ITP), in which splenectomy was not possible due to the persistence of a low platelet count despite treatment with corticosteroids, intravenous immunoglobulins (IVIG) and platelet transfusion treatment. As an attempt to increase platelet count prior to performing splenectomy, the thrombopoietin receptor agonist, romiplostim, was administered in combination with steroids and IVIG. A single administration of romiplostim was found to be markedly effective, allowing a rapid and notable platelet increase, required for a well tolerated splenectomy. This case confirms the potent activity of romiplostim in ITP, and indicates that patients with recurrent primary ITP who are unresponsive to conventional immunosuppressive therapy may benefit from the addition of a short course of romiplostim.
Collapse
|
229
|
Recognition of highly restricted regions in the β-propeller domain of αIIb by platelet-associated anti-αIIbβ3 autoantibodies in primary immune thrombocytopenia. Blood 2012; 120:1499-509. [DOI: 10.1182/blood-2012-02-409995] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractPlatelet-associated (PA) IgG autoantibodies play an essential role in primary immune thrombocytopenia (ITP). However, little is known about the epitopes of these Abs. This study aimed to identify critical binding regions for PA anti-αIIbβ3 Abs. Because PA anti-αIIbβ3 Abs bound poorly to mouse αIIbβ3, we created human-mouse chimera constructs. We first examined 76 platelet eluates obtained from patients with primary ITP. Of these, 26 harbored PA anti-αIIbβ3 Abs (34%). Further analysis of 15 patients who provided sufficient materials showed that the epitopes of these Abs were mainly localized in the N-terminal half of the β-propeller domain in αIIb (L1-W235). We could identify 3 main recognition sites in the region; 2 eluates recognized a conformation formed by the W1:1-2 and W2:3-4 loops, 5 recognized W1:2-3, and 4 recognized W3:4-1. The remaining 4 eluates could not be defined by the binding sites. Within these regions, we identified residues critical for binding, including S29 and R32 in W1:1-2; G44 and P45 in W1:2-3; and P135, E136, and R139 in W2:3-4. Of 11 eluates whose recognition sites were identified, 5 clearly showed restricted κ/λ-chain usage. These results suggested that PA anti-αIIbβ3 Abs in primary ITP tended to recognize highly restricted regions of αIIb with clonality.
Collapse
|
230
|
Mitsuhashi K, Ishiyama M, Imai Y, Shiseki M, Mori N, Teramura M, Seshimo A, Motoji T. Combined romiplostim and intravenous immunoglobulin therapy increased platelet count, facilitating splenectomy in a patient with refractory immune thrombocytopenic purpura unresponsive to monotherapy. Br J Haematol 2012; 158:798-800. [DOI: 10.1111/j.1365-2141.2012.09220.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 05/15/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Kenjiro Mitsuhashi
- Department of Haematology; Tokyo Women's Medical University; Tokyo; Japan
| | - Midori Ishiyama
- Department of Haematology; Tokyo Women's Medical University; Tokyo; Japan
| | - Yoichi Imai
- Department of Haematology; Tokyo Women's Medical University; Tokyo; Japan
| | - Masayuki Shiseki
- Department of Haematology; Tokyo Women's Medical University; Tokyo; Japan
| | - Naoki Mori
- Department of Haematology; Tokyo Women's Medical University; Tokyo; Japan
| | - Masanao Teramura
- Department of Haematology; Tokyo Women's Medical University; Tokyo; Japan
| | - Akiyoshi Seshimo
- Second Department of Surgery; Tokyo Women's Medical University; Tokyo; Japan
| | - Toshiko Motoji
- Department of Haematology; Tokyo Women's Medical University; Tokyo; Japan
| |
Collapse
|
231
|
Low dose cepharanthine ameliorates immune thrombocytopenic purpura associated with multiple myeloma. Int Immunopharmacol 2012; 13:242-4. [DOI: 10.1016/j.intimp.2012.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 04/06/2012] [Accepted: 04/20/2012] [Indexed: 11/24/2022]
|
232
|
