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González-López TJ, Bárez A, Bernardo-Gutiérrez Á, Bernat S, Fernández-Fuertes F, Guinea de Castro JM, Jiménez-Bárcenas R, Jarque I. Real-life clinical practice in Spain in the setting of new drug availability for ITP treatment. A Delphi-based Spanish expert panel consensus. Platelets 2024; 35:2336104. [PMID: 38742687 DOI: 10.1080/09537104.2024.2336104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/22/2024] [Indexed: 05/16/2024]
Abstract
Immune thrombocytopenia (ITP) is a common autoimmune hematological disorder. Despite this, diagnosis is still challenging due to clinical heterogeneity and the lack of a specific diagnostic test. New findings in the pathology and the availability of new drugs have led to the development of different guidelines worldwide. In the present study, the Delphi methodology has been used to get a consensus on the management of adult patients with ITP in Spain and to help in decision-making. The Delphi questionnaire has been designed by a scientific ad hoc committee and has been divided into 13 topics, with a total of 127 items, covering the maximum possible scenarios for the management of ITP. As a result of the study, a total consensus of 81% has been reached. It is concluded that this Delphi consensus provides practical recommendations on topics related to diagnosis and management of ITP patients to help doctors to improve outcomes. Some aspects remain unclear, without consensus among the experts. Thus, more advances are needed to optimize ITP management.
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Affiliation(s)
| | - Abelardo Bárez
- Department of Hematology, Complejo Asistencial de Ávila, Ávila, Spain
| | | | - Silvia Bernat
- Department of Hematology, Hospital Universitario de La Plana, Villarreal, Spain
| | - Fernando Fernández-Fuertes
- Department of Hematology, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
| | | | | | - Isidro Jarque
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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2
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Ahn SM, Choi EJ, Oh JS, Kim YG, Lee CK, Yoo B, Hong S. Prognostic Factors for Chronic Thrombocytopenia in Systemic Lupus Erythematosus with Immune Thrombocytopenia. Acta Haematol 2024:1-9. [PMID: 39074444 DOI: 10.1159/000540192] [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: 02/08/2024] [Accepted: 06/29/2024] [Indexed: 07/31/2024]
Abstract
INTRODUCTION We aimed to identify the clinical characteristics and risk factors for chronic immune thrombocytopenia (ITP) in patients with systemic lupus erythematosus (SLE). METHODS We retrospectively reviewed patients diagnosed with SLE-associated ITP between January 2000 and December 2021. Patient characteristics were analyzed according to the progression of chronic thrombocytopenia. No response was defined as a platelet count <30 × 109/L or less than double the baseline count after treatment. Factors associated with chronic ITP were evaluated by logistic regression analysis. RESULTS Among the 121 patients with SLE-associated ITP, 27 progressed to chronic ITP lasting more than 1 year after initial diagnosis. The median initial platelet count was significantly lower in patients with chronic thrombocytopenia than in those without the disease (16 vs. 51 × 109/L). Patients who did not achieve a response within 1 month of treatment exhibited a high probability of progressing to chronic ITP (55.6 vs. 22.3%, p < 0.001). Multivariable analysis revealed that severe thrombocytopenia at baseline (<20 × 109/L) (adjusted odds ratio [aOR] = 13.628, 95% confidence interval [CI] = 3.976-46.791) and no response within 1 month (aOR = 9.171, 95% CI = 2.776-30.298) were significantly associated with the risk of progression to chronic ITP in patients with SLE. Approximately one-quarter of the patients with SLE-associated ITP progressed to chronic ITP. CONCLUSION Severe thrombocytopenia and failure to achieve a response within 1 month were risk factors for the development of chronic ITP in those patients.
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Affiliation(s)
- Soo Min Ahn
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun-Ji Choi
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Seon Oh
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Information Medicine, Big Data Research Center, Asan Medical Center, Seoul, Republic of Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chang-Keun Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bin Yoo
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Moulis G, Michel M, Bonnotte B, Godeau B. The CARMEN-France registry of adult patients with immune thrombocytopenia and autoimmune hemolytic anemia in France. Rev Med Interne 2024:S0248-8663(24)00664-7. [PMID: 38960844 DOI: 10.1016/j.revmed.2024.06.006] [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: 04/10/2024] [Revised: 06/08/2024] [Accepted: 06/13/2024] [Indexed: 07/05/2024]
Abstract
The CARMEN-France registry is a prospective, multicenter registry in France including adult patients with a new diagnosis of immune thrombocytopenia or of autoimmune immune hemolytic anemia (2402 patients included in December 31, 2023). The recording of clinical, biological and treatment data allows detailed epidemiological and pharmacoepidemiological real-world studies. This review summarizes the CARMEN-France registry protocol, gives examples of studies conducted in the registry, and indicates future directions such as inclusion of patient reported outcomes, linkage with the French national health insurance database and linkage with other registries in Europe.
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Affiliation(s)
- Guillaume Moulis
- Service de médecine interne, centre de référence constitutif des cytopénies auto-immunes de l'adulte, CHU de Toulouse, Toulouse, France; CIC 1436, CHU de Toulouse, Toulouse, France.
| | - Marc Michel
- Service de médecine interne, centre de référence coordonnateur des cytopénies auto-immunes de l'adulte, CHU Henri-Mondor, AP-HP, Créteil, France
| | - Bernard Bonnotte
- Service de médecine interne, centre de référence constitutif des cytopénies auto-immunes de l'adulte, CHU de Dijon, Dijon, France
| | - Bertrand Godeau
- Service de médecine interne, centre de référence coordonnateur des cytopénies auto-immunes de l'adulte, CHU Henri-Mondor, AP-HP, Créteil, France
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4
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Martínez-Carballeira D, Bernardo Á, Caro A, Soto I, Gutiérrez L. Treatment of Immune Thrombocytopenia: Contextualization from a Historical Perspective. Hematol Rep 2024; 16:390-412. [PMID: 39051412 PMCID: PMC11270329 DOI: 10.3390/hematolrep16030039] [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: 05/22/2024] [Revised: 06/12/2024] [Accepted: 06/21/2024] [Indexed: 07/27/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by an isolated decrease in platelet count and an increased risk of bleeding. The pathogenesis is complex, affecting multiple components of the immune system and causing both peripheral destruction of platelets and inadequate production in the bone marrow. In this article, we review the treatment of ITP from a historical perspective, discussing first line and second line treatments, and management of refractory disease.
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Affiliation(s)
- Daniel Martínez-Carballeira
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Ángel Bernardo
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Alberto Caro
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Inmaculada Soto
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Laura Gutiérrez
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Department of Medicine, University of Oviedo, 33006 Oviedo, Spain
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5
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Brik-Simon D, Efros O, Levinsky Y, Amarilyo G, Tirosh I, Levy-Mendelovich S, Steinberg-Shemer O, Izraeli S, Yacobovich J, Gilad O. Excellent response to treatment with hydroxychloroquine in pediatric patients with SLE-related immune thrombocytopenia. Pediatr Blood Cancer 2024; 71:e30911. [PMID: 38348516 DOI: 10.1002/pbc.30911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Pediatric immune thrombocytopenia (ITP) may precede systemic autoimmune disorders. In adolescent patients with ITP, routine screening for systemic lupus erythematosus (SLE) may be performed by testing for antinuclear antibody (ANA) titer. Hydroxychloroquine (HCQ) is a safe and effective immunomodulatory drug in patients with SLE but rarely used in ITP. We analyzed the platelet count response and safety of HCQ in treating pediatric patients with SLE-related ITP. METHODS A retrospective study including pediatric patients with ITP and definite or incomplete SLE, who were treated with HCQ during 2010-2021. SLE was defined by ANA titer ≥ 1:160 as measured by immunofluorescence and ≥10 points according to the 2019 EULAR/ACR 2019 classification criteria, while patients with incomplete SLE achieved a score < 10. Complete response (CR) of the platelet count was defined as platelet count > 100 × 109/L; partial response (PR) as platelet count 30-100 × 109/L and exceeding ≥ twice baseline counts. RESULTS Of the 17 patients included (median age 15.5 years; IQR 3.6), 15 (88.2%) were female, 13 had definite SLE, and four had incomplete SLE. HCQ was initiated at a median of 17 months after ITP diagnosis with a median platelet count of 38 × 109/L (IQR 28). At 8 weeks, 8 (47.1%) patients responded, including 6 (35.3%) achieving CR. After one year, the overall response was 82.4%, with the remaining patients having stable platelet counts requiring no additional ITP therapy. The response was maintained at a median follow-up of 42 months. No adverse effects to HCQ were noted. CONCLUSION Pediatric patients with SLE-related ITP may benefit from treatment with HCQ.
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Affiliation(s)
- Dafna Brik-Simon
- Department of Pediatric Hematology Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Efros
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- National Hemophilia Center and Thrombosis Institute, Sheba Medical Center, Ramat Gan, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Levinsky
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Gil Amarilyo
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Rheumatology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Irit Tirosh
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Rheumatology Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel
| | - Sarina Levy-Mendelovich
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- National Hemophilia Center and Thrombosis Institute, Sheba Medical Center, Ramat Gan, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Sheba Talpiot Medical Leadership Program, Tel Hashomer, Israel
| | - Orna Steinberg-Shemer
- Department of Pediatric Hematology Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology Research Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Shai Izraeli
- Department of Pediatric Hematology Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joanne Yacobovich
- Department of Pediatric Hematology Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Gilad
- Department of Pediatric Hematology Oncology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
- National Hemophilia Center and Thrombosis Institute, Sheba Medical Center, Ramat Gan, Israel
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6
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Xu X, Zhang J, Xing H, Han L, Li X, Wu P, Tang J, Jing L, Luo J, Luo J, Liu L. Identification of metabolism-related key genes as potential biomarkers for pathogenesis of immune thrombocytopenia. Sci Rep 2024; 14:9040. [PMID: 38641637 PMCID: PMC11031595 DOI: 10.1038/s41598-024-59493-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/11/2024] [Indexed: 04/21/2024] Open
Abstract
Immune thrombocytopenia (ITP), an acquired autoimmune disease, is characterized by immune-mediated platelet destruction. A biomarker is a biological entity that contributes to disease pathogenesis and reflects disease activity. Metabolic alterations are reported to be associated with the occurrence of various diseases. As metabolic biomarkers for ITP have not been identified. This study aimed to identify metabolism-related differentially expressed genes as potential biomarkers for pathogenesis of ITP using bioinformatic analyses.The microarray expression data of the peripheral blood mononuclear cells were downloaded from the Gene Expression Omnibus database (GSE112278 download link: https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE112278 ). Key module genes were intersected with metabolism-related genes to obtain the metabolism-related key candidate genes. The hub genes were screened based on the degree function in the coytoscape sofware. The key ITP-related genes were subjected to functional enrichment analysis. Immune infiltration analysis was performed using a single-sample gene set enrichment analysis algorithm to evaluate the differential infiltration levels of immune cell types between ITP patient and control. Molecular subtypes were identified based on the expression of hub genes. The expression of hub genes in the ITP patients was validated using quantitative real-time polymerase chain reaction analysis. This study identified five hub genes (ADH4, CYP7A1, CYP1A2, CYP8B1, and NR1H4), which were be associated with the pathogenesis of ITP, and two molecular subtypes of ITP. Among these hub genes, CYP7A1 and CYP8B1 involved in cholesterol metabolism,were further verified in clinical samples.
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Affiliation(s)
- Xiangmei Xu
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
- Department of Oncology and Hematology, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, China
| | - Jiamin Zhang
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Hongyun Xing
- Department of Hematology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Liying Han
- Department of Hematology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Xiaoming Li
- Department of Hematology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Pengqiang Wu
- Department of Hematology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Jirui Tang
- Department of Hematology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Li Jing
- Department of Hematology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
| | - Jie Luo
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Jing Luo
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Lin Liu
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuzhong District, Chongqing, 400016, People's Republic of China.
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7
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Martínez-Carballeira D, Bernardo Á, Caro A, Soto I, Gutiérrez L. Pathophysiology, Clinical Manifestations and Diagnosis of Immune Thrombocytopenia: Contextualization from a Historical Perspective. Hematol Rep 2024; 16:204-219. [PMID: 38651450 PMCID: PMC11036214 DOI: 10.3390/hematolrep16020021] [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: 01/09/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/25/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by an isolated decrease in the platelet count and an increased risk of bleeding. The pathogenesis is complex, affecting multiple components of the immune system and causing both peripheral destruction of platelets and impaired central megakaryopoiesis and platelet production in the bone marrow. Here, we intend to contextualize the current knowledge on the pathophysiology, terminology, epidemiology, clinical manifestations, diagnosis, and prognosis of ITP from a historical perspective and the first references to the never-stopping garnering of knowledge about this entity. We highlight the necessity to better understand ITP in order to be able to provide ITP patients with personalized treatment options, improving disease prognosis and reducing the incidence or frequency of refractoriness.
