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Gotesman M, Shear M, Raheel S, Procassini M, Panosyan EH. Pediatric Immune Thrombocytopenia. Adv Pediatr 2024; 71:229-240. [PMID: 38944486 DOI: 10.1016/j.yapd.2024.02.007] [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] [Indexed: 07/01/2024]
Abstract
Pediatric immune thrombocytopenia (ITP) is a fairly common bleeding disorder PRESENTING with a decreased number of platelets. The typical clinical presentation involves mild bleeding symptoms with bruising and petechiae and occasional mucosal bleeding. ITP is thought to be an autoimmune disorder and more recently other mechanisms have been described. Most cases resolve spontaneously and can undergo watchful waiting as the platelet count improves. Initially, steroids or intravenous immunoglobulin G (IVIg) can be used to increase platelets. For those cases that do not resolve and become persistent or chronic, there are multiple treatment options, with new agents being studied in adults that will hopefully make it to clinical trials in pediatrics in the future.
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Affiliation(s)
- Moran Gotesman
- The Lundquist Institute of Biomedical Innovation, Torrance, CA, USA; Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA.
| | - Marni Shear
- Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
| | - Sahar Raheel
- Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
| | - Michael Procassini
- Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
| | - Eduard H Panosyan
- The Lundquist Institute of Biomedical Innovation, Torrance, CA, USA; Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
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Pincez T, Fernandes H, Fahd M, Pasquet M, Chahla WA, Granel J, Ducassou S, Thomas C, Garnier N, Jeziorski E, Bayart S, Chastagner P, Cheikh N, Guitton C, Paillard C, Lejeune J, Millot F, Li-Thiao Te V, Mallebranche C, Pellier I, Castelle M, Armari-Alla C, Carausu L, Piguet C, Benadiba J, Pluchart C, Stephan JL, Deparis M, Briandet C, Doré E, Marie-Cardine A, Barlogis V, Leverger G, Héritier S, Aladjidi N, Leblanc T. Pediatric refractory chronic immune thrombocytopenia: Identification, patients' characteristics, and outcome. Am J Hematol 2024; 99:1269-1280. [PMID: 38651646 DOI: 10.1002/ajh.27337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/06/2024] [Indexed: 04/25/2024]
Abstract
Refractory chronic immune thrombocytopenia (r-cITP) is one of the most challenging situations in chronic immune thrombocytopenia (cITP). Pediatric r-cITP is inconsistently defined in literature, contributing to the scarcity of data. Moreover, no evidence is available to guide the choice of treatment. We compared seven definitions of r-cITP including five pediatric definitions in 886 patients with cITP (median [min-max] follow-up 5.3 [1.0-29.3] years). The pediatric definitions identified overlapping groups of various sizes (4%-20%) but with similar characteristics (higher proportion of immunopathological manifestations [IM] and systemic lupus erythematosus [SLE]), suggesting that they adequately captured the population of interest. Based on the 79 patients with r-cITP (median follow-up 3.1 [0-18.2] years) according to the CEREVANCE definition (≥3 second-line treatments), we showed that r-cITP occurred at a rate of 1.15% new patients per year and did not plateau over time. In multivariate analysis, older age was associated with r-cITP. One patient (1%) experienced two grade five bleeding events after meeting r-cITP criteria and while not receiving second-line treatment. The cumulative incidence of continuous complete remission (CCR) at 2 years after r-cITP diagnosis was 9%. In this analysis, splenectomy was associated with a higher cumulative incidence of CCR (hazard ratio: 5.43, 95% confidence interval: 1.48-19.84, p = 7.8 × 10-4). In sum, children with cITP may be diagnosed with r-cITP at any time point of the follow-up and are at increased risk of IM and SLE. Second-line treatments seem to be effective for preventing grade 5 bleeding. Splenectomy may be considered to achieve CCR.
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Affiliation(s)
- Thomas Pincez
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Division of Hematology-Oncology, Charles-Bruneau Cancer Center, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montréal, Québec, Canada
| | - Helder Fernandes
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Mony Fahd
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Unit, Robert-Debré University Hospital, AP-HP, Paris, France
| | - Marlène Pasquet
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital, Toulouse, France
| | - Wadih Abou Chahla
- Department of Pediatric Hematology, Jeanne de Flandre Hospital, Lille University Hospital, Lille, France
| | - Jérome Granel
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Stéphane Ducassou
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Caroline Thomas
- Pediatric Hematology Unit, Nantes University Hospital, Nantes, France
| | - Nathalie Garnier
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon, Lyon, France
| | - Eric Jeziorski
- Pediatric Oncology Hematology Unit, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Sophie Bayart
- Pediatric Hematology Unit, Rennes University Hospital, Rennes, France
| | - Pascal Chastagner
- Department of Pediatric Hematology and Oncology, Children's University Hospital, Nancy, France
| | - Nathalie Cheikh
- Department of Pediatric Hematology-Oncology, Besançon University Hospital, Besançon, France
| | - Corinne Guitton
- Department of Pediatrics, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Catherine Paillard
- Department of Pediatric Hematology and Oncology, Hautepierre University Hospital, Strasbourg, France
| | - Julien Lejeune