Osaki A, Suda T, Waguri N, Ishikawa T, Yokoo T, Kamimura K, Tamura Y, Takamura M, Igarashi M, Kawai H, Yamagiwa S, Aoyagi Y. Formula to predict platelet count after partial splenic arterial embolization in patients with hypersplenism. J Vasc Interv Radiol 2012; 23:900-7. [PMID: 22633618 DOI: 10.1016/j.jvir.2012.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Revised: 02/28/2012] [Accepted: 03/14/2012] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To establish a formula to guide appropriate embolization volume for postprocedural platelet gain following partial splenic arterial embolization (PSE) for hypersplenism. MATERIALS AND METHODS The hepatic volume (Vh) and splenic volume (Vsp) were measured by using 2-mm-thick computed tomography images before and after PSE in 20 patients with various chronic liver diseases. A formula was derived from the relationship between the platelet count increase ratio (dPlt%) and the organ volumes, which was then evaluated in another cohort. RESULTS After an embolization of a median of 72.1% of the spleen (interquartile range, 38.2%-93.8%), the dPlt% was 67.7% ± 40.0 and significantly correlated with the increasing ratio of Vh to Vsp (P = .019, ρ = 0.52). Because the difference in Vh/Vsp ratio after PSE was significantly correlated with the spleen embolization ratio (eVsp%; P = .0003, ρ = 0.72), the estimated dPlt% could be derived from the Vh/Vsp ratio before PSE and the eVsp%. The estimated dPlt% was significantly correlated with the actual dPlt% (P = .0003, ρ = 0.72). When the formula was evaluated in another cohort of 14 cases, another strict correlation was observed (P < .0001, ρ = 0.92). CONCLUSIONS These data suggest that platelet count after PSE can be predicted before the procedure by using the Vh/Vsp ratio and the anticipated spleen embolization volume. The use of such a prediction can prevent too much or too little embolization, thereby leading to an improvement in the risk/return trade-off in PSE.
Collapse
Affiliation(s)
- Akihiko Osaki
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-dori, Chuo-ku, Niigata, Niigata 951-8122, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
233
|
Perdomo J, Yan F, Chong BH. A megakaryocyte with no platelets: Anti-platelet antibodies, apoptosis, and platelet production. Platelets 2012; 24:98-106. [DOI: 10.3109/09537104.2012.669508] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
234
|
How I treat immune thrombocytopenia: the choice between splenectomy or a medical therapy as a second-line treatment. Blood 2012; 120:960-9. [PMID: 22740443 DOI: 10.1182/blood-2011-12-309153] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The paradigm for managing primary immune thrombocytopenia (ITP) in adults has changed with the advent of rituximab and thrombopoietin receptor agonists (TPO-RAs) as options for second-line therapy. Splenectomy continues to provide the highest cure rate (60%-70% at 5+ years). Nonetheless, splenectomy is invasive, irreversible, associated with postoperative complications, and its outcome is currently unpredictable, leading some physicians and patients toward postponement and use of alternative approaches. An important predicament is the lack of studies comparing second-line options to splenectomy and to each other. Furthermore, some adults will improve spontaneously within 1-2 years. Rituximab has been given to more than 1 million patients worldwide, is generally well tolerated, and its short-term toxicity is acceptable. In adults with ITP, 40% of patients are complete responders at one year and 20% remain responders at 3-5 years. Newer approaches to using rituximab are under study. TPO-RAs induce platelet counts > 50 000/μL in 60%-90% of adults with ITP, are well-tolerated, and show relatively little short-term toxicity. The fraction of TPO-RA-treated patients who will be treatment-free after 12-24 months of therapy is unknown but likely to be low. As each approach has advantages and disadvantages, treatment needs to be individualized, and patient participation in decision-making is paramount.