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Affiliation(s)
- Daniel Martínez-Carballeira
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Ángel Bernardo
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Alberto Caro
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Inmaculada Soto
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Laura Gutiérrez
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Department of Medicine, University of Oviedo, 33006 Oviedo, Spain
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8
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Kashiwagi H, Kuwana M, Murata M, Shimada N, Takafuta T, Yamanouchi J, Kato H, Hato T, Tomiyama Y. Reference guide for the diagnosis of adult primary immune thrombocytopenia, 2023 edition. Int J Hematol 2024; 119:1-13. [PMID: 37957517 PMCID: PMC10770234 DOI: 10.1007/s12185-023-03672-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 11/15/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia due to accelerated platelet destruction and impaired platelet production. Diagnosis of ITP is still challenging because ITP has been diagnosed by exclusion. Exclusion of thrombocytopenia due to bone marrow failure is especially important in Japan because of high prevalence of aplastic anemia compared to Western countries. Hence, we propose a new diagnostic criteria involving the measurement of plasma thrombopoietin (TPO) levels and percentage of immature platelet fraction (RP% or IPF%); 1) isolated thrombocytopenia with no morphological evidence of dysplasia in any blood cell type in a blood smear, 2) normal or slightly increased plasma TPO level (< cutoff), 3) elevated RP% or IPF% (> upper limit of normal), and 4) absence of other conditions that potentially cause thrombocytopenia including secondary ITP. A diagnosis of ITP is made if conditions 1-4 are all met. Cases in which criterion 2 or 3 is not met or unavailable are defined as "possible ITP," and diagnosis of ITP can be made mainly by typical clinical course. These new criteria enable us to clearly differentiate ITP from aplastic anemia and other forms of hypoplastic thrombocytopenia and can be highly useful in clinical practice for avoiding unnecessary bone marrow examination as well as for appropriate selection of treatments.
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Affiliation(s)
- Hirokazu Kashiwagi
- Department of Blood Transfusion, Osaka University Hospital, Suita, Osaka, 565-0871, 2-15, Yamadaoka, Japan.
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Murata
- Center for Clinical Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Naoki Shimada
- Center for Basic Medical Research, International University of Health and Welfare, Ohtawara, Tochigi, Japan
| | - Toshiro Takafuta
- Department of Internal Medicine, Hiroshima City Funairi Citizens Hospital, Hiroshima, Hiroshima, Japan
| | - Jun Yamanouchi
- Division of Blood Transfusion and Cell Therapy, Ehime University Hospital, Toon, Ehime, Japan
| | - Hisashi Kato
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Takaaki Hato
- Japanese Red Cross Ehime Blood Center, Matsuyama, Ehime, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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9
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Moulis G, Aladjidi N, Godeau B. Clinical significance of antinuclear antibodies in primary immune thrombocytopenia. Br J Haematol 2023; 203:131-135. [PMID: 37646171 DOI: 10.1111/bjh.19069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 07/23/2023] [Accepted: 07/31/2023] [Indexed: 09/01/2023]
Abstract
There are discrepancies across guidelines about whether the dosage of antinuclear antibodies (ANAs) is of use at the diagnosis of primary immune thrombocytopenia (ITP). This review describes the current knowledge about ANA prevalence in patients with primary ITP, and their potential usefulness as biomarkers for ITP evolution, response to treatments and increased risk of subsequent development of systemic lupus and thrombosis.
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Affiliation(s)
- Guillaume Moulis
- Department of Internal Medicine, Referral Center for Autoimmune Cytopenia in Adults, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Team PEPSS, Toulouse University Hospital, Toulouse, France
| | - Nathalie Aladjidi
- Pediatric Hemato-Immunology, Referral Center for Autoimmune Cytopenia in Children, CEREVANCE, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Bertrand Godeau
- Internal Medicine Department, Referral Center for Autoimmune Cytopenia in Adults, Hospital Henri Mondor, University Hospital Federation TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), University of Paris Est Créteil, Créteil, France
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10
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Cines DB. Pathogenesis of refractory ITP: Overview. Br J Haematol 2023; 203:10-16. [PMID: 37735546 PMCID: PMC10539016 DOI: 10.1111/bjh.19083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/09/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
A subset of individuals with 'primary' or 'idiopathic' immune thrombocytopenia (ITP) who fail to respond to conventional first- and second-line agents or who lose responsiveness are considered to have 'refractory' disease (rITP), placing them at increased risk of bleeding and complications of intensive treatment. However, the criteria used to define the refractory state vary among studies, which complicates research and clinical investigation. Moreover, it is unclear whether rITP is simply 'more severe' ITP, or if there are specific pathogenic pathways that are more likely to result in refractory disease, and whether the presence or development of rITP can be established or anticipated based on these differences. This paper reviews potential biological features that may be associated with rITP, including genetic and epigenetic risk factors, dysregulation of T cells and cytokine networks, antibody affinity and specificity, activation of complement, impaired platelet production and alterations in platelet viability and clearance. These findings indicate the need for longitudinal studies using novel clinically available methodologies to identify and monitor pathogenic T cells, platelet antibodies and other clues to the development of refractory disease.
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Affiliation(s)
- Douglas B Cines
- Department of Pathology and Laboratory Medicine, Perelman-University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Department of Medicine, Perelman-University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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11
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Schifferli A, Moulis G, Godeau B, Leblanc T, Aladjidi N, Michel M, Leverger G, Elalfy M, Grainger J, Chitlur M, Heiri A, Holzhauer S, Le Gavrian G, Imbach P, Kühne T. Adolescents and young adults with newly diagnosed primary immune thrombocytopenia. Haematologica 2023; 108:2783-2793. [PMID: 37051753 PMCID: PMC10542823 DOI: 10.3324/haematol.2022.282524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
Current immune thrombocytopenia (ITP) guidelines target children and adults, leading to oversimplification. Adolescents and young adults (AYAS) comprise a separate group with distinct health and psychosocial issues. This study aimed to describe the clinical presentation and therapeutic strategies of ITP among AYAS. We analyzed data from two large ITP registries (PARC-ITP; CARMEN-France) and included newly diagnosed ITP patients (aged 12-25 years) with an initial platelet counts of <100×109/L. Patients with secondary ITP or non-immune thrombocytopenia (n=57) and pregnant women (n=10) were excluded. Of the 656 cases of AYAS with primary ITP registered from 2004 up to 2021, 12-month follow-up data were available for 72%. The initial median platelet count was 12×109/L. In 109 patients (17%), the diagnosis was incidental, without documented bleeding. Apart from gynecological bleeding, the clinical and therapeutical characteristics of females and males were similar. Platelet-enhancing drugs were reported in 66%, 45%, and 30% of patients at diagnosis, 1-6 months, and 6-12 months after diagnosis, respectively. Corticosteroids were the preferred treatment at all time points. At 12 months, 50% of all patients developed chronic ITP. In the subgroup of patients with initial severe thrombocytopenia (<20×109/L), those receiving frontline treatment had a higher remission rate at 1 year than those who followed an initial watch-and-wait strategy (53% and 32%; P<0.05). Our analysis indicates that the remission rate at 1 year may be associated with the initial treatment strategy. This hypothesis must be confirmed in prospective studies.
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Affiliation(s)
- Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland.
| | - Guillaume Moulis
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; Centre d'Investigation Clinique 1436, équipe PEPSS, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Bertrand Godeau
- Department of Internal Medicine, National Reference Center for Adult Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique Hopitaux de Paris, Université Paris-Est Créteil, France
| | - Thierry Leblanc
- Department of Hematology, APHP-Robert Debré Hospital, Paris, France
| | - Nathalie Aladjidi
- Centre de Référence National des Cytopénies Autoimmunes de l'Enfant (CEREVANCE), Pediatric Hematologic Unit, Centre d'Investigation Clinique Plurithématique (CICP) INSERM 1401, University Hospital of Bordeaux, Bordeaux, France
| | - Marc Michel
- Department of Internal Medicine, National Reference Center for Adult Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique Hopitaux de Paris, Université Paris-Est Créteil, France
| | - Guy Leverger
- Hôpital Armand-Trousseau AP-HP, Sorbonne université, service d'hémato-oncologie pédiatrique, Paris, France
| | - Mohsen Elalfy
- Department of Pediatric Hematology/Oncology, Ain Shams University, Cairo, Egypt
| | - John Grainger
- Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Meera Chitlur
- Carmen and Ann Adams Department of Pediatrics, Division of Hematology/Oncology, Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Andrea Heiri
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité, Berlin, Germany
| | - Gautier Le Gavrian
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Paul Imbach
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Thomas Kühne
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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12
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Ollier N, Piel-Julian ML, Mahévas M, Viallard JF, Comont T, Chèze S, Audia S, Ebbo M, Terriou L, Lega JC, Jeandel PY, Bonnotte B, Michel M, Lapeyre-Mestre M, Godeau B, Moulis G. Platelet count threshold for hemorrhage in patients with immune thrombocytopenia treated with antiplatelet agents. Blood 2023; 142:1099-1101. [PMID: 37478400 DOI: 10.1182/blood.2023020311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023] Open
Abstract
A significant proportion of older patients with immune thrombocytopenia (ITP) also have clinical indications for treatment of cardiovascular disease with antiplatelet agents. Ollier and colleagues sought to determine the frequency of bleeding in patients with ITP on aspirin therapy, finding that the pattern of bleeding, segregated by platelet count, is similar to that observed in other adults with ITP not on aspirin. They show that a platelet count of <20 × 109/L is associated with most bleeding in ITP patients on antiplatelet agents.
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Affiliation(s)
- Natasha Ollier
- Department of Internal Medicine, Toulouse University Hospital, France
| | | | - Matthieu Mahévas
- Department of Internal Medicine, National Referral Center for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est Créteil University, France
| | | | - Thibault Comont
- Department of Internal Medicine, Toulouse University Institute for Cancer, France
| | - Stéphane Chèze
- Department of Hematology, Caen University Hospital, France
| | - Sylvain Audia
- Department of Internal Medicine, Dijon University Hospital, France
| | - Mikaël Ebbo
- Department of Internal Medicine, Marseille University Hospital, Assistance Publique-Hôpitaux de Marseille, France
| | - Louis Terriou
- Department of Internal Medicine, Lille University Hospital, France
| | - Jean-Christophe Lega
- Department of Internal Medicine, Lyon University Hospital, Hôpitaux Civils de Lyon, France
| | | | - Bernard Bonnotte
- Department of Internal Medicine, Dijon University Hospital, France
| | - Marc Michel
- Department of Internal Medicine, National Referral Center for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est Créteil University, France
| | - Maryse Lapeyre-Mestre
- Clinical Investigation Center 1436, Team PEPSS (PharmacoEpidemiology, Populations, cohortS, biomarkerS), Toulouse University Hospital, France
- Department of Clinical Pharmacology, Toulouse University Hospital, France
| | - Bertrand Godeau
- Department of Internal Medicine, National Referral Center for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est Créteil University, France
| | - Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, France
- Clinical Investigation Center 1436, Team PEPSS (PharmacoEpidemiology, Populations, cohortS, biomarkerS), Toulouse University Hospital, France
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13
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Wong RSM, Yavaşoğlu İ, Yassin MA, Tarkun P, Yoon SS, Wei X, Elghandour A, Angchaisuksiri P, Ozcan M, Yang R, Mattar M, Rahman M, Ingles S, Goldbrunner M, Frueh JA, Jang JH. Eltrombopag in patients with chronic immune thrombocytopenia in Asia-Pacific, the Middle East, and Turkey: final analysis of CITE. Blood Adv 2023; 7:4773-4781. [PMID: 36103340 PMCID: PMC10469381 DOI: 10.1182/bloodadvances.2022008287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 11/20/2022] Open
Abstract
CITE was a prospective, noninterventional study in adult patients with chronic immune thrombocytopenia treated with eltrombopag under routine clinical care in Asia-Pacific, the Middle East, and Turkey. Data to assess eltrombopag usage, compliance, and outcomes were collected from May 2017 to December 2020. Platelet response was defined as platelet count ≥50 × 103/μL in the absence of rescue medications and splenectomy. Quality of life was evaluated using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire. Noncompliance was defined as the number of missed doses and number of days where the patient did not follow food instructions. A total of 231 patients were enrolled; the median (range) duration of eltrombopag treatment was 484.5 (1-642) days. Compliance to prescribed eltrombopag dose since the previous routine visit was high at ≥96.0%. Baseline median platelet count was 19.0 × 103/μL, which increased to ≥50 × 103/μL at month 2 and mostly fluctuated between 70 × 103/μL and 100 × 103/μL thereafter. The median time to first platelet response was 1.05 (95% confidence interval: 0.92-1.28) months, and the median (interquartile range) maximum duration of platelet response was 193 (57-456) days. FACIT-F scores improved from a mean (standard deviation) 34.4 (12.1) at baseline to 38.5 (9.1) at month 18. Adverse events occurred in 50.9% of patients (n = 116), the most common being upper respiratory tract infection (8.3%) and headache (6.6%). These findings confirmed the effectiveness of eltrombopag treatment in routine practice and reassured that real-world compliance to eltrombopag-prescribed doses and dietary instructions in Asia-Pacific, the Middle East, and Turkey were in line with current recommendations.