- Department of Pediatric Hematology-Oncology, Clocheville Hospital, Tours University Hospital, Tours, France
| | - Frédéric Millot
- Department of Pediatric Hematology, Poitiers University Hospital, Poitiers, France
| | - Valérie Li-Thiao Te
- Department of Pediatric Hematology/Oncology, Amiens University Hospital, Amiens, France
| | - Coralie Mallebranche
- Pediatric Immuno-Hemato-Oncology, Angers University Hospital, CRCI2NA, UMR Inserm CNRS, Université d'Angers, Université de Nantes, Angers, France
| | - Isabelle Pellier
- Pediatric Immuno-Hemato-Oncology, Angers University Hospital, CRCI2NA, UMR Inserm CNRS, Université d'Angers, Université de Nantes, Angers, France
| | - Martin Castelle
- Pediatric Hematology-Immunology and Rheumatology Department, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Corinne Armari-Alla
- Pediatric Hematology-Oncology Department, Grenoble University Hospital, Grenoble, France
| | - Liana Carausu
- Department of Pediatric Hematology, CHU de Brest, Brest, France
| | - Christophe Piguet
- Pediatric Oncology Hematology Unit, Limoges University Hospital, Limoges, France
| | - Joy Benadiba
- Department of Hematology-Oncology Pediatrics, Nice University Hospital, Nice, France
| | - Claire Pluchart
- Pediatric Hematology-Oncology Unit, Institut Jean Godinot, Reims University Hospital, Reims, France
| | - Jean-Louis Stephan
- Department of Pediatric Oncology, University Hospital of Saint Etienne, North Hospital, Saint Etienne, France
| | - Marianna Deparis
- Pediatric Oncology-Hematology Unit Department, Caen University Hospital, Caen, France
| | - Claire Briandet
- Department of Pediatrics, Dijon University Hospital, Dijon, France
| | - Eric Doré
- Pediatric Unit, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Aude Marie-Cardine
- Department of Pediatric Hematology and Oncology, Rouen University Hospital, Rouen, France
| | - Vincent Barlogis
- Department of Pediatric Hematology, La Timone Hospital, Marseille University Hospital, Marseille, France
| | - Guy Leverger
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Oncology Unit, Hôpital Armand Trousseau, AP-HP, Sorbonne Université Paris, Paris, France
| | - Sébastien Héritier
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Oncology Unit, Hôpital Armand Trousseau, AP-HP, Sorbonne Université Paris, Paris, France
| | - Nathalie Aladjidi
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Thierry Leblanc
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Unit, Robert-Debré University Hospital, AP-HP, Paris, France
- Université Paris-Cité, Paris, France
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Semple JW, Schifferli A, Cooper N, Saad H, Mytych DT, Chea LS, Newland A. Immune thrombocytopenia: Pathophysiology and impacts of Romiplostim treatment. Blood Rev 2024:101222. [PMID: 38942688 DOI: 10.1016/j.blre.2024.101222] [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: 04/21/2024] [Revised: 06/04/2024] [Accepted: 06/18/2024] [Indexed: 06/30/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disease caused by immune-mediated platelet destruction and decreased platelet production. ITP is characterized by an isolated thrombocytopenia (<100 × 109/L) and increased risk of bleeding. The disease has a complex pathophysiology wherein immune tolerance breakdown leads to platelet and megakaryocyte destruction. Therapeutics such as corticosteroids, intravenous immunoglobulins (IVIg), rituximab, and thrombopoietin receptor agonists (TPO-RAs) aim to increase platelet counts to prevent hemorrhage and increase quality of life. TPO-RAs act via stimulation of TPO receptors on megakaryocytes to directly stimulate platelet production. Romiplostim is a TPO-RA that has become a mainstay in the treatment of ITP. Treatment significantly increases megakaryocyte maturation and growth leading to improved platelet production and it has recently been shown to have additional immunomodulatory effects in treated patients. This review will highlight the complex pathophysiology of ITP and discuss the usage of Romiplostim in ITP and its ability to potentially immunomodulate autoimmunity.
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Affiliation(s)
- John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden, Clinical Immunology and Transfusion Medicine, Office of Medical Services, Region Skåne, Lund, Sweden; Departments of Pharmacology, Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, USA.
| | - Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | | | | | | | | | - Adrian Newland
- Barts and The London School of Medicine and Dentistry, London, UK.
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Bharadwaj N, Munireddy J, Selvam S, Bharadwaj V, Prakash A. Dapsone for paediatric chronic immune thrombocytopenia: Short report from a tertiary centre in South India. Br J Haematol 2024; 204:1024-1028. [PMID: 38220217 DOI: 10.1111/bjh.19277] [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: 06/22/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024]
Abstract
Immune thrombocytopenia (ITP) resolves in most children within 3-12 months of diagnosis. Chronic ITP affects 10%-20% of patients, some of whom require treatment. Several second-line agents are efficacious in this group of patients. This paper describes our experience of using dapsone as a single second-line agent in children with chronic ITP. One hundred and three children with chronic ITP were seen at our centre from January 2012 to December 2016. Forty-five children met the inclusion criteria and received dapsone; 17 (37.8%) were boys; and 28 (62.2%) were girls. Early response to dapsone was seen in 37.8% of patients. The median duration of long-term follow-up was 50 months, and at least a partial response was seen in 64.4% of the patients. Dapsone offers good initial response rates and sustained remission in paediatric chronic ITP, comparable to other therapeutic agents available.