Collapse
|
235
|
Zucker ML, Hagedorn CH, Murphy CA, Stanley S, Reid KJ, Skikne BS. Mechanism of thrombocytopenia in chronic hepatitis C as evaluated by the immature platelet fraction. Int J Lab Hematol 2012; 34:525-32. [PMID: 22708981 DOI: 10.1111/j.1751-553x.2012.01429.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Thrombocytopenia occurs frequently in chronic hepatitis C. The mechanism of this association was investigated utilizing the immature platelet fraction (IPF%) as an index of platelet production together with assay of thrombopoietin (TPO). METHODS In a cross-sectional study, 47 patients with chronic hepatitis C were studied, 29 with thrombocytopenia and 18 without thrombocytopenia (six patients in each group were on interferon therapy). RESULTS IPF% was elevated in the thrombocytopenic compared with the nonthrombocytopenic group (9.0 ± 4.8% vs. 4.7 ± 2.4%, P < 0.001), and an increase in IPF% was significantly associated with thrombocytopenia on multivariable analysis (P < 0.05). Splenomegaly was more common in thrombocytopenic than in nonthrombocytopenic subjects (66% vs. 6%, P < 0.001), and on multivariable analysis, splenomegaly was the factor associated with the highest relative risk of thrombocytopenia (RR = 1.9, P < 0.05). IPF% values were elevated in a similar proportion of thrombocytopenic patients with and without splenomegaly (58% and 60%, respectively). There was no difference in TPO levels between thrombocytopenic and nonthrombocytopenic patients, and TPO levels were not related to the risk of thrombocytopenia on multivariable analysis. Significantly more thrombocytopenic than nonthrombocytopenic subjects had abnormal liver function tests, cirrhosis, and portal hypertension, and a decrease in serum albumin was significantly associated with thrombocytopenia (P < 0.005) on multivariable analysis. CONCLUSIONS Factors associated with liver disease in general are associated with thrombocytopenia in chronic hepatitis C. Peripheral platelet destruction or sequestration is the major mechanism for thrombocytopenia, with hypersplenism being an important cause. Low TPO levels were not related to the occurrence of thrombocytopenia in this study.
Collapse
Affiliation(s)
- M L Zucker
- Department of Pathology, Kansas University Medical Center, Kansas City, KS, USA.
| | | | | | | | | | | |
Collapse
|
236
|
Tomiyama Y, Miyakawa Y, Okamoto S, Katsutani S, Kimura A, Okoshi Y, Ninomiya H, Kosugi H, Nomura S, Ozaki K, Ikeda Y, Hattori T, Katsura K, Kanakura Y. A lower starting dose of eltrombopag is efficacious in Japanese patients with previously treated chronic immune thrombocytopenia. J Thromb Haemost 2012; 10:799-806. [PMID: 22409309 DOI: 10.1111/j.1538-7836.2012.04695.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Eltrombopag is an oral, non-peptide thrombopoietin receptor agonist that has shown efficacy and safety in chronic immune thrombocytopenia (ITP). However, ethnic differences in eltrombopag exposure have been reported: area under the curve exposure to eltrombopag was 87% greater among ITP patients of East Asian descent than among ITP patients of non-East Asian ITP descent. OBJECTIVES To evaluate the efficacy and safety of eltrombopag by using, in Japanese ITP patients, lower starting (12.5 mg) and maximum (50 mg) doses of eltrombopag than the standard starting (50 mg) and maximum (75 mg) doses approved in the USA and Europe. PATIENTS We examined 23 Japanese patients with previously treated chronic ITP with a platelet count of < 30,000 μL(-1) in a multicenter study comprising a randomized, double-blind, placebo-controlled phase for 6-week evaluation (15 eltrombopag, and eight placebo) and an open-label phase for 6-month evaluation (23 eltrombopag). RESULTS AND CONCLUSIONS The response rate (platelet count of ≥ 50,000 μL(-1) ) at week 6 of the 6-week double-blind phase was 60% in eltrombopag-treated patients and 0% in placebo-treated patients. Ten of 23 patients (43.5%) responded for ≥ 75% of predefined assessment visits during the 6-month open-label phase. Notably, 22% (5/23) of patients responded to 12.5 mg of eltrombopag, which was administered within the first 3 weeks of eltrombopag treatment. Bleeding decreased with eltrombopag treatment as compared with baseline. Eltrombopag was generally well tolerated; one patient experienced a transient ischemic attack on day 9. Eltrombopag (12.5-50 mg) is effective for the management of Japanese patients with chronic ITP (NCT00540423).