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Affiliation(s)
- Raymond Siu Ming Wong
- Sir Y.K. Pao Centre for Cancer and Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - İrfan Yavaşoğlu
- Department of Hematology, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey
| | - Mohamed A. Yassin
- National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Pınar Tarkun
- Department of Hematology, Medical Faculty, Kocaeli University, Kocaeli, Turkey
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Xie Wei
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | | | | | - Mehmet Ozcan
- Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Renchi Yang
- Institute of Haematology and Hospital of Blood Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mervat Mattar
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | | | | | | | - Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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14
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Morad MA, Doudar NA, Tawfeek N, Yacoub M, Azoz T, El Demerdash D. IL-4Rα (rs1801275) A>G polymorphism in Egyptian immune thrombocytopenia (ITP) patients: a single center experience. Hematol Transfus Cell Ther 2023:S2531-1379(23)00085-8. [PMID: 37202334 DOI: 10.1016/j.htct.2023.03.022] [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: 10/13/2022] [Revised: 01/12/2023] [Accepted: 03/30/2023] [Indexed: 05/20/2023] Open
Abstract
INTRODUCTION Chronic immune thrombocytopenia (cITP) is characterized by dysregulation of the immune response. Until recently, the role of Th2-related cytokine gene polymorphisms was unclear. Interleukin 4 (IL-4) exerts its functions by binding to three types of IL-4 receptor (IL-4R) complexes. We aimed to explore the potential association between the gene polymorphism of IL-4Rα and cITP. METHODS We investigated the clinical impact of the IL-4Rα (rs1801275) A>G single nucleotide polymorphism (SNP) using the polymerase chain reaction (PCR) followed by the restriction fragment length polymorphism (RFLP) method in 82 cITP patients and 60 healthy controls (HCs). RESULTS The IL-4Rα (rs1801275) A>G polymorphism analysis showed the mutant GG genotype was significantly higher in control females (p = 0.033). The wild AA genotype had a higher bleeding score (p = 0.02) in the adulthood onset group. Furthermore, the wild AA genotype in the cITP childhood onset group was significantly associated with the disease severity, as well as the response to treatment (p = 0.040). CONCLUSION The mutant G allele is protective against the susceptibility to cITP in the Egyptian females. The IL-4Rα (rs1801275) A>G polymorphism may affect the clinical severity of cITP and treatment response in the Egyptian population.
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Affiliation(s)
| | - Noha A Doudar
- Beni-Suef University Hospital, Faculty of Medicine, Beni-Suef University, Egypt
| | - Nehad Tawfeek
- Kasr Al-Ainy Hospital, Faculty of Medicine, Cairo University, Egypt
| | - Maha Yacoub
- Kasr Al-Ainy Hospital, Faculty of Medicine, Cairo University, Egypt
| | - Taha Azoz
- Faculty of Medicine, Cairo University, Egypt
| | - Doaa El Demerdash
- Kasr Al-Ainy Hospital, Faculty of Medicine, Cairo University, Egypt.
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15
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Litvin R, Dasgupta M, Deenadayalan V, Cuartas-Mesa MC, Olafimihan AG, Park DY, Zia M, Shaka H. Trends in outcomes and racial disparities in adult hospitalizations for immune thrombocytopenia over a decade. Ann Hematol 2023:10.1007/s00277-023-05249-8. [PMID: 37147362 DOI: 10.1007/s00277-023-05249-8] [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: 03/15/2023] [Accepted: 04/19/2023] [Indexed: 05/07/2023]
Abstract
Immune thrombocytopenia (ITP) is a diagnosis of exclusion characterized by a low platelet count in patients for whom other etiologies have been ruled out. It occurs due to autoimmune-mediated platelet destruction and thrombopoietin deficiency. ITP is a rare hematologic disorder in adults, and scarce information exists on the hospitalization outcomes among these patients. To address this knowledge gap, we conducted a nationwide population-based study from 2010 to 2019 using the National Inpatient Sample. We found a trend toward an increase in the annual admissions for ITP (from 392.2 to 417.3, p = 0.07). There was a decrease in mortality exclusively for White patients over the period studied (p = 0.03), which was not seen in Black or Hispanic patients. There was an increase in total charges adjusted for inflation for all subgroups (p < 0.01). Length of stay decreased during the decade analyzed (p < 0.01) for the total population and most subgroups. The rates of epistaxis and melena increased (p < 0.01), while rates of intracranial hemorrhage and hematemesis did not change significantly. Advances have been made in the ITP management over the past decade. However, this has not resulted in a decrease in the number of hospitalizations or total healthcare charges during hospitalization. Furthermore, a decrease in mortality was observed in White patients but not in other races. Prospective studies are needed to better characterize the financial burden of the disease, as well as to investigate racial variability in access to care, disease behavior, and response to treatment.
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Affiliation(s)
- Rafaella Litvin
- Department of Medicine, Cook County Health, Chicago, IL, USA.
| | - Mona Dasgupta
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | | | | | | | - Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | - Maryam Zia
- Department of Hematology and Oncology, Cook County Health, Chicago, IL, USA
| | - Hafeez Shaka
- Department of Medicine, Cook County Health, Chicago, IL, USA
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16
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Use of thrombopoietin receptor agonists in adults with immune thrombocytopenia: a systematic review and Central European expert consensus. Ann Hematol 2023; 102:715-727. [PMID: 36826482 PMCID: PMC9951167 DOI: 10.1007/s00277-023-05114-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/26/2023] [Indexed: 02/25/2023]
Abstract
There are currently three thrombopoietin receptor agonists (TPO-RAs) approved in Europe for treating patients with immune thrombocytopenia (ITP): romiplostim (Nplate®), eltrombopag (Revolade®), and avatrombopag (Doptelet®). However, comparative clinical data between these TPO-RAs are limited. Therefore, the purpose of this study was to perform a literature review and seek expert opinion on the relevance and strength of the evidence concerning the use of TPO-RAs in adults with ITP. A systematic search was conducted in PubMed and Embase within the last 10 years and until June 20, 2022. A total of 478 unique articles were retrieved and reviewed for relevance. The expert consensus panel comprised ITP senior hematologists from eight countries across Central Europe. The modified Delphi method, consisting of two survey rounds, a teleconference and email correspondence, was used to reach consensus. Forty articles met the relevancy criteria and are included as supporting evidence, including five meta-analyses analyzing all three European-licensed TPO-RAs and comprising a total of 31 unique randomized controlled trials (RCTs). Consensus was reached on seven statements for the second-line use of TPO-RAs in the management of adult ITP patients. In addition, the expert panel discussed TPO-RA treatment in chronic ITP patients with mild/moderate COVID-19 and ITP patients in the first-line setting but failed to reach consensus. This work will facilitate informed decision-making for healthcare providers treating adult ITP patients with TPO-RAs. However, further studies are needed on the use of TPO-RAs in the first-line setting and specific patient populations.
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17
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Pamuk ON, Ali SM, Hasni S. Development of systemic lupus erythematosus in patients with immune thrombocytopenic purpura: A systematic meta-analysis. Autoimmun Rev 2023; 22:103297. [PMID: 36781038 PMCID: PMC10078978 DOI: 10.1016/j.autrev.2023.103297] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/09/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Recent population-based cohort studies suggest that the incidence of systemic lupus erythematosus (SLE) is increased in patients with immune thrombocytopenic purpura (ITP). We performed a systematic review and meta-analysis to evaluate the development of SLE in patients with ITP. METHODS Literature search was performed in PubMed, Web of Science and Cochrane Library for studies published prior to October 2022. Studies were included that reported development of SLE in ITP patients. Forest plot was used to detect overall SLE frequency in ITP and compare risk ratios for SLE development in different ITP subgroups. Study heterogeneity was assessed by using I2 statistics. RESULTS 26 eligible studies comprising 14867 ITP patients were included in analysis. 311 ITP patients developed SLE during the follow-up period (range: 1.1-14 years) (2.09%, 95%CI: 1.87-2.33). Relative risk (RR) for developing SLE was significantly higher in female ITP patients (RR: 4.23, 95%CI: 2.52-7.12, p < 0.0001). Anti-nuclear antibody (ANA) was reported in 23 studies, there were 766/4377 ANA positive patients with ITP (17.5%). The risk of SLE development in ANA positive ITP patients was significant (RR: 26.29, 95%CI: 14.45-47.81, p < 0.0001). CONCLUSIONS Our study suggests ITP patients are at high risk of developing SLE in future. Pooled data revealed that females and patients with a positive ANA titer are at a significantly high risk of developing SLE.
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Affiliation(s)
- Omer Nuri Pamuk
- Division of Rheumatology, University Hospitals/Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA; Rheumatology Fellowship and Training Branch, NIAMS, NIH, Bethesda, MD, USA.
| | - Saja Mustafa Ali
- Rheumatology Fellowship and Training Branch, NIAMS, NIH, Bethesda, MD, USA
| | - Sarfaraz Hasni
- Lupus Clinical Trials Unit, NIAMS, NIH, Bethesda, MD, USA
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18
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Allegra A, Cicero N, Mirabile G, Giorgianni CM, Gangemi S. Novel Biomarkers for Diagnosis and Monitoring of Immune Thrombocytopenia. Int J Mol Sci 2023; 24:ijms24054438. [PMID: 36901864 PMCID: PMC10003036 DOI: 10.3390/ijms24054438] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/12/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Lower-than-normal platelet counts are a hallmark of the acquired autoimmune illness known as immune thrombocytopenia, which can affect both adults and children. Immune thrombocytopenia patients' care has evolved significantly in recent years, but the disease's diagnosis has not, and it is still only clinically achievable with the elimination of other causes of thrombocytopenia. The lack of a valid biomarker or gold-standard diagnostic test, despite ongoing efforts to find one, adds to the high rate of disease misdiagnosis. However, in recent years, several studies have helped to elucidate a number of features of the disease's etiology, highlighting how the platelet loss is not only caused by an increase in peripheral platelet destruction but also involves a number of humoral and cellular immune system effectors. This made it possible to identify the role of immune-activating substances such cytokines and chemokines, complement, non-coding genetic material, the microbiome, and gene mutations. Furthermore, platelet and megakaryocyte immaturity indices have been emphasized as new disease markers, and prognostic signs and responses to particular types of therapy have been suggested. Our review's goal was to compile information from the literature on novel immune thrombocytopenia biomarkers, markers that will help us improve the management of these patients.
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Affiliation(s)
- Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98100 Messina, Italy
- Correspondence:
| | - Nicola Cicero
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (BIOMORF), University of Messina, 98100 Messina, Italy
| | - Giuseppe Mirabile
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98100 Messina, Italy
| | - Concetto Mario Giorgianni
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (BIOMORF), University of Messina, 98100 Messina, Italy
| | - Sebastiano Gangemi
- Allergy and Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
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19
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Anat GG. Current approaches for the diagnosis and management of immune thrombocytopenia. Eur J Intern Med 2023; 108:18-24. [PMID: 36424271 DOI: 10.1016/j.ejim.2022.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/05/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
Abstract
Immune thrombocytopenia (ITP), is an acquired autoimmune disorder characterized by the destruction of platelets and megakaryocytes, resulting in thrombocytopenia (platelet count <100 × 10⁹/L). This review focuses on the diagnosis and current management of ITP. The diagnosis of ITP is based principally on the exclusion of other causes of isolated thrombocytopenia using patient history, physical examination, blood count, and evaluation of the peripheral blood film. The clinical treatment goals should be to resolve bleeding events and to prevent severe bleeding episodes. The platelet count should be improved to attain a minimum of > 20-30 × 10⁹/L. Therapy should be given as an inpatient in newly diagnosed ITP with a platelet count of > 20 × 10⁹/L or if there is active bleeding. Corticosteroids are considered the standard initial treatment for newly diagnosed patients. Subsequent medical therapies with robust evidence include thrombopoietin receptor agonists (TPO-RAs), rituximab and fostamatinib. Surgical therapy with splenectomy may be considered for patients failing medical therapy. The choice between therapy options is highly dependent upon patient values and preferences.