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Affiliation(s)
- Niteesh Bharadwaj
- Pediatric Hematology Oncology, St John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Jyothi Munireddy
- Pediatric Hematology Oncology, St John's Medical College Hospital, Bengaluru, Karnataka, India
| | | | - Vandana Bharadwaj
- Pediatric Hematology Oncology, St John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Anand Prakash
- Pediatric Hematology Oncology, St John's Medical College Hospital, Bengaluru, Karnataka, India
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Thakre R, Gharde P, Raghuwanshi M. Idiopathic Thrombocytopenic Purpura: Current Limitations and Management. Cureus 2023; 15:e49313. [PMID: 38143653 PMCID: PMC10748795 DOI: 10.7759/cureus.49313] [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: 08/21/2023] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenia, is a blood disorder characterized by a reduction in the number of platelets. A reduction in the number of platelets beyond the normal levels leads to several consequences. A severe reduction in blood platelet levels leads to a rash of purple spots on the skin, joints, etc. due to leakage in the small blood vessels, easy bruising, bleeding gums, intestinal bleeding, and hemorrhage. Suppose a case of ITP resolves in fewer than six months. In that case, it is an acute case of ITP. Still, if a case settles in more than six months, it is a case of ITP. The cause of a reduced platelet count can be increased peripheral destruction or impaired production; this is termed an autoimmune condition in which the body's immune system attacks platelets thinking it to be a foreign antigen. ITP in children occurs commonly following a previous viral attack. Even though evaluating patients' reports is useful for understanding and guiding the treatment, these estimates might not be regularly evaluated in clinical settings. First-line drugs in the treatment of ITP are corticosteroids, and long-term use of these drugs has several side effects, such as excessive increase in weight, mental health disturbances, and sleep disturbances; additional therapies to treat hemorrhage are usually momentary. As a result, it is essential to recognize the flaws in current procedures and adopt innovative measures for the management and minimization of difficulties.
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Affiliation(s)
- Rakshanda Thakre
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Gharde
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mohit Raghuwanshi
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Stogiannis D, Blanas K, Tsapra E, Theodora M. Is Childhood Immune Thrombocytopenia Associated With Acquired Toxoplasmosis? An Unusual Case of Infection That Led to Acute ITP in a Greek Male Toddler and Implications for Guidelines. Pediatr Infect Dis J 2023; 42:e411-e415. [PMID: 37862699 DOI: 10.1097/inf.0000000000004067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
INTRODUCTION Childhood immune thrombocytopenic purpura (ITP) is a heterogeneous immune-mediated process triggered by infections, vaccines, allergies and parasites. Currently, there is little evidence in the literature beyond case reports of an association with Toxoplasma gondii (T. gondii). METHODS The authors describe the unusual case of an earlier healthy 2.5-year-old Greek boy who developed acute ITP with a life-threatening platelet count a few days after a T. gondii infection. Evidence for the infection onset was found incidentally 3 months after the initial admission to the hospital and only after any other plausible cause of thrombocytopenia was excluded, according to diagnosis guidelines. RESULTS The boy underwent 3 intravenous immunoglobulin treatments within a trimester, a period during which his alarming platelets count levels led to housebound activities. A quite slow recovery was only ignited after the third treatment, which was administered in conjunction with a mild antibiotic medication for the T. gondii infection. Full recovery was obtained 9 months after the initial admission, although the boy's potential scored high in clinical prediction models for developing transient ITP. CONCLUSION There is a need for more research on ITPs with no obvious cause to investigate a causal association with toxoplasmosis. Currently, testing for diseases of greater rarity and of higher diagnostic cost than T. gondii is included in the ITP guidelines. Hence, routinely testing for toxoplasmosis when considering potential childhood ITP triggers and infection treatment complementary to treating the ITP might be the key to accelerating the healing process and improving the quality of life of otherwise confined children.
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Affiliation(s)
| | - Kostas Blanas
- Maternity Department, Rea Maternity Hospital, Greece
| | - Eleni Tsapra
- Pediatric Department, Euroclinic Children's Hospital, Greece
| | - Marianna Theodora
- Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University, Greece
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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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Ren X, Zhang M, Zhang X, Zhao P, Zhai W. Low-dose intravenous immunoglobulin for children with newly diagnosed immune thrombocytopenia: protocol of a systematic review and meta-analysis. BMJ Open 2023; 13:e071644. [PMID: 37385744 PMCID: PMC10314640 DOI: 10.1136/bmjopen-2023-071644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 05/21/2023] [Indexed: 07/01/2023] Open
Abstract
INTRODUCTION Intravenous immunoglobulin (IVIg) is a first-line treatment for children with newly diagnosed immune thrombocytopenia (ITP). However, the cost of IVIg is high. Higher doses of IVIg are associated with a more insupportable financial burden to paediatric patients' families and may produce more adverse reactions. Whether low-dose IVIg can quickly stop bleeding and induce a durable response in treating children with newly diagnosed ITP is not yet established. METHODS AND ANALYSIS We will extensively search five English databases (PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature) and three Chinese databases (CNKI, Wanfang and VIP). International Clinical Trials Registry Platform and ClinicalTrials.gov will also be searched as supplementary. Randomised controlled trials and prospective observational studies compared the efficacy of low-dose IVIg and high-dose or moderate-dose IVIg will be included. The primary outcome is the proportion of patients achieving durable response. Estimates of effect will be pooled with either a random-effect model or a fixed-effect model according to the heterogeneity of studies. If significant heterogeneity exists, we will conduct subgroup analysis and sensitivity analysis to explore the source of heterogeneity and evaluate the robustness of the results. Publication bias will also be assessed, if possible. The risk of bias will be assessed using the Risk of Bias 2 and Risk Of Bias In Non-randomised Studies of Interventions tools. The certainty of evidence will be evaluated using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. ETHICS AND DISSEMINATION No ethical approval is required since this systematic review is based on previously published studies. The findings of this study will be presented at international conferences or published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022384604.