Collapse
MESH Headings
- Administration, Oral
- Adult
- Aged
- Asian People
- Benzoates/administration & dosage
- Benzoates/adverse effects
- Benzoates/pharmacokinetics
- Blood Platelets/drug effects
- Blood Platelets/immunology
- Blood Platelets/metabolism
- Chronic Disease
- Double-Blind Method
- Female
- Hematologic Agents/administration & dosage
- Hematologic Agents/adverse effects
- Hematologic Agents/pharmacokinetics
- Hemorrhage/blood
- Hemorrhage/ethnology
- Hemorrhage/immunology
- Hemorrhage/prevention & control
- Humans
- Hydrazines/administration & dosage
- Hydrazines/adverse effects
- Hydrazines/pharmacokinetics
- Japan/epidemiology
- Male
- Middle Aged
- Placebos
- Platelet Count
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/ethnology
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrazoles/pharmacokinetics
- Receptors, Thrombopoietin/agonists
- Receptors, Thrombopoietin/blood
- Time Factors
- Treatment Outcome
Collapse
Affiliation(s)
- Y Tomiyama
- Osaka University Hospital, Suita, Osaka, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
237
|
Olsson B, Jernås M, Wadenvik H. Increased plasma levels of granzymes in adult patients with chronic immune thrombocytopenia. Thromb Haemost 2012; 107:1182-4. [PMID: 22476618 DOI: 10.1160/th12-01-0012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 02/23/2012] [Indexed: 12/25/2022]
|
238
|
Schulze H, Gaedicke G. Immune thrombocytopenia in children and adults: what's the same, what's different? Haematologica 2012; 96:1739-41. [PMID: 22147771 DOI: 10.3324/haematol.2011.055830] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
239
|
Mokhtar GM, Tantawy AAG, El Sherif NHK. Romiplostim therapy in children with unresponsive chronic immune thrombocytopenia. Platelets 2012; 23:264-73. [DOI: 10.3109/09537104.2011.619601] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
240
|
Primäre Immunthrombozytopenie des Erwachsenen – Diagnostik und Therapie, Konsensus-Statement der Österreichischen Gesellschaft für Hämatologie und Onkologie (ÖGHO). Wien Klin Wochenschr 2012; 124:111-23. [DOI: 10.1007/s00508-012-0123-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 01/09/2012] [Indexed: 11/26/2022]
|
241
|
Fischer U, Ruckert C, Hubner B, Eckermann O, Binder V, Bakchoul T, Schuster FR, Merk S, Klein HU, Führer M, Dugas M, Borkhardt A. CD34+ gene expression profiling of individual children with very severe aplastic anemia indicates a pathogenic role of integrin receptors and the proapoptotic death ligand TRAIL. Haematologica 2012; 97:1304-11. [PMID: 22315490 DOI: 10.3324/haematol.2011.056705] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
UNLABELLED BACKGROUND Very severe aplastic anemia is characterized by a hypoplastic bone marrow due to destruction of CD34(+) stem cells by autoreactive T cells. Investigation of the pathomechanism by patient-specific gene expression analysis of the attacked stem cells has previously been impractical because of the scarcity of these cells at diagnosis. DESIGN AND METHODS Employing unbiased RNA amplification, patient-specific gene expression profiling was carried out for CD34(+) cells from patients newly diagnosed with very severe aplastic anemia (n=13), refractory anemia (n=8) and healthy controls (n=10). These data were compared to profiles of myelodysplastic disease (n=55), including refractory anemia (n=18). To identify possible targets of autoimmune attack, presence of autoreactive antibodies was tested in pre-therapeutic sera of patients with very severe aplastic anemia (n=19). RESULTS CD34(+) gene expression profiling distinguished between healthy controls, children with aplastic or refractory anemia and clonal disease. Interferon stimulated genes such as the apoptosis inducing death ligand TRAIL were strongly up-regulated in CD34(+) cells of patients with aplastic anemia, in particular in patients responding to immunosuppressive treatment. In contrast, mRNA expression of integrin GPVI and the integrin complexes GPIa/IIa, GPIIb/IIIa, GPIB/GPIX/GPV was significantly down-regulated and corresponding antibodies were detected in 7 of 11 profiled patients and in 11 of 19 aplastic anemia patients. CONCLUSIONS As a potential diagnostic tool, patient-specific gene expression profiling of CD34(+) stem cells made it possible to make the difficult differential diagnosis of most patients with aplastic and refractory anemia. Profiling indicated a prognostic correlation of TRAIL expression and patient benefit from immunosuppressive therapy. Downregulation of integrin expression and concurrent presence of autoreactive anti-integrin-antibodies suggested a previously unrecognized pathological role of integrins in aplastic anemia.