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Affiliation(s)
- Gafter-Gvili Anat
- Department of Medicine A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
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20
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Liu XG, Hou Y, Hou M. How we treat primary immune thrombocytopenia in adults. J Hematol Oncol 2023; 16:4. [PMID: 36658588 PMCID: PMC9850343 DOI: 10.1186/s13045-023-01401-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an immune-mediated bleeding disorder characterized by decreased platelet counts and an increased risk of bleeding. Multiple humoral and cellular immune abnormalities result in accelerated platelet destruction and suppressed platelet production in ITP. The diagnosis remains a clinical exclusion of other causes of thrombocytopenia. Treatment is not required except for patients with active bleeding, severe thrombocytopenia, or cases in need of invasive procedures. Corticosteroids, intravenous immunoglobulin, and anti-RhD immunoglobulin are the classical initial treatments for newly diagnosed ITP in adults, but these agents generally cannot induce a long-term response in most patients. Subsequent treatments for patients who fail the initial therapy include thrombopoietic agents, rituximab, fostamatinib, splenectomy, and several older immunosuppressive agents. Other potential therapeutic agents, such as inhibitors of Bruton's tyrosine kinase and neonatal Fc receptor, are currently under clinical evaluation. An optimized treatment strategy should aim at elevating the platelet counts to a safety level with minimal toxicity and improving patient health-related quality of life, and always needs to be tailored to the patients and disease phases. In this review, we address the concepts of adult ITP diagnosis and management and provide a comprehensive overview of current therapeutic strategies under general and specific situations.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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21
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Taparia K, Wall E, Arnold DM, Sun HL. Frequency and utility of bone marrow examination in relapsed/refractory immune thrombocytopenia. J Thromb Haemost 2022; 20:2119-2126. [PMID: 35751575 DOI: 10.1111/jth.15802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/13/2022] [Accepted: 06/17/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diagnosis of immune thrombocytopenia (ITP) is one of exclusion. Although guidelines recommend against routine bone marrow examination (BME) at time of ITP diagnosis, the role of BME in relapsed/refractory ITP is unclear. OBJECTIVES To examine the frequency and predictors of BME in relapsed/refractory ITP. PATIENTS/METHODS This multicenter retrospective cohort study included adults with ITP who received second-line therapy in Alberta, Canada from 2012 to 2019. We calculated the frequency of BME and rate of abnormal marrow findings. Logistic regression was performed to assess predictors of BME and predictors of bone marrow pathology. RESULTS Of 324 patients with presumed ITP, 181 (56%) underwent BME. We observed a marked decline in the rates of BME among patients >60 years over the past decade, but not in patients younger than age 60 years. On multivariable logistic regression, older age (adjusted OR [aOR] 1.03, p = .0001), anemia (aOR 2.5, p = .01), splenomegaly (aOR 3.2, p = .01), splenectomy (aOR 2.4, p = .02), and lack of splenectomy response (aOR 3.4, p = .04) were significant predictors of BME. Abnormal marrow findings were found in eight (2% of overall cohort; 4% of BME): four myelodysplastic syndrome, one aplastic anemia, one chronic lymphocytic leukemia, one metastatic cancer, and one megaloblastic anemia. Seven (88%) underwent BME for bicytopenias/pancytopenias. Macrocytosis (aOR 9.6, p = .03) and rural residence (aOR 6.7, p = .02) were independent predictors of abnormal bone marrow findings. CONCLUSIONS Although routine BME is frequently performed in relapsed/refractory ITP, abnormal findings are rare. Future prospective studies are needed to help identify a subgroup of relapsed/refractory ITP who may benefit from BME.
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Affiliation(s)
| | - Erika Wall
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Haowei Linda Sun
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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22
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Rong X, Jiang L, Qu M, Yang S, Wang K, Jiang L. Risk factors and characteristics of ischemic stroke in patients with immune thrombocytopenia: A retrospective cohort study. J Stroke Cerebrovasc Dis 2022; 31:106693. [PMID: 36054971 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106693] [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: 05/19/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Previous research has found that patients with immune thrombocytopenia (ITP) have an increased risk of thrombosis, such as venous thromboembolism (VT), ischemic stroke (IS)/transient ischemic attack (TIA), and cardiovascular disease (CVD), but the risk factors for stroke in patients with ITP have yet to be determined. This study aims to determine the risk factors and characteristics of ischemic stroke in patients with ITP. MATERIALS AND METHODS This study included adults with incident primary ITP diagnosed in a tertiary medical center between 2010 and 2020. The t-test and Mann-Whitney U test were used to compare the variables between IS and non-IS groups, and the multivariate logistic regression model was employed to evaluate correlations. RESULTS The study enrolled 1824 individuals, of whom 17 (0.93%) had IS, and 138 (1:8) were randomly chosen from 1807 non-IS patients. Age was found to be substantially associated with stroke in the multivariate analysis (OR 1.07, 95% CI: 1.026-1.116; p = 0.001). We found no correlation between platelet counts (PLT) (OR 1.013, 95% CI: 0.995-1.033; p = 0.164), mean platelet volume (MPV), platelet larger cell ratio (P-LCR), prothrombin time (PT) (OR 1.455, 95% CI 0.979-2.164; p = 0.064), activated partial thromboplastin time (APTT), D-dimer, fibrinogen or antinuclear antibody (ANA) and stroke. Of 17 ITP-IS patients, 7 (53.8%) were cryptogenic, greater than the general IS population. Three (23.1%) of them had an embolic pattern. CONCLUSION For ITP patients, age was a significant predictor of stroke. ITP-IS patients had a more cryptogenic origin, with some showing an embolic pattern.
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Affiliation(s)
- Xi Rong
- Department of Neurology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, China
| | - Lidan Jiang
- Weifang Center for Disease Control and Prevention, Weifang 261061, China
| | - Meijie Qu
- Department of Neurology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, China
| | - Shaonan Yang
- Department of Neurology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, China
| | - Kun Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, China
| | - Liwei Jiang
- Department of Otolaryngology-Head and Neck Surgery, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, China.
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23
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Hamzah R, Yusof N, Tumian NR, Abdul Aziz S, Mohammad Basri NS, Leong TS, Ho KW, Selvaratnam V, Tan SM, Muhamad Jamil SA. Clinical Epidemiology, Treatment Outcome and Mortality Rate of Newly Diagnosed Immune Thrombocytopenia in Adult Multicentre Study in Malaysia. J Blood Med 2022; 13:337-349. [PMID: 35761846 PMCID: PMC9233512 DOI: 10.2147/jbm.s358993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Immune thrombocytopenia (ITP) is well characterized in Western, European and other Asia-Pacific countries. Nevertheless, the clinical epidemiology, treatment pattern and disease outcome of ITP in Malaysia are still limited and not well known. Objective This study aimed to describe the clinical epidemiology, treatment outcome and mortality of ITP patients in haematology tertiary multicentre in Malaysia. Methods Clinical and laboratory data of newly diagnosed adults with ITP by a platelet count <100 × 109/L from January 2010 to December 2020 were identified and analyzed. Results Out of 500 incident ITP, 71.8% were females with a striking age preponderance of both genders among those aged 18–29 years. The median age was 36 years. The median platelet count was 17.5 × 109/L, 23.0% had a secondary ITP, 34.6% had a Charlson’s score ≥1, 53.0% had bleeding symptoms including 2.2% intracranial bleedings (ICB). Helicobacter pylori screening was performed in <5% of cases. Persistency and chronicity rates were 13.6% and 41.8%, respectively. Most (80.6%) were treated at diagnosis onset and 31.2% needed second-line treatment. Throughout the course of ITP, 11.0% of patients died; 3.0% and 8.0% with bleeding and non-bleeding related ITP. Conclusion This study confirms the epidemiology of ITP is comparable with worldwide studies. Our incidence is high in the female, Malay ethnicity, primary ITP and events of cutaneous bleeding at ITP onset with 18–29 years predominance age group for both genders. The frequency of persistent and chronic ITP is inconsistent with published literature. Corticosteroids and immunotherapies are the most prescribed first-line and second-line pharmacological treatments. Thrombopoietin receptor agonist medications (TPO-RAs) usage is restricted and splenectomy is uncommon. Our mortality rate is similar but ITP related bleeding death is fourth-fold lower than previous studies. Mortality risks of our ITP patients include age ≥60 years, male, severe bleeding at presentation, CCI≥1 and secondary ITP.
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Affiliation(s)
- Roszymah Hamzah
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia.,Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Nurasyikin Yusof
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Nor Rafeah Tumian
- Haematology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Suria Abdul Aziz
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Nur Syahida Mohammad Basri
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Tze Shin Leong
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Kim Wah Ho
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Veena Selvaratnam
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Sen Mui Tan
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Siti Afiqah Muhamad Jamil
- Faculty of Computer and Mathematical Sciences, Universiti Teknologi Mara, Shah Alam, Selangor, Malaysia
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24
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Transient Complete Recovery of Chronic Refractory Idiopathic Thrombocytopenic Purpura after Treatment with Monoclonal Antibody Targeting SARS-CoV-2 Spike Protein. Case Rep Hematol 2022; 2022:8335541. [PMID: 35685064 PMCID: PMC9172208 DOI: 10.1155/2022/8335541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/05/2022] [Indexed: 11/18/2022] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenic purpura, is an immune-mediated acquired disease characterized by transient or persistent decrease of the platelet count due to autoimmune-related destruction of platelets. Therapy for ITP relies on competing and inhibiting the autoantibody binding and destruction (intravenous immunoglobulin and anti-D immunoglobulin and spleen tyrosine kinase (Syk) inhibitor fostamatinib), augmenting platelet production (thrombopoietin receptor agonists), immunosuppression to reduce the autoantibody production, as well as splenectomy. Studies on autoantigens on the platelets suggested epitopes to be located predominantly on the GP IIb/IIIa receptor or integrin αIIbβ3, though the trigger for the development of ITP is unclear. We report a case here of a 37-year-old gentleman who has chronic ITP managed on eltrombopag, who after receiving monoclonal antibody against SARS-CoV-2 (mAb) i.e. casirivimab and imdevimab for his COVID-19 infection, demonstrated complete recovery of his platelet count for a short period of time. We discuss a few potential mechanisms of action and propose further studies to elucidate the therapeutic effect of COVID-19 mAb in ITP.
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25
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Janssens A, Selleslag D, Depaus J, Beguin Y, Lambert C. Primary immune thrombocytopenia in adults: Belgian recommendations for diagnosis and treatment anno 2021 made by the Belgian Hematology Society. Acta Clin Belg 2022; 77:470-483. [PMID: 33635747 DOI: 10.1080/17843286.2021.1876310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The Belgian Hematology Society (BHS) updated the 2013 guidelines for diagnosis and treatment of primary immune thrombocytopenia (ITP) [1]. As knowledge about ITP pathophysiology is increasing, the mode of action of old therapies is better understood and novel drugs are introduced to target more specific pathways.Corticosteroids with or without intravenous immunoglobulins (IgIV) remain the first-line treatment. According to the updated international guidelines a short course of corticosteroids rather than a prolonged treatment has to be recommended. The same guidelines stress that consequent therapies as thrombopoietic agents (TPO-RAs) and rituximab should be available independent of duration of ITP.Although the majority of recommendations is based on very low-quality evidence, it is strongly advised to individualize the ITP management taking patient values. and preferences in account. The main treatment goal in all ITP patients must be to maintain a safe platelet count to prevent or stop bleeding with a minimum of toxicity and not to normalize the platelet count.