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Affiliation(s)
- Xiangge Ren
- College of Pediatrics, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Miaomiao Zhang
- College of Pediatrics, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Xiaohan Zhang
- College of Pediatrics, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Peidong Zhao
- College of Pediatrics, Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Wensheng Zhai
- Department of Pediatrics, Children's Purpura and Nephropathy Center, The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan, China
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Cheng X, Wang Z, Dong S, Ma J, Meng J, Wang X, Wu R. Outcomes of switching to avatrombopag following treatment failure with eltrombopag in paediatric immune thrombocytopenia: A real-world study in China. Br J Haematol 2023. [PMID: 37188335 DOI: 10.1111/bjh.18864] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/17/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder characterized by isolated thrombocytopenia and a haemorrhagic risk. Thrombopoietin receptor agonists (TPO-RAs) are highly effective for ITP and are widely used to treat patients with steroid treatment failure or dependency. However, although treatment response to TPO-RAs may differ according to the type, the potential impact of switching from eltrombopag (ELT) to avatrombopag (AVA) with respect to efficacy or tolerance in children remains unknown. This study aimed to evaluate the outcomes of switching from ELT to AVA in paediatric patients with ITP. We retrospectively evaluated children with chronic immune thrombocytopenia (cITP) switched from ELT to AVA owing to treatment failure at the Hematology-Oncology Center of Beijing Children's Hospital between July 2021 and May 2022. Overall, 11 children (seven and four boys and girls respectively) with a median age of 8.3 (range: 3.8-15.3) years were included. The overall response and complete response (platelet [PLT] count ≥100 × 109 /L) rates during AVA treatment were 81.8% (9/11) and 54.6% (6/11) respectively. The median PLT count was significantly increased from ELT to AVA (7 [range: 2-33] × 109 /L vs. 74 [15-387] × 109 /L; p = 0.007). The median time to PLT count ≥30 × 109 /L was 18 (range: 3-120) days. Overall, 7/11 patients (63.6%) used concomitant medications, and concomitant medication use was gradually discontinued within 3-6 months after AVA initiation. In conclusion, AVA after ELT is effective in the heavily pretreated paediatric cITP population, with high response rates even in those with an inadequate response to a prior TPO-RA.
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Affiliation(s)
- Xiaoling Cheng
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhifa Wang
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Shuyue Dong
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jingyao Ma
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jinxi Meng
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Wang
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
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10
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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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11
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Pincez T, Fernandes H, Pasquet M, Abou Chahla W, Granel J, Héritier S, Fahd M, Ducassou S, Thomas C, Garnier N, Barlogis V, Jeziorski E, Bayart S, Chastagner P, Cheikh N, Guitton C, Paillard C, Lejeune J, Millot F, Li-Thiao Te V, Mallebranche C, Pellier I, Neven B, Armari-Alla C, Carausu L, Piguet C, Benadiba J, Pluchart C, Stephan JL, Deparis M, Briandet C, Doré E, Marie-Cardine A, Leblanc T, Leverger G, Aladjidi N. Impact of age at diagnosis, sex, and immunopathological manifestations in 886 patients with pediatric chronic immune thrombocytopenia. Am J Hematol 2023; 98:857-868. [PMID: 36882195 DOI: 10.1002/ajh.26900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023]
Abstract
Pediatric chronic immune thrombocytopenia (cITP) is a heterogeneous condition in terms of bleeding severity, second-line treatment use, association with clinical and/or biological immunopathological manifestations (IMs), and progression to systemic lupus erythematosus (SLE). No risk factors for these outcomes are known. Specifically, whether age at ITP diagnosis, sex, or IMs impact cITP outcomes is unknown. We report the outcomes of patients with pediatric cITP from the French nationwide prospective cohort OBS'CEREVANCE. We used multivariate analyses to investigate the effect of age at ITP diagnosis, sex, and IMs on cITP outcomes. We included 886 patients with a median (min-max) follow-up duration of 5.3 (1.0-29.3) years. We identified an age cutoff that dichotomized the risk of the outcomes and defined two risk groups: patients with ITP diagnosed <10 years (children) and ≥ 10 years (adolescents). Adolescents had a two to four-fold higher risk of grade ≥3 bleeding, second-line treatment use, clinical and biological IMs, and SLE diagnosis. Moreover, female sex and biological IMs were independently associated with higher risks of biological IMs and SLE diagnosis, second-line treatment use, and SLE diagnosis, respectively. The combination of these three risk factors defined outcome-specific risk groups. Finally, we showed that patients clustered in mild and severe phenotypes, more frequent in children and adolescents, respectively. In conclusion, we identified that age at ITP diagnosis, sex, and biological IMs impacted the long-term outcomes of pediatric cITP. We defined risk groups for each outcome, which will help clinical management and further studies.