Collapse
Affiliation(s)
- Ute Fischer
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Heinrich Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
242
|
Ayesh MH, Alawneh K, Khassawneh B, Khader Y, Kasasbeh A. Adult primary and secondary immune thrombocytopenic purpura: a comparative analysis of characteristics and clinical course. Clin Appl Thromb Hemost 2012; 19:327-30. [PMID: 22275396 DOI: 10.1177/1076029611433641] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study was conducted to compare the platelet count and the presence of bleeding manifestations at initial diagnosis of immune thrombocytopenic purpura (ITP) between patients with primary and secondary ITP. Medical records for 67 consecutive adult patients with ITP were reviewed retrospectively and the relevant data were abstracted. Thirty-eight (56.7%) patients were diagnosed as having primary ITP and 29 (43.3%) were considered to have secondary ITP. At the time of diagnosis, the median initial platelet count (median: 60 × 10(9)/L) for patients with secondary ITP was significantly (P < .005) higher than that for patients with primary ITP (median: 3.5 × 10(9)/L). Ecchymosis and/or purpura was observed in 4 (13.8%) patients with secondary ITP and in 33 (86.6%) patients with primary ITP (P value <.005). In conclusion, patients with secondary ITP had higher platelet count at diagnosis and were less likely to present with bleeding manifestations than those with primary ITP.
Collapse
Affiliation(s)
- Mahmoud H Ayesh
- Department of Internal Medicine, King Abdullah University Hospital, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan.
| | | | | | | | | |
Collapse
|
243
|
Nishimoto T, Satoh T, Takeuchi T, Ikeda Y, Kuwana M. Critical role of CD4(+)CD25(+) regulatory T cells in preventing murine autoantibody-mediated thrombocytopenia. Exp Hematol 2012; 40:279-89. [PMID: 22240606 DOI: 10.1016/j.exphem.2012.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Revised: 12/05/2011] [Accepted: 01/03/2012] [Indexed: 01/03/2023]
Abstract
Autoimmune response suppression by regulatory T cells (Tregs) helps to maintain peripheral immune tolerance, and defects in this mechanism are thought to play a role in the pathogenesis of various autoimmune diseases. In patients with immune thrombocytopenia, naturally occurring CD4(+)CD25(+) Tregs are both functionally impaired and reduced in number. This study was undertaken to investigate Tregs' role in preventing immune thrombocytopenia in mice. Treg-deficient mice were prepared by inoculation of Treg-depleted CD4(+)CD25(-) T cells isolated from BALB/c mice into syngeneic nude mice intravenously. Platelet count, proportion of reticulated platelets, platelet-associated IgG, platelet-associated anti-platelet antibodies, and IgG anti-platelet antibody production in splenocyte cultures were examined by flow cytometry. Of 69 Treg-deficient mice, 25 (36%) spontaneously developed thrombocytopenia that lasted at least 5 weeks. The platelet-associated IgG level and proportion of reticulated platelets were elevated in the thrombocytopenic mice. Platelet eluates and splenocyte culture supernatants prepared from thrombocytopenic mice, but not from nonthrombocytopenic mice, contained IgG antibodies capable of binding to intact platelets. Simultaneous transfer of Tregs completely prevented the onset of thrombocytopenia, but Treg transfer after the onset of thrombocytopenia had no apparent effect. Treatment with IgG anti-cytotoxic T lymphocyte-associated antigen 4 antibody canceled this Treg-governed suppressive effect. In summary, these results indicate that Tregs play a critical role in preventing murine autoantibody-mediated thrombocytopenia by engaging cytotoxic T lymphocyte-associated antigen 4.