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Affiliation(s)
- A. Janssens
- Department of Hematology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - D. Selleslag
- Department of Hematology, AZ Sint-Jan Brugge, Brugge, Belgium
| | - J. Depaus
- Department of Hematology, CHU UCL Namur, Yvoir, Belgium
| | - Y. Beguin
- Department of Hematology, Centre Hospitalier Universitaire Liège, Liège, Belgium
| | - C. Lambert
- Department of Hematology, Cliniques Universitaire St Luc, Bruxelles, Belgium
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26
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Walter O, Ribes A, Germain J, Rieu JB, Comont T, Plat A, Rivière B, Deluche L, Delarue L, LeGoff I, Greze M, Dubourdieu B, Rauzy O, Mansat-De Mas V, Moulis G. Association between megakaryocyte abnormalities on bone marrow smear and response to thrombopoietin receptor agonists in adult patients with primary immune thrombocytopenia. Platelets 2022; 33:1153-1158. [PMID: 35348426 DOI: 10.1080/09537104.2022.2053089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Impaired platelet production is a mechanism of immune thrombocytopenia (ITP). Morphological abnormalities of megakaryocytes (MKs) are sometimes observed in this disease. Two studies have suggested an association between MK abnormalities and response to corticosteroids in primary ITP, but none have investigated this association for thrombopoietin-receptor agonists (TPO-RAs). This was the aim of this study. The source of population was the French CARMEN registry with prospective follow-up of adult patients with incident ITP. We included patients with primary ITP, treated by TPO-RA and with a bone marrow smear before initiating TPO-RA. MK abnormalities were categorized by the presence of dysplasia and by the stage of maturation. Among 451 patients screened, 38 were included in the analysis. There was no difference in the median percentage of dysplastic MKs between responders to TPO-RA (4.0%, 95% confidence interval - CI: 2.3-6.4) and non-responders (4.5%, 95% CI: 0.7-7.1). There was a slightly higher proportion of granular MKs (4.5%, 95% CI: 3-6) and basophilic MKs (30.1%, 95% CI: 21.9-39.1) in non-responders compared to responders (granular: 2.0%, 95% CI: 0-4.1; basophilic: 21.3%, 95% CI: 11.4-40.7). In conclusion, MK abnormalities were not associated with response achievement in ITP patients treated with TPO-RA in this series of 38 patients.
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Affiliation(s)
- Ondine Walter
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France.,CIC 1436, team PEPSS, Toulouse University Hospital, Toulouse, France
| | - Agnès Ribes
- Laboratory of Hematology, Toulouse University Hospital, Toulouse, France
| | - Johanne Germain
- CIC 1436, team PEPSS, Toulouse University Hospital, Toulouse, France
| | - Jean-Baptiste Rieu
- Laboratory of Hematology, Toulouse University Hospital, Toulouse, France
| | - Thibaut Comont
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | - Albertine Plat
- Laboratory of Hematology, Tarbes Hospital, Tarbes, France
| | - Brigitte Rivière
- Laboratory of Hematolgy, Castres-Mazamet Hospital, Castres, France
| | | | | | | | - Monique Greze
- Laboratory of Hematology, Albi Hospital, Albi, France
| | | | - Odile Rauzy
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | | | - Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France.,CIC 1436, team PEPSS, Toulouse University Hospital, Toulouse, France
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27
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Lee JY, Lee JH, Kim SA, Suh KJ, Kim JW, Kim SH, Lee JO, Kim JW, Kim YJ, Lee KW, Kim JH, Lee JS, Bang SM. Treatment patterns of thrombopoietin receptor agonists among adults with primary immune thrombocytopenia: A Korean nationwide population-based study. Thromb Res 2022; 213:114-118. [DOI: 10.1016/j.thromres.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/23/2022] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
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28
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Tărniceriu CC, Hurjui LL, Florea ID, Hurjui I, Gradinaru I, Tanase DM, Delianu C, Haisan A, Lozneanu L. Immune Thrombocytopenic Purpura as a Hemorrhagic Versus Thrombotic Disease: An Updated Insight into Pathophysiological Mechanisms. Medicina (B Aires) 2022; 58:medicina58020211. [PMID: 35208534 PMCID: PMC8875804 DOI: 10.3390/medicina58020211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/25/2022] [Accepted: 01/29/2022] [Indexed: 11/16/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is a blood disorder characterized by a low platelet count of (less than 100 × 109/L). ITP is an organ-specific autoimmune disease in which the platelets and their precursors become targets of a dysfunctional immune system. This interaction leads to a decrease in platelet number and, subsequently, to a bleeding disorder that can become clinically significant with hemorrhages in skin, on the mucous membrane, or even intracranial hemorrhagic events. If ITP was initially considered a hemorrhagic disease, more recent studies suggest that ITP has an increased risk of thrombosis. In this review, we provide current insights into the primary ITP physiopathology and their consequences, with special consideration on hemorrhagic and thrombotic events. The autoimmune response in ITP involves both the innate and adaptive immune systems, comprising both humoral and cell-mediated immune responses. Thrombosis in ITP is related to the pathophysiology of the disease (young hyperactive platelets, platelets microparticles, rebalanced hemostasis, complement activation, endothelial activation, antiphospholipid antibodies, and inhibition of natural anticoagulants), ITP treatment, and other comorbidities that altogether contribute to the occurrence of thrombosis. Physicians need to be vigilant in the early diagnosis of thrombotic events and then institute proper treatment (antiaggregant, anticoagulant) along with ITP-targeted therapy. In this review, we provide current insights into the primary ITP physiopathology and their consequences, with special consideration on hemorrhagic and thrombotic events. The accumulated evidence has identified multiple pathophysiological mechanisms with specific genetic predispositions, particularly associated with environmental conditions.
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Affiliation(s)
- Claudia Cristina Tărniceriu
- Department of Morpho-Functional Sciences I, Discipline of Anatomy, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania;
- Hematology Clinic, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania
| | - Loredana Liliana Hurjui
- Department of Morpho-Functional Sciences II, Discipline of Physiology, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
- Central Clinical Laboratory-Hematology Department, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania;
- Correspondence: authors: (L.L.H.); (I.D.F.)
| | - Irina Daniela Florea
- Department of Morpho-Functional Sciences I, Discipline of Imunology, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania
- Correspondence: authors: (L.L.H.); (I.D.F.)
| | - Ion Hurjui
- Department of Morpho-Functional Sciences II, Discipline of Biophysics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Irina Gradinaru
- Department of Implantology Removable Dentures Technology, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania;
| | - Daniela Maria Tanase
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700111 Iasi, Romania;
| | - Carmen Delianu
- Central Clinical Laboratory-Hematology Department, “Sf. Spiridon” County Clinical Emergency Hospital, 700111 Iasi, Romania;
- Department of Biochemistry, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Anca Haisan
- Surgery Department, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania;
- Emergency Department, “Sf. Spiridon” Emergency County Hospital, 700111 Iasi, Romania
| | - Ludmila Lozneanu
- Department of Morpho-Functional Sciences I, Discipline of Histology, “Grigore T. Popa” University of Medicine and Pharmacy, Universității str 16, 700115 Iasi, Romania;
- Department of Pathology, “Sf. Spiridon” Emergency County Hospital, 700111 Iasi, Romania
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29
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Sokal A, de Nadaï T, Maquet J, Comont T, Limal N, Michel M, Beyne-Rauzy O, Godeau B, Adoue D, Mahévas M, Moulis G. Primary immune thrombocytopenia in very elderly patients: particularities in presentation and management: results from the prospective CARMEN-France Registry. Br J Haematol 2021; 196:1262-1270. [PMID: 34738634 DOI: 10.1111/bjh.17935] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/19/2021] [Indexed: 02/04/2023]
Abstract
Data about the presentation and the management of primary immune thrombocytopenia (ITP) in very elderly patients (VEPs; aged ≥80 years) are lacking. The aim of the present study was to describe ITP in this subgroup. The data source was the prospective CARMEN-France registry. Patients included between 2013 and 2018 were selected. ITP presentation and management in VEPs was compared to elderly patients (EPs; aged 65-79 years). We assessed factors associated with bleeding at ITP onset in VEPs. Of 541 patients, 184 were included: 87 in the VEP group and 97 in the EP group. The mean age was 85·7 years in the VEP group. Comorbidities were more frequent in the VEP group (67·4% vs. 47·9%). The median platelet count at ITP onset was similar but severe bleeding tended to be more frequent in VEPs (10·3% vs. 4·1%, P = 0·1) as well as mortality. Exposure to ITP drugs, response to first-line treatment, need of second-line treatment, evolution towards persistency, occurrence of bleeding, infection and thrombosis did not differ between groups. In VEPs, factors associated to bleeding were female sex [odds ratio (OR) 4·75, 95% confidence interval (CI) 1·31-17·32] and platelet count of <20 × 109 /l (OR 10·05, 95% CI 4·83-67·39). Exposure to anticoagulants was strongly associated with severe bleeding (OR 7·61, 95% CI 1·77-32·83).
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Affiliation(s)
- Aurélien Sokal
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Thomas de Nadaï
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Julien Maquet
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Thibault Comont
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse - Oncopôle, Toulouse, France
| | - Nicolas Limal
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Odile Beyne-Rauzy
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse - Oncopôle, Toulouse, France
| | - Bertrand Godeau
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Daniel Adoue
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse - Oncopôle, Toulouse, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Guillaume Moulis
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Centre d'Investigation Clinique 1436, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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30
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Mahévas M, Azzaoui I, Crickx E, Canoui-Poitrine F, Gobert D, Languille L, Limal N, Guillaud C, Croisille L, Jeljeli M, Batteux F, Baloul S, Fain O, Pirenne F, Weill JC, Reynaud CA, Godeau B, Michel M. Efficacy, safety and immunological profile of combining rituximab with belimumab for adults with persistent or chronic immune thrombocytopenia: results from a prospective phase 2b trial. Haematologica 2021; 106:2449-2457. [PMID: 32817288 PMCID: PMC8409028 DOI: 10.3324/haematol.2020.259481] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Indexed: 12/24/2022] Open
Abstract
B-cell activating factor may be involved in the failure of B-cell depleting therapy with rituximab in immune thrombocytopenia (ITP) by promoting the emergence of splenic long-lived plasma cells. From results obtained in mouse models, we hypothesized that combining rituximab with sequential injections of belimumab could increase the rate of response at one year in patients with persistent or chronic ITP by preventing the emergence of these long-lived plasma cells. The study was a single-center, single arm, prospective phase 2b trial (RITUX-PLUS, NCT03154385) investigating the safety and efficacy of rituximab given at a fixed dose of 1,000 mg, two weeks apart, combined with five infusions of belimumab, 10 mg/kg at week 0 (W0)+2 days, W2+2 days, W4, W8 and W12 for adults with primary persistent or chronic ITP. The primary endpoint was the total number of patients achieving an overall response (complete response + response) at W52 according to a standard definition. In total, 15 non-splenectomized adults, nine (60%) with persistent IPT and six (40%) with chronic ITP, were included. No severe adverse event, infection, or severe hypogammaglobulinemia was observed. Thirteen patients achieved an initial overall response. At W52, 12 (80%) patients achieved an overall response, including ten (66.7%) with complete response. When compared with a cohort of patients receiving rituximab alone, the kinetics of B-cell repopulation appeared similar, but the number of circulating T follicular helper cells was significantly decreased with belimumab combination therapy. Combining rituximab and belimumab seems a promising strategy in ITP, with high efficacy and acceptable safety.