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Affiliation(s)
- Thomas Pincez
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Center, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montréal, Québec, Canada
| | - Helder Fernandes
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Pediatric Hemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Marlène Pasquet
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital, Toulouse, France
| | - Wadih Abou Chahla
- Department of Pediatric Hematology, Jeanne de Flandre Hospital, Lille University Hospital, Lille, France
| | - Jérome Granel
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Pediatric Hemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Sébastien Héritier
- Sorbonne Université, AP-HP, Armand Trousseau University Hospital, Pediatric Hematology Oncology Unit, Paris, France
| | - Mony Fahd
- Pediatric Hematology Unit, Robert-Debré University Hospital AP-HP, Paris, France
| | - Stéphane Ducassou
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Pediatric Hemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Caroline Thomas
- Pediatric Hematology Unit, Nantes University Hospital, Nantes, France
| | - Nathalie Garnier
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon, Lyon, France
| | - Vincent Barlogis
- Department of Pediatric Hematology, La Timone Hospital, Marseille University Hospital, Marseille, France
| | - Eric Jeziorski
- Pediatric Oncology Hematology Unit, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Sophie Bayart
- Pediatric Hematology Unit, Rennes University Hospital, Rennes, France
| | - Pascal Chastagner
- Department of Pediatric Hematology and Oncology, Children's University Hospital, Nancy, France
| | - Nathalie Cheikh
- Department of Pediatric Hematology-Oncology, Besançon University Hospital, Besançon, France
| | - Corinne Guitton
- Department of Pediatrics, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Catherine Paillard
- Department of Pediatric Hematology and Oncology, Hautepierre University Hospital, Strasbourg, France
| | - Julien Lejeune
- Department of Pediatric Hematology-Oncology, Clocheville Hospital, Tours University Hospital, Tours, France
| | - Frédéric Millot
- Department of Pediatric Hematology, Poitiers University Hospital, Poitiers, France
| | - Valérie Li-Thiao Te
- Department of Pediatric Hematology/Oncology, Amiens University Hospital, Amiens, France
| | | | | | - Bénédicte Neven
- Pediatric Hematology-Immunology and Rheumatology Department, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Corinne Armari-Alla
- Pediatric Hematology-Oncology Department, Grenoble University Hospital, Grenoble, France
| | - Liana Carausu
- Department of Pediatric Hematology, CHU de Brest, Brest, France
| | - Christophe Piguet
- Pediatric Oncology Hematology Unit, Limoges University Hospital, Limoges, France
| | - Joy Benadiba
- Department of Hematology-Oncology Pediatrics, Nice University Hospital, Nice, France
| | - Claire Pluchart
- Pediatric Hematology-Oncology Unit, Institut Jean Godinot, Reims University Hospital, Reims, France
| | - Jean-Louis Stephan
- Department of Pediatric Oncology, North Hospital, University Hospital of Saint Etienne, Saint Etienne, France
| | - Marianna Deparis
- Pediatric Oncology- Hematology Unit Department, Caen University Hospital, Caen, France
| | - Claire Briandet
- Department of Pediatrics, Dijon University Hospital, Dijon, France
| | - Eric Doré
- Pediatric Unit, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Aude Marie-Cardine
- Department of Pediatric Hematology and Oncology, Rouen University Hospital, Rouen, France
| | - Thierry Leblanc
- Pediatric Hematology Unit, Robert-Debré University Hospital AP-HP, Paris, France
| | - Guy Leverger
- Sorbonne Université, AP-HP, Armand Trousseau University Hospital, Pediatric Hematology Oncology Unit, Paris, France
| | - Nathalie Aladjidi
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Pediatric Hemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
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12
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Cheng CN, Yang YN, Yeh YH, Chen LW, Chen JS, Lin YC. Predictors of Remission in Severe Childhood Immune Thrombocytopenia. Diagnostics (Basel) 2023; 13:diagnostics13030341. [PMID: 36766447 PMCID: PMC9914323 DOI: 10.3390/diagnostics13030341] [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: 12/05/2022] [Revised: 01/08/2023] [Accepted: 01/14/2023] [Indexed: 01/19/2023] Open
Abstract
Childhood immune thrombocytopenia (ITP; platelet count < 100 × 109/L) is the most common bleeding disorder in children. A total of 3-5% of children with ITP face a greater risk of bleeding, resulting in significant morbidity and mortality. Childhood ITP is often benign and self-limited; however, children with severe ITP (platelet count < 30 × 109/L) require investigation and monitoring. In addition, 20% of ITP patients may not go into remission (platelet counts < 100 × 109/L by 12 months after diagnosis) and may develop chronic ITP. The early identifying predictors associated with the resolution of severe ITP at the time of diagnosis may be helpful for family guidance. However, there is still controversy about the associations between the clinical factors at the time of initial diagnosis and the definitions of disease remission assessed at different timepoints after diagnosis. This retrospective study aimed to analyze the shared clinical factors among the disease remission definitions at three arbitrarily set timepoints-3, 6, and 12 months after diagnosis. This study retrieved records for hospitalized children aged under 18 years and diagnosed with ITP from the hospital registry in a tertiary university hospital. Clinical variables were recorded by reviewing the medical records with structured data entry for ITP admission. The serial follow-up platelet counts within 12 months after diagnosis were recorded. The times of ITP remission were identified by experienced pediatric hematologists. Patients with mild-form ITP (platelet counts ≥ 30 × 109/L) at diagnosis or who were lost to follow-up within 3 months were excluded. From 1988 to 2019, 546 children were enrolled, and a total of 497 children with severe ITP were included in the further analysis. In total, one (0.2%) died of an intracranial hemorrhage, 363 (73.2%) children went into remission at 3 months, 40 (8.1%) went into remission between 6 and 12 months, and 104 (20.9%) developed chronic ITP. The shared significant predictors for remission by the third, sixth, and twelfth months included pre-adolescent age (<10 years) at diagnosis, abrupt onset (duration of symptoms prior to admission ≤ 2 weeks), and speedy recovery (platelet count > 100 × 109/L at 1 month post diagnosis). ITP patients with positive viral serology tests or vaccination within 4 weeks had trends of delayed remission. In conclusion, diagnosis before preadolescent age, abrupt onset, and speedy recovery may share favorable factors for the remission of childhood ITP assessed at different timepoints.