Collapse
Affiliation(s)
- Tetsuya Nishimoto
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | | | | | | | | |
Collapse
|
244
|
Diagnosis and Management of Immune Thrombocytopenia in the Era of Thrombopoietin Mimetics. Hematology 2011; 2011:384-90. [DOI: 10.1182/asheducation-2011.1.384] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Abstract
The recognition of that patients with Immune Thrombocytopenia (ITP) have functional thrombopoietin deficiency and decreased platelet production due to immune-mediated megakaryocytic injury has challenged the traditional view of this disease as predominantly a disorder of antibody-mediated platelet destruction. The therapy of chronic refractory ITP has been transformed by the approval of the thrombopoietin minetics, romiplostim and eltrombopag, which have shown remarkable efficacy in randomized trials. The use of these agents earlier in the disease course after failure of corticosteroid therapy remains controversial. In this article, we review the current data on the efficacy and safety of thrombopoietin receptor agonists and discuss other therapies as well as diagnostic work up of ITP.
Collapse
|
245
|
|
246
|
Prevalence of diagnosed adult immune thrombocytopenia in the United Kingdom. Adv Ther 2011; 28:1096-104. [PMID: 22139790 DOI: 10.1007/s12325-011-0084-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Data regarding the prevalence of immune thrombocytopenia (ITP) is limited, and is derived from North American population-based analyses. Therefore, the authors conducted the first study outside the United States (US) using the United Kingdom (UK) General Practice Research Database (GPRD) to estimate the adult prevalence of ITP in the UK. METHODS This study estimated the diagnosed prevalence of ITP in the adult population in UK using the GPRD from January 1, 1992 to December 31, 2009. RESULTS The unadjusted, overall 18-year period prevalence was 50.29/100,000 (95% CI: 48.51, 52.06). The age- and gender-adjusted, overall 18-year period prevalence was 50.00/100,000 (95% CI: 49.20, 50.90). ITP prevalence was lower in adults aged 18-49 years of age (30.09/100,000, 95% CI: 28.27, 31.90) than in older adults aged 50-64 years of age (58.22/100,000, 95% CI: 53.88, 62.57) or ≥65 years of age (93.80/100,000, 95% CI: 88.76, 98.85). Prevalence was higher among females (59.32/100,000, 95% CI: 56.63, 62.01) than in males (40.66/100,000, 95% CI: 38.36, 42.96). Prevalence in the GPRD increased over time (1992 [16.33/100,000, 95% CI: 13.70, 19.00], 2000 [36.93/100,000, 95% CI: 34.50, 39.30], and 2009 [58.49/100,000, 95% CI: 55.80, 61.20]). CONCLUSION This new analysis of general practice in the UK provides robust prevalence estimates of diagnosed ITP among adults in Europe. ITP prevalence is higher in women and increases with age and over time.