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Affiliation(s)
- Matthieu Mahévas
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | | | - Etienne Crickx
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Florence Canoui-Poitrine
- University Paris-Est, Paris Est Creteil University, CEpiA, Henri-Mondor Hospital, Creteil, France
| | | | - Laetitia Languille
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Nicolas Limal
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Constance Guillaud
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Laure Croisille
- Service d'immunologie plaquettaire, Hopital Henri Mondor, Creteil, France
| | - Mohamed Jeljeli
- Service d'Immunologie biologique, Hopital Cochin, Institut Cochin, Paris, France
| | - Fréderic Batteux
- Service d'Immunologie biologique, Hopital Cochin, Institut Cochin, Paris, France
| | - Samia Baloul
- University Paris-Est, Paris Est Creteil University, CEpiA, Henri-Mondor Hospital, Creteil, France
| | - Olivier Fain
- Sorbonne Université, Service de Medecine Interne, Hopital Saint-Antoine, Paris, France
| | | | - Jean-Claude Weill
- Institut Necker Enfants Malades, Université Paris Descartes, Paris, France
| | | | - Bertrand Godeau
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
| | - Marc Michel
- Centre Hospitalier Universitaire Henri-Mondor, Université Paris Est Creteil, Creteil, France
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Lafaurie M, Maquet J, Baricault B, Ekstrand C, Christiansen CF, Linder M, Bahmanyar S, Nørgaard M, Sailler L, Lapeyre-Mestre M, Sommet A, Moulis G. Risk factors of hospitalisation for thrombosis in adults with primary immune thrombocytopenia, including disease-specific treatments: a French nationwide cohort study. Br J Haematol 2021; 195:456-465. [PMID: 34386974 DOI: 10.1111/bjh.17709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/30/2021] [Indexed: 12/12/2022]
Abstract
We aimed to assess the risk factors of venous thrombosis (VT) and arterial thrombosis (AT) in adults with primary immune thrombocytopenia (ITP), particularly in relation to treatments. The population comprised all incident primary ITP adults in France between 2009 and 2017 (FAITH cohort; NCT03429660) built in the national health database. Outcomes were the first hospitalisation for VT and AT. Multivariable Cox regression models included baseline risk factors, time-varying exposure to ITP drugs, splenectomy and to cardiovascular drugs. The cohort included 10 039 patients. A higher risk of hospitalisation for VT was observed with older age, history of VT, history of cancer, splenectomy [hazard ratio (HR) 3·23, 95% confidence interval (CI) 2·26-4·61], exposure to corticosteroids (HR 3·55, 95% CI 2·74-4·58), thrombopoietin-receptor agonists (TPO-RAs; HR 2·28, 95% CI 1·59-3·26) and intravenous immunoglobulin (IVIg; HR 2·10, 95% CI 1·43-3·06). A higher risk of hospitalisation for AT was observed with older age, male sex, a history of cardiovascular disease, splenectomy (HR 1·50, 95% CI 1·12-2·03), exposure to IVIg (HR 1·85, 95% CI 1·36-2·52) and TPO-RAs (HR 1·64, 95% CI 1·26-2·13). Rituximab was not associated with an increased risk. These findings help to estimate the risk of thrombosis in adult patients with ITP and to select treatment.
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Affiliation(s)
- Margaux Lafaurie
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Julien Maquet
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | | | - Charlotta Ekstrand
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | | | - Marie Linder
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Shahram Bahmanyar
- Centre for Pharmaco-Epidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Mette Nørgaard
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Laurent Sailler
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | - Maryse Lapeyre-Mestre
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Agnès Sommet
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France.,UMR 1027, INSERM, Toulouse University, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Guillaume Moulis
- CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
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32
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Song F, Al-Samkari H. Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice. J Blood Med 2021; 12:653-664. [PMID: 34345191 PMCID: PMC8323851 DOI: 10.2147/jbm.s259101] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune process resulting in increased destruction and inadequate production of platelets that can result in bleeding, fatigue, and reduced health-related quality of life. While treatment is not required for many patients with ITP, the occurrence of bleeding manifestations, severe thrombocytopenia, and requirement for invasive procedures are among the reasons necessitating initiation of therapy. Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are typical first-line and rescue treatments, but these agents typically do not result in a durable remission in adult patients. Most patients requiring treatment therefore require subsequent line therapies, such as thrombopoietin receptor agonists (TPO-RAs), rituximab, fostamatinib, splenectomy, or a number of other immunosuppressive agents. In this focused review, we discuss management of adult ITP in the acute and chronic settings.
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Affiliation(s)
- Fei Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA.,Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
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33
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Baysal M, Baş V, Ümit E, Kırkızlar HO, Demir AM. Could Anti-Nuclear Antibody Positivity be a Factor for Affecting Treatment Response in Immune Thrombocytopenia Patients on Eltrombopag? Turk J Haematol 2021; 39:38-42. [PMID: 34162172 PMCID: PMC8886267 DOI: 10.4274/tjh.galenos.2021.2021.0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective Eltrombopag remains a prominent option in the treatment of steroid-dependent or steroid-refractory Immune thrombocytopenia (ITP) patients. Unfortunately, a group of patients did not respond to eltrombopag. Antinuclear Antibody (ANA) positivity can be seen up to 30 % in ITP patients. Despite being widely used, markers to show the response for eltrombopag are lacking and needed. In the present study, we aimed to show the association between ANA positivity and eltrombopag response in ITP patients. Material and Methods Patients who were diagnosed with ITP at Trakya University Faculty of Medicine Hematology and who received eltrombopag treatment due to their resistance to steroids and other treatments were included in our study. ANA measurement was made with indirect fluorescent antibody and titers of 1:160 and above were considered positive and ANA measurement was made before starting eltrombopag. Results Forty-five patients were included in our study. 33 were female and 12 were male. The mean age of the patients was 45, 73. Years. There were 14 patients with ANA positivity and 31 patients found to be ANA negative. Response rates were higher in ANA negative patients compared to ANA positive patients in the first and sixth months of the eltrombopag treatment (p < 0, 05). Conclusion ANA positivity in ITP may indicate unresponsiveness to eltrombopag treatment, and this should be supported by prospective studies involving more patients.
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Affiliation(s)
- Mehmet Baysal
- Trakya University Faculty of Medicine, Department of Hematology, Edirne, Turkey
| | - Volkan Baş
- Trakya University Faculty of Medicine, Department of Hematology, Edirne, Turkey
| | - Elif Ümit
- Trakya University Faculty of Medicine, Department of Hematology, Edirne, Turkey
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34
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Shang Y, Guan H, Zhou F. Biological Characteristics of Umbilical Cord Mesenchymal Stem Cells and Its Therapeutic Potential for Hematological Disorders. Front Cell Dev Biol 2021; 9:570179. [PMID: 34012958 PMCID: PMC8126649 DOI: 10.3389/fcell.2021.570179] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 04/08/2021] [Indexed: 01/14/2023] Open
Abstract
Umbilical cord mesenchymal stem cells (UC-MSCs) are a class of multifunctional stem cells isolated and cultured from umbilical cord. They possessed the characteristics of highly self-renewal, multi-directional differentiation potential and low immunogenicity. Its application in the field of tissue engineering and gene therapy has achieved a series of results. Recent studies have confirmed their characteristics of inhibiting tumor cell proliferation and migration to nest of cancer. The ability of UC-MSCs to support hematopoietic microenvironment and suppress immune system suggests that they can improve engraftment after hematopoietic stem cell transplantation, which shows great potential in treatment of hematologic diseases. This review will focus on the latest advances in biological characteristics and mechanism of UC-MSCs in treatment of hematological diseases.
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Affiliation(s)
- Yufeng Shang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Haotong Guan
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
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35
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Jachiet V, Moulis G, Hadjadj J, Seguier J, Laribi K, Schleinitz N, Vey N, Sacre K, Godeau B, Beyne-Rauzy O, Bouvet R, Broner J, Brun N, Comont T, Gaudin C, Lambotte O, Le Clech L, Peterlin P, Roy-Peaud F, Salvado C, Versini M, Isnard F, Kahn JE, Gobert D, Adès L, Fenaux P, Fain O, Mekinian A. Clinical spectrum, outcome and management of immune thrombocytopenia associated with myelodysplastic syndromes and chronic myelomonocytic leukemia. Haematologica 2021; 106:1414-1422. [PMID: 33626866 PMCID: PMC8094121 DOI: 10.3324/haematol.2020.272559] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
Myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML) are associated with systemic inflammatory or autoimmune diseases in 10-20 % of cases. Among them, immune thrombocytopenia (ITP) has been reported but large studies assessing this association are missing. Whether such patients have a particular phenotype and require particular management is unclear. This study analyzes the clinical spectrum, outcome and therapeutic management of patients with ITP associated with MDS or CMML, in comparison (i) to patients with primary ITP without MDS/CMML and (ii) to patients with MDS/CMML without ITP. Forty-one MDS/CMML-associated ITP patients were included, with chronic ITP in 26 (63%) patients, low-risk myelodysplasia in 30 (73%) patients and CMML in 24 (59%) patients. An associated autoimmune disease was noted in 10 (24%) patients. In comparison to primary ITP patients, MDS/CMML-associated ITP patients had a higher occurrence of severe bleeding despite similar platelet counts at diagnosis. First-line treatment consisted of glucocorticoids (98%) and intravenous immunoglobulin (IVIg) (56%). Response achievement with IVIg was more frequent in primary ITP than in MDS/CMML-associated ITP patients. Response rates to second-line therapies were not statistically different between primary ITP and MDS/CMMLassociated ITP patients. Ten percent (n=4) of patients with MDS/CMML-associated ITP had multirefractory ITP versus none in primary ITP controls. After a median follow-up of 60 months, there was no difference in overall survival between MDS/CMML-associated ITP and primary ITP patients. Leukemia-free-survival was significantly better in MDS/CMMLassociated ITP patients than in MDS/CMML without ITP MDS/CMML-associated ITP have a particular outcome with more severe bleeding and multirefractory profile than primary ITP, similar response profile to primary ITP therapy except for IVIg, and less progression toward acute myeloid leukemia than MDS/CMML without ITP.
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MESH Headings
- Humans
- Leukemia, Myeloid, Acute
- Leukemia, Myelomonocytic, Chronic/complications
- Leukemia, Myelomonocytic, Chronic/diagnosis
- Leukemia, Myelomonocytic, Chronic/therapy
- Myelodysplastic Syndromes/complications
- Myelodysplastic Syndromes/diagnosis
- Myelodysplastic Syndromes/therapy
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Thrombocytopenia
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Affiliation(s)
- Vincent Jachiet
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris
| | - Guillaume Moulis
- Service de médecine interne, CHU de Toulouse, France; CIC 1436, CHU de Toulouse, France; UMR 1027 Inserm-Université de Toulouse
| | - Jérome Hadjadj
- Imagine Institute, laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, Université de Paris, F-75015, Paris ; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Assistance Publique Hôpitaux de Paris-Centre (APHP-CUP), Université de Paris, F-75014
| | - Julie Seguier
- Département de médecine interne, Hôpital de la Timone, AP-HM, Aix Marseille Université, Marseille
| | - Kamel Laribi
- Department of Hematology, Centre hospitalier Le Mans, Le Mans
| | - Nicolas Schleinitz
- Département de médecine interne, Hôpital de la Timone, AP-HM, Aix Marseille Université, Marseille
| | - Norbert Vey
- Haematology Department, Institut Paoli-Calmettes, Aix-Marseille Université, Marseille
| | - Karim Sacre
- Departement de Médecine Interne, Hôpital Bichat, APHP, Université de Paris, INSERM U1149, Paris
| | - Bertrand Godeau
- Hôpitaux de Paris, Hôpital Henri Mondor, Médecine Interne, Centre de Référence des Cytopénies Autoimmunes de L'Adulte, Université Paris-Est Créteil, F-94010, Créteil
| | - Odile Beyne-Rauzy
- Department of internal medicine, Toulouse University Hospital, Institut universitaire du cancer de Toulouse, and University of Toulouse, F-31059, Toulouse
| | - Romain Bouvet
- Médecine interne et maladies systémiques, CHU Dijon Bourgogne, 21000 Dijon
| | - Jonathan Broner
- Internal Médicine Department, Nîmes University Hospital, University of Montpellier, Nîmes
| | - Natacha Brun
- Service de Médecine Interne, Centre Hospitalier de Rodez, Rodez
| | - Thibault Comont
- Department of internal medicine, Toulouse University Hospital, Institut universitaire du cancer de Toulouse, and University of Toulouse, F-31059, Toulouse
| | - Clément Gaudin
- Department of oncogeriatric medicine, University Hospital Purpan, Toulouse
| | - Olivier Lambotte
- Hôpitaux de Paris, Hôpital Bicêtre, Médecine Interne et Immunologie Clinique, F-94275, Le Kremlin-Bicêtre, France; INSERM U1184, Immunology of Viral Infections and Autoimmune Diseases, F-94276, Le Kremlin-Bicêtre, France; Université Paris Sud, UMR 1184, F-94276, Le Kremlin-Bicêtre, France; CEA, DSV/iMETI, IDMIT, F-92265, Fontenay-aux-Roses
| | - Lenaïg Le Clech
- Department of Internal Medicine, Infectious Diseases and Haematology, Cornouaille Hospital Quimper
| | | | - Frédérique Roy-Peaud
- Service de médecine interne, maladies infectieuses et tropicales, CHU de Poitiers, Poitiers
| | | | | | - Françoise Isnard
- Department of Clinical Hematology, Saint-Antoine Hospital, AP-HP, Paris
| | | | - Delphine Gobert
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris
| | - Lionel Adès
- Hopital Saint-Louis (APHP) and Paris University and INSERM U944, Paris
| | - Pierre Fenaux
- Hopital Saint-Louis (APHP) and Paris University and INSERM U944, Paris
| | - Olivier Fain
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris
| | - Arsène Mekinian
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris.