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Affiliation(s)
- Chao-Neng Cheng
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan
- Department of Pediatrics, College of Medicine, National Cheng-Kung University, Tainan 701401, Taiwan
| | - Yuan-Ning Yang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan
| | - Yun-Hsuan Yeh
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan
| | - Li-Wen Chen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan
- Department of Pediatrics, College of Medicine, National Cheng-Kung University, Tainan 701401, Taiwan
| | - Jiann-Shiuh Chen
- Department of Pediatrics, College of Medicine, National Cheng-Kung University, Tainan 701401, Taiwan
- Correspondence: (J.-S.C.); (Y.-C.L.); Tel.: +886-62353535-4181 (J.-S.C.); +886-62353535-5289 (Y.-C.L.)
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan 704302, Taiwan
- Correspondence: (J.-S.C.); (Y.-C.L.); Tel.: +886-62353535-4181 (J.-S.C.); +886-62353535-5289 (Y.-C.L.)
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13
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Liu Y, Wang Y, Zhang C, Feng Q, Hou M, Peng J, Hu X, Wang S. HDAC3 single-nucleotide polymorphism rs2530223 is associated with increased susceptibility and severity of primary immune thrombocytopenia. Int J Lab Hematol 2022; 44:875-882. [PMID: 35484920 DOI: 10.1111/ijlh.13857] [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: 12/03/2021] [Revised: 03/03/2022] [Accepted: 04/03/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is an autoimmune hemorrhagic disorder characterized by a low platelet count and increased risk of bleeding. We previously reported that low-dose chidamide, a histone deacetylase (HDAC) inhibitor, restores immune tolerance in patients with ITP. This study aimed to evaluate the association of a single-nucleotide polymorphism (SNP) rs2530223 in the HDAC3 gene with susceptibility to ITP and its clinical features. METHODS Patients with ITP and age-matched healthy participants were recruited for this case-control study. Genotyping of the HDAC3 rs2530223 polymorphism was performed using MassARRAY platform. RESULTS Individuals with T allele of HDAC3 rs2530223 exhibited a 1.472-fold increased risk of ITP susceptibility (OR 1.472; 95% CI 1.100-1.969; p = .009), while ones with the TT genotype under the codominant and recessive models, and the TC/TT genotypes under the dominant model all revealed increased risk of ITP susceptibility (dominant odds ratio[OR] 1.965; 95% CI: 1.046-3.656; p = .036; codominant OR 2.264; 95% CI 1.175-4.360; p = .015; and recessive OR 1.512; 95% CI 1.028-2.224; p = .036, respectively). Regarding platelet counts in ITP patients, we observed that the TC/TT genotypes exhibited a 3.932-fold increased risk for platelet (PLT) <30 × 109 /L (OR 3.932; 95% CI 1.426-10.842; p = .008). CONCLUSION This study indicates that HDAC3 rs2530223 may be an important genetic factor related to ITP susceptibility and platelet count in ITP patients, providing new perspectives on disease progression, new therapeutic targets, and severity prediction.
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Affiliation(s)
- Yan Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yin Wang
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Cheng Zhang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qi Feng
- 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
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiang Hu
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shuwen Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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14
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A single-arm, long-term efficacy and safety study of subcutaneous romiplostim in children with immune thrombocytopenia. Blood Adv 2022; 7:396-405. [PMID: 35413092 PMCID: PMC9979726 DOI: 10.1182/bloodadvances.2021006014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 02/24/2022] [Accepted: 03/27/2022] [Indexed: 02/02/2023] Open
Abstract
Romiplostim is a thrombopoietin (TPO) receptor agonist approved for children and adults with immune thrombocytopenia (ITP) for ≥6 months, recommended as second-line treatment. This phase 3b, single-arm, multicenter study investigated long-term efficacy and safety of romiplostim in children ≥1 to <18 years old with ≥6 months' ITP duration and platelet counts ≤30 × 109/L. Children received weekly subcutaneous romiplostim (1 μg/kg titrated to 10 μg/kg) to maintain platelets within 50 to 200 × 109/L. A subset underwent bone marrow examinations. The primary end point was percentage of time with platelet response during the first 6 months' treatment (counts ≥50 × 109/L without rescue medication within the preceding 4 weeks). Overall, 203 patients (median age, 10.0 years) received ≥1 dose of romiplostim, median treatment duration was ∼3 years, and median average weekly dose was 6.9 μg/kg. Ninety-five (46.8%) discontinued (lack of efficacy, n = 43 [21.2%]). Platelet responses were achieved a median (interquartile range) of 50.0% (16.7%-83.3%) of the time during the first 6 months, increasing to 78.2% (26.7%-90.4%) during the overall 36-month treatment period. Eleven patients (5.4%) achieved sustained responses (consecutive counts ≥50 × 109/L without ITP medications for ≥24 weeks). Treatment-related adverse events (AEs) occurred in 56 patients (27.6%), with 8 (3.9%) experiencing serious treatment-related AEs; all of these led to discontinuation, including 4 cases of neutralizing antibodies (romiplostim, n = 3; TPO, n = 1). Bleeding occurred in 141 patients (69.5%), decreasing over time; grade ≥3 bleeding events occurred in 20 (9.9%). At year 2, eight of 63 evaluable patients (12.7%) had grade 2 reticulin. Long-term romiplostim resulted in sustained on-treatment platelet responses with an overall safety profile consistent with previous studies. This trial was registered at www.clinicaltrials.gov as #NCT02279173.