Collapse
|
247
|
Hoemberg M, Stahl D, Schlenke P, Sibrowski W, Pachmann U, Cassens U. The isotype of autoantibodies influences the phagocytosis of antibody-coated platelets in autoimmune thrombocytopenic purpura. Scand J Immunol 2011; 74:489-95. [PMID: 21790706 DOI: 10.1111/j.1365-3083.2011.02600.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Autoimmune thrombocytopenic purpura (AITP) is an acquired autoimmune bleeding disorder, characterized by isolated thrombocytopenia because of destruction of auto-antibody-coated platelets by Fc-receptor-mediated phagocytosis. The destruction of autoantibody-sensitized platelets by FcγR-bearing phagocytic cells and the following antigen presentation are considered to play a key role for the pathophysiology of AITP. Although different isotypes of AITP-mediating autoantibodies, e.g. IgG, IgM and IgA, are frequently found in AITP patients, their role in the pathophysiology of AITP remains unclear. Using a flow cytometric monocyte-based phagocytosis assay, we investigated the impact of disease-associated autoantibody isotype in antibody-mediated phagocytosis of platelets. Platelets, labelled with 5-chloromethyl fluorescein diacetate (CMFDA), were incubated with AITP patients' serum characterized by pure IgG or IgM antiplatelet autoantibodies. Labelled platelets were incubated with monocytes. Phagocytosis was defined as the product of percentage of CMFDA-positive monocytes and mean fluorescence intensity of CMFDA. Adherence of platelets to monocytes was quantified by anti-CD61-PerCp in a CMFDA(+) CD14(+) gate. IgG-coated platelets showed a significantly higher phagocytic index than IgM-coated platelets (mean 796 ± 157 versus 539 ± 78, P < 0.01). There were no significant differences regarding platelet adherence to monocytes. The isotype of autoantibodies influences the quantity of in vitro phagocytosis of autologous platelets by monocytes. Therefore, the AITP-mediating autoantibody isotype should be considered more carefully in pathophysiologic models and furthermore in diagnostic, therapeutic and prognostic approaches in AITP.
Collapse
Affiliation(s)
- M Hoemberg
- Institute of Transfusion Medicine and Transplantation Immunology, University Hospital Muenster, Germany.
| | | | | | | | | | | |
Collapse
|
248
|
Toltl LJ, Nazi I, Jafari R, Arnold DM. Piecing together the humoral and cellular mechanisms of immune thrombocytopenia. Semin Thromb Hemost 2011; 37:631-9. [PMID: 22102266 DOI: 10.1055/s-0031-1291373] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The precise mechanisms leading to platelet-targeted autoimmunity in immune thrombocytopenia (ITP) are not known. Cellular checkpoints normally regulate immunological self-reactivity during the development of B and T cells through cell deletion, receptor editing, induction of anergy, and extrinsic cellular suppression. When these checkpoints fail, tolerance to self-antigens may be lost. In this review, we summarize the various immune mechanisms contributing to the development of ITP and relate them back to the checkpoint model of autoimmunity. These mechanisms, including increased levels of lymphocyte growth factors, resistance to death signals, and loss of T-regulatory function, result in an environment permissive to the development of platelet-reactive B and T cells. The mechanisms that lead to thrombocytopenia once tolerance for platelet antigens is lost are examined, including complement-dependent and apoptotic pathways. An improved understanding of ITP pathogenesis will ultimately guide the development of better therapies.
Collapse
Affiliation(s)
- Lisa J Toltl
- Department of Medicine, Hamilton, Ontario, Canada
| | | | | | | |
Collapse
|
249
|
Psaila B, Bussel JB, Frelinger AL, Babula B, Linden MD, Li Y, Barnard MR, Tate C, Feldman EJ, Michelson AD. Differences in platelet function in patients with acute myeloid leukemia and myelodysplasia compared to equally thrombocytopenic patients with immune thrombocytopenia. J Thromb Haemost 2011; 9:2302-10. [PMID: 21920014 PMCID: PMC3210015 DOI: 10.1111/j.1538-7836.2011.04506.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe thrombocytopenia is a major risk factor for hemorrhage, but platelet function and bleeding risk at low platelet counts are poorly understood, because of the limitations of platelet function testing at very low platelet counts. OBJECTIVES To examine and compare platelet function in severely thrombocytopenic patients with acute myeloid leukemia (AML) or myelodysplasia (MDS) with that in patients with immune thrombocytopenia (ITP). METHODS Whole blood flow cytometric measurement of platelet activation and platelet reactivity to agonists was correlated with the immature platelet fraction (IPF) and bleeding symptoms. RESULTS Patients with AML/MDS had smaller platelets, lower IPF and substantially lower platelet surface expression of activated glycoprotein (GP)IIb-IIIa and GPIb, both with and without addition of ex vivo ADP or thrombin receptor-activating peptide, than patients with ITP. In both ITP and AML/MDS patients, increased platelet surface GPIb on circulating platelets and expression of activated GPIIb-IIIa and GPIb on ex vivo activated platelets correlated with a higher IPF. Whereas platelet reactivity was higher for AML/MDS patients with bleeding than for those with no bleeding, platelet reactivity was lower for ITP patients with bleeding than for those with no bleeding. CONCLUSIONS AML/MDS patients have lower in vivo platelet activation and ex vivo platelet reactivity than patients with ITP. The proportion of newly produced platelets correlates with the expression of platelet surface markers of activation. These differences might contribute to differences in bleeding tendency between AML/MDS and ITP patients. This study is the first to define differences in platelet function between AML/MDS patients and ITP patients with equivalent degrees of thrombocytopenia.