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36
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Schifferli A, Heiri A, Imbach P, Holzhauer S, Seidel MG, Nugent D, Michel M, Kühne T. Misdiagnosed thrombocytopenia in children and adolescents: analysis of the Pediatric and Adult Registry on Chronic ITP. Blood Adv 2021; 5:1617-1626. [PMID: 33710335 PMCID: PMC7993109 DOI: 10.1182/bloodadvances.2020003004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/23/2021] [Indexed: 02/06/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) in children is a diagnosis of exclusion, but cases of secondary ITP and nonimmune thrombocytopenia (non-IT) are generally difficult to recognize in a timely fashion. We describe a pediatric population with a revised diagnosis of secondary ITP or non-IT within 24 months of follow-up. Data were extracted from the Pediatric and Adult Registry on Chronic ITP, an international multicenter registry collecting data prospectively in patients with newly diagnosed primary ITP. Between 2004 and 2019, a total of 3974 children aged 3 months to 16 years were included. Secondary ITP and non-IT were reported in 113 patients (63 female subjects). Infectious (n = 53) and autoimmune (n = 42) diseases were identified as the main causes, with median ages at diagnosis of 3.2 years (interquartile range: 1.2; 6.7 years) and 12.4 years (interquartile range: 7.6; 13.7 years), respectively. Other causes included malignancies, aplastic anemia, immunodeficiency, and drug use. Patients with malignancy and aplastic anemia had significantly higher initial platelet counts (37 and 52 × 109/L) than did those with infection or autoimmune diseases (12 and 13 × 109/L). Characteristics of patients with secondary ITP due to infection were similar to those of children with primary ITP at first presentation, indicating similar mechanisms. Significant differences were found for age, sex, comorbidities, initial bleeding, sustained need for treatment, and disease persistence for the remaining noninfectious group compared with primary ITP. Based on our findings, we propose a diagnostic algorithm that may serve as a basis for further discussion and prospective trials.
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Affiliation(s)
- Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Andrea Heiri
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Paul Imbach
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Markus G Seidel
- Research Unit for Pediatric Hematology and Immunology, Division of Pediatric Hemato-/Oncology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Diane Nugent
- Children's Hospital of Orange County, University of California Irvine, Irvine, CA; and
| | - Marc Michel
- Department of Internal Medicine, National Reference Center for Adult Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hopitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Thomas Kühne
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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37
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Jaime-Pérez JC, Ramos-Dávila EM, Meléndez-Flores JD, Gómez-De León A, Gómez-Almaguer D. Insights on chronic immune thrombocytopenia pathogenesis: A bench to bedside update. Blood Rev 2021; 49:100827. [PMID: 33771403 DOI: 10.1016/j.blre.2021.100827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 12/17/2022]
Abstract
Immune thrombocytopenia (ITP) is a heterogeneous disease with an unpredictable course. Chronicity can develop in up to two-thirds of adults and 20-25% of children, representing a significant burden on patients' quality of life. Despite acceptable responses to treatment, precise etiology and pathophysiology phenomena driving evolution to chronicity remain undefined. We analyzed reported risk factors for chronic ITP and associated them with proposed underlying mechanisms in its pathogenesis, including bone marrow (BM) microenvironment disturbances, clinical features, and immunological markers. Their understanding has diagnostic implications, such as screening for the presence of specific antibodies or BM examination employing molecular tools, which could help predict prognosis and recognize main pathogenic pathways in each patient. Identifying these underlying mechanisms could guide the use of personalized therapies such as all-trans retinoic acid, mTor inhibitors, FcRn inhibitors, oseltamivir, and others. Further research should lead to tailored treatments and chronic course prevention, improving patients' quality of life.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico.
| | - Eugenia M Ramos-Dávila
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Jesús D Meléndez-Flores
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Andrés Gómez-De León
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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38
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Terrell DR, Neunert CE, Cooper N, Heitink-Pollé KM, Kruse C, Imbach P, Kühne T, Ghanima W. Immune Thrombocytopenia (ITP): Current Limitations in Patient Management. ACTA ACUST UNITED AC 2020; 56:medicina56120667. [PMID: 33266286 PMCID: PMC7761470 DOI: 10.3390/medicina56120667] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/28/2020] [Indexed: 01/19/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an acquired autoimmune disorder characterized by isolated thrombocytopenia caused by increased platelet destruction and impaired platelet production. First-line therapies include corticosteroids, intravenous immunoglobulin, and anti-D immunoglobulin. For patients who are refractory to these therapies, those who become corticosteroid dependent, or relapse following treatment with corticosteroid, options include splenectomy, rituximab, and thrombopoietin-receptor agonists, alongside a variety of additional immunosuppressive and experimental therapies. Despite recent advances in the management of ITP, many areas need further research. Although it is recognized that an assessment of patient-reported outcomes in ITP is valuable to understand and guide treatment, these measures are not routinely measured in the clinical setting. Consequently, although corticosteroids are first-line therapies for both children and adults, there are no data to suggest that corticosteroids improve health-related quality of life or other patient-related outcomes in either children or adults. In fact, long courses of corticosteroids, in either children or adults, may have a negative impact on a patient's health-related quality of life, secondary to the impact on sleep disturbance, weight gain, and mental health. In adults, additional therapies may be needed to treat overt hemorrhage, but unfortunately the results are transient for the majority of patients. Therefore, there is a need to recognize the limitations of current existing therapies and evaluate new approaches, such as individualized treatment based on the probability of response and the size of effect on the patient's most bothersome symptoms and risk of adverse effects or complications. Finally, a validated screening tool that identifies clinically significant patient-reported outcomes in routine clinical practice would help both patients and physicians to effectively follow a patient's health beyond simply treating the laboratory findings and physical symptoms of ITP. The goal of this narrative review is to discuss management of newly diagnosed and refractory patients with ITP, with a focus on the limitations of current therapies from the patient's perspective.
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Affiliation(s)
- Deirdra R. Terrell
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Correspondence:
| | - Cindy E. Neunert
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA;
| | - Nichola Cooper
- Centre for Haematology, Department of Medicine, Hammersmith Hospital, Imperial College London, London SW7 2BU, UK;
| | - Katja M. Heitink-Pollé
- Department of Pediatric Hemato-oncology, Princess Maxima Center, 3584 Utrecht, The Netherlands;
| | - Caroline Kruse
- Platelet Disorder Support Association, Cleveland, OH 44141, USA;
| | - Paul Imbach
- Medical Faculty, University of Basel, 4051 Basel, Switzerland;
| | - Thomas Kühne
- University Children’s Hospital, Oncology/Hematology, 4056 Basel, Switzerland;
| | - Waleed Ghanima
- Departments of Hemato-oncology and Research, Østfold Hospital, 1714 Grålum, Norway;
- Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
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39
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Wu YJ, Hou M, Liu HX, Peng J, Ma LM, Yang LH, Feng R, Liu H, Liu Y, Feng J, Zhang HY, Zhou ZP, Wang WS, Shen XL, Zhao P, Fu HX, Zeng QZ, Wang XL, Huang QS, He Y, Jiang Q, Jiang H, Lu J, Zhao XY, Zhao XS, Chang YJ, Xu LP, Li YY, Wang QF, Zhang XH. A risk score for predicting hospitalization for community-acquired pneumonia in ITP using nationally representative data. Blood Adv 2020; 4:5846-5857. [PMID: 33232474 PMCID: PMC7686895 DOI: 10.1182/bloodadvances.2020003074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/27/2020] [Indexed: 12/25/2022] Open
Abstract
Infection is one of the primary causes of death from immune thrombocytopenia (ITP), and the lungs are the most common site of infection. We identified the factors associated with hospitalization for community-acquired pneumonia (CAP) in nonsplenectomized adults with ITP and established the [corrected] (ACPA) prediction model to predict the incidence of hospitalization for CAP. This was a retrospective study of nonsplenectomized adult patients with ITP from 10 large medical centers in China. The derivation cohort included 145 ITP inpatients with CAP and 1360 inpatients without CAP from 5 medical centers, and the validation cohort included the remaining 63 ITP inpatients with CAP and 526 inpatients without CAP from the other 5 centers. The 4-item ACPA model, which included age, Charlson Comorbidity Index score, initial platelet count, and initial absolute lymphocyte count, was established by multivariable analysis of the derivation cohort. Internal and external validation were conducted to assess the performance of the model. The ACPA model had an area under the curve of 0.853 (95% confidence interval [CI], 0.818-0.889) in the derivation cohort and 0.862 (95% CI, 0.807-0.916) in the validation cohort, which indicated the good discrimination power of the model. Calibration plots showed high agreement between the estimated and observed probabilities. Decision curve analysis indicated that ITP patients could benefit from the clinical application of the ACPA model. To summarize, the ACPA model was developed and validated to predict the occurrence of hospitalization for CAP, which might help identify ITP patients with a high risk of hospitalization for CAP.
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Affiliation(s)
- Ye-Jun Wu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology and Biostatistics, Peking University People's Hospital, Beijing, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Liang-Ming Ma
- Affiliated Shanxi Big Hospital of Shanxi Medical University, Taiyuan, China
| | - Lin-Hua Yang
- Department of Hematology, Second Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Ru Feng
- Department of Hematology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Hui Liu
- Department of Hematology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Yi Liu
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Jia Feng
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Hong-Yu Zhang
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Ze-Ping Zhou
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Wen-Sheng Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Xu-Liang Shen
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Peng Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qiao-Zhu Zeng
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xing-Lin Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qiu-Sha Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yun He
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hao Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiang-Yu Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Su Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yue-Ying Li
- Chinese Academy of Sciences Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
- China National Center for Bioinformation, Beijing, China; and
- Beijing Institute of Genomics (BIG), University of Chinese Academy of Sciences, Beijing, China
| | - Qian-Fei Wang
- Chinese Academy of Sciences Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
- China National Center for Bioinformation, Beijing, China; and
- Beijing Institute of Genomics (BIG), University of Chinese Academy of Sciences, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
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40
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Wang YM, Yu YF, Liu Y, Liu S, Hou M, Liu XG. The association between antinuclear antibody and response to rituximab treatment in adult patients with primary immune thrombocytopenia. ACTA ACUST UNITED AC 2020; 25:139-144. [PMID: 32167032 DOI: 10.1080/16078454.2020.1740430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Antinuclear antibodies (ANAs) can be detected in about 30% of patients with primary immune thrombocytopenia (ITP), yet their relationship with treatment response to rituximab remains elusive.Methods: we retrospectively reviewed the clinical records of hospitalized adult ITP patients who were treated with rituximab from three medical centers across China. Rituximab was given intravenously at 100 mg weekly for 4 weeks, or at a single dose of 375 mg/m2. All included patients had their ANAs tested before rituximab treatment.Results: A total of 287 patients fulfilled the inclusion criteria and were eligible for analysis. ANAs were positive in 98 (34.1%) of the included patients. The incidence of overall response and complete response (CR) in ANA-positive patients was significantly higher than that in ANA-negative patients (overall response: 76.5% vs. 55.0%, P < 0.001; CR: 46.9% vs. 29.1%, P = 0.003). However, sustained response (SR) rates in ANA-positive patients at 6, 12 and 24 months were all lower compared with ANA-negative patients (all P < 0.05). The overall duration of response (DOR) estimated by Kaplan-Meier analysis in ANA-negative patients was greater than that in ANA-positive patients (P < 0.001).Conclusion: ITP patients with positive ANA test were likely to achieve a better initial response to rituximab treatment, while their long-term outcome was unfavorable. Therefore, ANA test could be useful for predicting rituximab response in ITP.