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15
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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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16
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Hallan DR, Simion C, Sciscent BY, Lee J, Rizk E. Immune Thrombocytopenic Purpura and Intracerebral Hemorrhage, Incidence, and Mortality. Cureus 2022; 14:e24447. [PMID: 35637831 PMCID: PMC9128758 DOI: 10.7759/cureus.24447] [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: 02/05/2022] [Accepted: 04/24/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Intracerebral hemorrhage (ICH) is a devastating complication of immune thrombocytopenic purpura (ITP). Using a large database, we sought to determine its incidence and mortality. METHODS We used a de-identified database (TriNetX) to gather information on patients with ITP with subsequent ICH (cohort 1), propensity score-matched with patients with ITP and no ICH (cohort 2). Primary endpoint was mortality, with secondary endpoints of percutaneous endoscopic gastrostomy (PEG) placement, craniotomy, palliative care encounters, intensive care unit (ICU) management, seizure, falls, pulmonary embolism (PE), myocardial infarction (MI), deep venous thrombosis (DVT), ischemic stroke (IS), and other venous embolism and thrombosis (VTE). RESULTS Incidence of ICH in patients with ITP was 1.540% in all ages, and 0.774% in those under age 18. After matching, 942 patients from each cohort were identified. Mean age was 58.3 years versus 61.2 years in cohort 1 and 2, respectively. Mortality rate was 34.076% vs. 20.17% (p <0.0001, OR 2.046 with 95% CI 1.661,2.520) at five years. Thirty-day survival was 83.46% vs. 95.17% (p<0.0001), and 365-day survival 68.59% vs. 85.33% (p<0.0001). PEG placement was seen in 21 (2.229%) patients in cohort 1, and less than 10 patients (<1.062%) in cohort 2 (p<0.0464). 2.442% vs. 0% underwent craniotomy (p<0.0001), palliative care was involved in 15.711% vs. 7.962% (p<0.0001), ICU care was seen in 27.389% vs. 11.783% (p<0.0001), with a mean ICU stay of 8.075 vs. 5.812 days (p=0.0537). 6.582% vs. 3.715% had PE (p=0.0049), 7.643% vs. 7.113% experienced MI (p=0.6595), 9.236% vs. 4.883% had DVTs (p=0.0002), 23.673% vs. 5.732% had seizures (p<0.0001), 9.023% vs. 6.582% suffered falls (p=0.0482), 7.537% vs. 3.503% suffered IS (p<0.0001), and 15.074% vs. 8.174% experienced other VTE (p<0.0001). CONCLUSION ICH occurs in approximately 1.54% of ITP patients, and is associated with a 34% mortality rate, increased PEG tube placement rates, palliative care involvement, ICU care, craniotomy, PE, IS, DVT, seizures, and falls.
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Affiliation(s)
- David R Hallan
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Christopher Simion
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Bao Y Sciscent
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - John Lee
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Elias Rizk
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Dionisi M, Cairoli S, Simeoli R, De Gennaro F, Paganelli V, Carta R, Rossi F, Dionisi-Vici C, Palumbo G, Goffredo BM. Pharmacokinetic Evaluation of Eltrombopag in ITP Pediatric Patients. Front Pharmacol 2021; 12:772873. [PMID: 34938187 PMCID: PMC8685423 DOI: 10.3389/fphar.2021.772873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/11/2021] [Indexed: 01/15/2023] Open
Abstract
Background: Eltrombopag (EPAG) is an oral thrombopoietin receptor agonist, approved for refractory primary immune thrombocytopenia (ITP) in pediatric patients. In two pediatric RCTs, EPAG led to an improvement of platelet counts and a reduction in bleeding severity. However, a significant number of pediatric patients did not achieve the primary endpoints. We performed a pharmacokinetic evaluation of EPAG in pediatric patients with refractory ITP. Methods: Outpatients aged from 1 to 17 y, affected by refractory ITP to first-line treatment, were enrolled for a pharmacokinetic assessment. The analysis of drug plasma concentration was performed by the LC-MS/MS platform. Non-compartmental and statistical subgroup analyses were carried out using the R package ncappc. Results: Among 36 patients eligible for PK analysis, the median dose of EPAG given once daily was 50 mg. The EPAG peak occurs between 2 and 4 h with a population Cmax and AUC 0-24 geo-mean of 23, 38 μg/ml, and 275, 4 µg*h/mL, respectively. The pharmacokinetic profile of EPAG did not show a dose proportionality. Female patients showed a statistically significant increase of dose-normalized exposure parameters, increasing by 110 and 123% for Cmax and AUC 0-24, respectively, when compared to male patients. Patients aged 1-5 y showed values increased by more than 100% considering both exposure parameters, compared to older children. Furthermore, patients presenting complete response (83%), showed augmented EPAG exposure parameters compared to subjects with partial or no response. Conclusion: These data highlight the need to further explore the variability of EPAG exposure and its pharmacokinetic/pharmacodynamic profile in pediatric patients also in a real-life setting.