Collapse
Affiliation(s)
- Bethan Psaila
- Platelet Disorders Center, Division of Pediatric Hematology-Oncology, Weill-Cornell Medical College, New York, NY, U.S.A
- Department of Haematology, Imperial College School of Medicine, London, U.K
| | - James B. Bussel
- Platelet Disorders Center, Division of Pediatric Hematology-Oncology, Weill-Cornell Medical College, New York, NY, U.S.A
| | - Andrew L. Frelinger
- Center for Platelet Function Studies, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, U.S.A
- Center for Platelet Research Studies, Division of Hematology/Oncology, Children’s Hospital Boston, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, U.S.A
| | - Bracken Babula
- Platelet Disorders Center, Division of Pediatric Hematology-Oncology, Weill-Cornell Medical College, New York, NY, U.S.A
| | - Matthew D. Linden
- Center for Platelet Function Studies, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, U.S.A
| | - Youfu Li
- Center for Platelet Function Studies, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, U.S.A
| | - Marc R. Barnard
- Center for Platelet Function Studies, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, U.S.A
- Center for Platelet Research Studies, Division of Hematology/Oncology, Children’s Hospital Boston, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, U.S.A
| | - Chinara Tate
- Platelet Disorders Center, Division of Pediatric Hematology-Oncology, Weill-Cornell Medical College, New York, NY, U.S.A
| | - Eric J. Feldman
- Division of Hematology and Medical Oncology, Weill-Cornell Medical College, New York, NY, U.S.A
| | - Alan D. Michelson
- Center for Platelet Function Studies, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, U.S.A
- Center for Platelet Research Studies, Division of Hematology/Oncology, Children’s Hospital Boston, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, U.S.A
| |
Collapse
|
250
|
Abstract
Immune thrombocytopenia (ITP) is not infrequently encountered during reproductive years with an estimated incidence of 0.1-1 per 1000 pregnancies. An international consensus group recently re-defined ITP and outlined standardized response criteria and up-to-date investigation and management. The pathogenesis encompasses autoantibody platelet destruction and immune-mediated decreased platelet production. Maternal antibodies may cross the placenta and have the potential to cause fetal and/or neonatal thrombocytopenia. The diagnosis and subsequent management of ITP in pregnancy requires a multidisciplinary approach involving the midwife, obstetrician, haematologist and anaesthetist. Women with ITP diagnosed prior to pregnancy should receive preconception counselling to outline potential treatments and provide information regarding expected maternal and neonatal outcome. Management prior to 36 weeks aims to avoid treatment in the absence of bleeding and ensure an acceptable platelet count for planned procedures. At 34-36 weeks, women are generally reviewed to consider whether a tailored course of treatment is required in preparation for delivery. Further research is required to determine a suitable platelet count for neuraxial anaesthesia. The mode of delivery should be guided by obstetric indication. It is pertinent to consider both the risk of maternal bleeding and thrombosis in maternal ITP. The risk of neonatal intracranial haemorrhage in association with ITP is less than 1%. Postpartum a cord blood platelet count should be checked. Additional management is dependent upon the neonatal platelet count. Data collection using the new standardized terminology should provide robust comparable epidemiological data regarding ITP in pregnancy.
Collapse
|