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Affiliation(s)
- Yan-Ming Wang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, People's Republic of China.,Department of Hematology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, People's Republic of China
| | - Ya-Fei Yu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, People's Republic of China
| | - Yu Liu
- School of Chemistry and Pharmaceutical Engineering, Qilu University of Technology, Jinan, People's Republic of China
| | - Shuang Liu
- Department of Hematology, Taian Central Hospital, Taian, People's Republic of China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, People's Republic of China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Jinan, People's Republic of China
| | - Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, People's Republic of China
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41
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Michel M, Lega JC, Terriou L. [Secondary ITP in adults]. Rev Med Interne 2020; 42:50-57. [PMID: 33139079 DOI: 10.1016/j.revmed.2020.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 08/07/2020] [Indexed: 12/13/2022]
Abstract
Secondary forms of immune thrombocytopenia (ITP) represent approximately 20% of all ITP cases in adulthood and this rate increases with age. Since some causes may influence both the prognosis and outcome but also the management of ITP, a minimal workup must be performed at ITP diagnosis to look for an associated or underlying cause. Among adults, B-cell lymphomas and mainly chronic lymphocytic leukemia, systemic auto-immune diseases such as systemic lupus or primary immunodeficiencies mainly represented by common variable immunodeficiency are the most frequent causes of secondary ITP. Whereas first-line therapy used for secondary ITP is usually similar to the one commonly used in primary ITP and relies mostly on corticosteroids±intravenous immunoglobulin according to the severity of bleeding, second and third-line treatments must take into account the type and degree of activity of the underlying disease.
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Affiliation(s)
- M Michel
- Service de médecine interne, centre de référence pour les cytopénies auto-immunes de l'adulte, CHU Henri-Mondor, université Paris Est Créteil, Assistance publique-Hôpitaux de Paris, Créteil, France.
| | - J-C Lega
- Service de médecine interne et vasculaire, centre de compétences cytopénies auto-immunes, hôpital Lyon Sud, Lyon, France
| | - L Terriou
- Département de médecine interne et immunologie clinique, CHU de Lille, Lille, France
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42
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Significance of antinuclear antibodies in primary immune thrombocytopenia: results of the CARMEN registry. Blood Adv 2020; 4:1974-1977. [PMID: 32384539 DOI: 10.1182/bloodadvances.2020001664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/01/2020] [Indexed: 12/26/2022] Open
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43
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Moulis G, Comont T, Adoue D. New insights into the epidemiology of immune thrombocytopenia in adult patients: Impact for clinical practice. Rev Med Interne 2020; 42:11-15. [PMID: 32798089 DOI: 10.1016/j.revmed.2020.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/26/2020] [Indexed: 12/28/2022]
Abstract
New insights into immune thrombocytopenia (ITP) epidemiology in adult patients highlight three main outcomes of morbidity and mortality: bleeding, infection and thrombosis. This review depicts current evidence about incidence and risk factors of bleeding, infection and thrombosis as well as predictors of chronicity, and shows how this assessment impacts the choice of ITP second-line treatment at the individual-level basis.
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Affiliation(s)
- G Moulis
- Service de Médecine Interne, CHU de Toulouse, France; UMR 1027 INSERM, Université de Toulouse, France; CIC 1436, CHU de Toulouse, France.
| | - T Comont
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse- Oncopôle, France
| | - D Adoue
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse- Oncopôle, France
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44
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Godeau B, Bonnotte B, Michel M. [Challenges and potential solutions in first-line treatments for immune thrombocytopenia in adults]. Rev Med Interne 2020; 42:25-31. [PMID: 32713675 DOI: 10.1016/j.revmed.2020.06.018] [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] [Revised: 06/04/2020] [Accepted: 06/20/2020] [Indexed: 10/23/2022]
Abstract
The first line treatment of immune thrombocytopenic purpura (ITP) is well established and based on short course of corticosteroids associated with intravenous immunoglobulins (IVIg) for the most severe forms. Predniso(lo)ne is the corticosteroid agent usually given but dexamethasone appears as an alternative. Some guidelines recommend to use dexamethasone as first line when a rapid increase of platelet count is required. Dexamethasone could be used rather than IVIg for moderate to severe but non life-threatening bleeding manifestations. Other therapeutic options such as anti FcRn monoclonal antibodies or recombinant FcγR currently in development for ITP could be an option in the future. In newly diagnosed ITP, we unfortunately lack robust predictive risk factors of severity and chronic outcome. Identifying such factors could be helpful for considering the early use of some treatments which are commonly used as second or third line.
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Affiliation(s)
- B Godeau
- Service de médecine interne, Centre de références sur les cytopénies auto-immunes de l'adulte, CHU Henri Mondor, APHP, UPEC, 94010 Créteil, France.
| | - B Bonnotte
- Service de médecine interne et immunologie clinique, CHU Dijon Bourgogne, Université Bourgogne-Franche Comté, Inserm, EFS UMR1098, 21000 Dijon, France
| | - M Michel
- Service de médecine interne, Centre de références sur les cytopénies auto-immunes de l'adulte, CHU Henri Mondor, APHP, UPEC, 94010 Créteil, France
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45
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Zhao P, Hou M, Liu Y, Liu HX, Huang RB, Yao HX, Niu T, Peng J, Jiang M, Han YQ, Hu JD, Zhou H, Zhou ZP, Qiu L, Zhang LS, Wang X, Wang HQ, Feng R, Yang LH, Ma LM, Wang SQ, Kong PY, Wang WS, Sun HP, Sun J, Zhou HB, Zhu TN, Wang LR, Zhang JY, Huang QS, Liu X, Fu HX, Li YY, Wang QF, Jiang Q, Jiang H, Lu J, Zhang XH. Risk stratification and outcomes of intracranial hemorrhage in patients with immune thrombocytopenia under 60 years of age. Platelets 2020; 32:633-641. [PMID: 32614630 DOI: 10.1080/09537104.2020.1786042] [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] [Indexed: 02/08/2023]
Abstract
Intracranial hemorrhage (ICH) is a devastating complication of immune thrombocytopenia (ITP). However, information on ICH in ITP patients under the age of 60 years is limited, and no predictive tools are available in clinical practice. A total of 93 adult patients with ITP who developed ICH before 60 years of age were retrospectively identified from 2005 to 2019 by 27 centers in China. For each case, 2 controls matched by the time of ITP diagnosis and the duration of ITP were provided by the same center. Multivariate analysis identified head trauma (OR = 3.216, 95%CI 1.296-7.979, P =.012), a platelet count ≤ 15,000/μL at the time of ITP diagnosis (OR = 1.679, 95%CI 1.044-2.698, P =.032) and severe/life-threatening bleeding (severe bleeding vs. mild bleeding, OR = 1.910, 95%CI 1.088-3.353, P =.024; life-threatening bleeding vs. mild bleeding, OR = 2.620, 95%CI 1.360-5.051, P =.004) as independent risk factors for ICH. Intraparenchymal hemorrhage (OR = 5.191, 95%CI 1.717-15.692, P =.004) and a history of severe bleeding (OR = 4.322, 95%CI 1.532-12.198, P =.006) were associated with the 30-day outcome of ICH. These findings may facilitate ICH risk stratification and outcome prediction in patients with ITP.
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Affiliation(s)
- Peng Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yi Liu
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology, Peking University People's Hospital, Beijing, China
| | - Rui-Bin Huang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hong-Xia Yao
- Department of Hematology, Hainan General Hospital, Haikou, China
| | - Ting Niu
- Department of Hemotology, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Ming Jiang
- Department of Hematology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yan-Qiu Han
- Department of Hematology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Jian-Da Hu
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hu Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Ze-Ping Zhou
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Lin Qiu
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Lian-Sheng Zhang
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Hua-Quan Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Ru Feng
- Department of Hematology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Lin-Hua Yang
- Department of Hematology, Second Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Liang-Ming Ma
- Department of Hematology, Affiliated Shanxi Big Hospital of Shanxi Medical University, Taiyuan, China
| | - Shun-Qing Wang
- Department of Hematology, Guangzhou First People's Hospital, Guangzhou, China
| | - Pei-Yan Kong
- Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Wen-Sheng Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Hui-Ping Sun
- Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Sun
- Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - He-Bing Zhou
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Tie-Nan Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Ru Wang
- Fuxing Hospital, Capital Medical University, Beijing, China
| | - Jing-Yu Zhang
- Department of Hematology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qiu-Sha Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yue-Ying Li
- Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
| | - Qian-Fei Wang
- Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hao Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
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46
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Positivity rate of systematic bone marrow smear in patients over 60 years old with newly diagnosed immune thrombocytopenia. Blood Adv 2020; 4:2136-2138. [PMID: 32421809 DOI: 10.1182/bloodadvances.2020001654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/13/2020] [Indexed: 12/24/2022] Open
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47
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Castelli R, Gidaro A, Deliliers GL. Risk Of Thrombosis In Elderly Immune Primary Trombocytopenic Patients Treated with Thrombopoietin Receptors Agonists. J Thromb Thrombolysis 2020; 50:903-907. [DOI: 10.1007/s11239-020-02083-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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48
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Miltiadous O, Hou M, Bussel JB. Identifying and treating refractory ITP: difficulty in diagnosis and role of combination treatment. Blood 2020; 135:472-490. [PMID: 31756253 PMCID: PMC7484752 DOI: 10.1182/blood.2019003599] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 11/08/2019] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is the most common acquired thrombocytopenia after chemotherapy-induced thrombocytopenia. Existing guidelines describe the management and treatment of most patients who, overall, do well, even if they present with chronic disease, and they are usually not at a high risk for bleeding; however, a small percentage of patients is refractory and difficult to manage. Patients classified as refractory have a diagnosis that is not really ITP or have disease that is difficult to manage. ITP is a diagnosis of exclusion; no specific tests exist to confirm the diagnosis. Response to treatment is the only affirmative confirmation of diagnosis. However, refractory patients do not respond to front-line or other treatments; thus, no confirmation of diagnosis exists. The first section of this review carefully evaluates the diagnostic considerations in patients with refractory ITP. The second section describes combination treatment for refractory cases of ITP. The reported combinations are divided into the era before thrombopoietin (TPO) and rituximab and the current era. Current therapy appears to have increased effectiveness. However, the definition of refractory, if it includes insufficient response to TPO agents, describes a group with more severe and difficult-to-treat disease. The biology of refractory ITP is largely unexplored and includes oligoclonality, lymphocyte pumps, and other possibilities. Newer treatments, especially rapamycin, fostamatinib, FcRn, and BTK inhibitors, may be useful components of future therapy given their mechanisms of action; however, TPO agents, notwithstanding failure as monotherapy, appear to be critical components. In summary, refractory ITP is a complicated entity in which a precise specific diagnosis is as important as the development of effective combination treatments.
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Affiliation(s)
- Oriana Miltiadous
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
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Martellosio JP, Barra A, Roy-Peaud F, Souchaud-Debouverie O, Martin M, Lateur C, Gombert JM, Roblot P, Puyade M. Performance diagnostique des rapports κ/λ des chaines légères libres sériques (test Freelite®) et IgGκ/IgGλ (test Hevylite®) comme marqueurs pronostiques de chronicisation du purpura thrombopénique immunologique de l’adulte. Rev Med Interne 2020; 41:3-7. [DOI: 10.1016/j.revmed.2019.10.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 10/08/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
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Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, Ghanima W, Godeau B, González-López TJ, Grainger J, Hou M, Kruse C, McDonald V, Michel M, Newland AC, Pavord S, Rodeghiero F, Scully M, Tomiyama Y, Wong RS, Zaja F, Kuter DJ. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv 2019; 3:3780-3817. [PMID: 31770441 PMCID: PMC6880896 DOI: 10.1182/bloodadvances.2019000812] [Citation(s) in RCA: 563] [Impact Index Per Article: 112.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/18/2019] [Indexed: 01/19/2023] Open
Abstract
Over the last decade, there have been numerous developments and changes in treatment practices for the management of patients with immune thrombocytopenia (ITP). This article is an update of the International Consensus Report published in 2010. A critical review was performed to identify all relevant articles published between 2009 and 2018. An expert panel screened, reviewed, and graded the studies and formulated the updated consensus recommendations based on the new data. The final document provides consensus recommendations on the diagnosis and management of ITP in adults, during pregnancy, and in children, as well as quality-of-life considerations.
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Affiliation(s)
- Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University and Canadian Blood Services, Hamilton, ON, Canada
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Beng H Chong
- St. George Hospital, NSW Health Pathology, University of New South Wales, Sydney, NSW, Australia
| | - Nichola Cooper
- Department of Haematology, Hammersmith Hospital, London, United Kingdom
| | | | - Waleed Ghanima
- Departments of Research, Medicine and Oncology, Østfold Hospital Trust, Grålum, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Bertrand Godeau
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | | | - John Grainger
- Department of Haematology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Ming Hou
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, China
| | | | - Vickie McDonald
- Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Marc Michel
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Adrian C Newland
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sue Pavord
- Haematology Theme Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, United Kingdom
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Osaka, Japan
| | - Raymond S Wong
- Sir YK Pao Centre for Cancer and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy; and
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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