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Affiliation(s)
- Marco Dionisi
- National Center for Drug Research and Evaluation, National Institute of Health (ISS), Rome, Italy
| | - Sara Cairoli
- Department of Pediatric Specialties and Liver-kidney Transplantation, Division of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Raffaele Simeoli
- Department of Pediatric Specialties and Liver-kidney Transplantation, Division of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Valeria Paganelli
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Scientific Institute for Research and Healthcare, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Roberto Carta
- Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Scientific Institute for Research and Healthcare, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carlo Dionisi-Vici
- Department of Pediatric Specialties and Liver-kidney Transplantation, Division of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giuseppe Palumbo
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy.,Department of Pediatric Hemato-Oncology and Cell and Gene Therapy, Scientific Institute for Research and Healthcare, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Bianca Maria Goffredo
- Department of Pediatric Specialties and Liver-kidney Transplantation, Division of Metabolic Biochemistry, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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18
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Han P, Hou Y, Zhao Y, Liu Y, Yu T, Sun Y, Wang H, Xu P, Li G, Sun T, Hu X, Liu X, Li L, Peng J, Zhou H, Hou M. Low-dose decitabine modulates T-cell homeostasis and restores immune tolerance in immune thrombocytopenia. Blood 2021; 138:674-688. [PMID: 33876188 PMCID: PMC8394906 DOI: 10.1182/blood.2020008477] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 04/06/2021] [Indexed: 12/25/2022] Open
Abstract
Our previous clinical study showed that low-dose decitabine exhibited sustained responses in nearly half of patients with refractory immune thrombocytopenia (ITP). The long-term efficacy of decitabine in ITP is not likely due to its simple role in increasing platelet production. Whether decitabine has the potential to restore immune tolerance in ITP is unknown. In this study, we analyzed the effect of decitabine on T-cell subpopulations in ITP in vitro and in vivo. We found that low-dose decitabine promoted the generation and differentiation of regulatory T (Treg) cells and augmented their immunosuppressive function. Splenocytes from CD61 knockout mice immunized with CD61+ platelets were transferred into severe combined immunodeficient mouse recipients to induce a murine model of ITP. Low-dose decitabine alleviated thrombocytopenia and restored the balance between Treg and helper T (Th) cells in active ITP mice. Treg deletion and depletion offset the effect of decitabine in restoring CD4+ T-cell subpopulations in ITP mice. For patients who received low-dose decitabine, the quantity and function of Treg cells were substantially improved, whereas Th1 and Th17 cells were suppressed compared with the pretreatment levels. Next-generation RNA-sequencing and cytokine analysis showed that low-dose decitabine rebalanced T-cell homeostasis, decreased proinflammatory cytokines, and downregulated phosphorylated STAT3 in patients with ITP. STAT3 inhibition analysis suggested that low-dose decitabine might restore Treg cells by inhibiting STAT3 activation. In conclusion, our data indicate that the immunomodulatory effect of decitabine provides one possible mechanistic explanation for the sustained response achieved by low-dose decitabine in ITP.
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MESH Headings
- Adult
- Aged
- Animals
- Female
- Humans
- Male
- Mice
- Middle Aged
- Blood Platelets/immunology
- Decitabine/administration & dosage
- Immune Tolerance/drug effects
- Immunologic Factors/administration & dosage
- Mice, Knockout
- Mice, SCID
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/pathology
- Recovery of Function/drug effects
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/pathology
- Th1 Cells/immunology
- Th1 Cells/pathology
- Th17 Cells/immunology
- Th17 Cells/pathology
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Affiliation(s)
| | - Yu Hou
- Department of Hematology
- Shangdong Key Laboratory of Immunochematology, and
| | | | | | | | | | | | | | | | - Tao Sun
- Department of Hematology
- Shangdong Key Laboratory of Immunochematology, and
| | - Xiang Hu
- Department of Hematology
- Shangdong Key Laboratory of Immunochematology, and
| | - Xinguang Liu
- Department of Hematology
- Shandong Provincial Clinical Medicine Research Center for Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Lizhen Li
- Department of Hematology
- Shangdong Key Laboratory of Immunochematology, and
| | - Jun Peng
- Department of Hematology
- Shangdong Key Laboratory of Immunochematology, and
- Shandong Provincial Clinical Medicine Research Center for Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hai Zhou
- Department of Hematology
- Shangdong Key Laboratory of Immunochematology, and
- Shandong Provincial Clinical Medicine Research Center for Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology
- Shangdong Key Laboratory of Immunochematology, and
- Shandong Provincial Clinical Medicine Research Center for Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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19
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Guarina A, Marinoni M, Lassandro G, Saracco P, Perrotta S, Facchini E, Notarangelo LD, Russo G, Giordano P, Romano F, Bertoni E, Gorio C, Boscarol G, Motta M, Spinelli M, Barone A, Zecca M, Compagno F, Ladogana S, Maggio A, Miano M, Dell'Orso G, Chiocca E, Fotzi I, Petrone A, Tornesello A, D'Alba I, Salvatore S, Casale M, Puccio G, Ramenghi U, Farruggia P. Association of Immune Thrombocytopenia and Celiac Disease in Children: A Retrospective Case Control Study. Turk J Haematol 2021; 38:175-180. [PMID: 34002598 PMCID: PMC8386315 DOI: 10.4274/tjh.galenos.2021.2021.0128] [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: The association between celiac disease (CD) and immune thrombocytopenia (ITP) is still uncertain. The aim of this study was to characterize the coexistence of these two diseases in Italian children. Materials and Methods: This is a retrospective multicenter study investigating the occurrence of CD in 28 children with ITP diagnosed from January 1, 2000, to December 31, 2019. Results: The first diagnosis was ITP in 57.1% and CD in 32.1% of patients. In 3 patients (10.7%), the two diagnoses were simultaneous. All the potential and silent cases of CD in our cohort were diagnosed in the groups of “ITP first” and “simultaneous diagnosis”. In all children ITP was mild, and in 2 out of 8 not recovered from ITP at the time of CD diagnosis a normalization of platelet counts (>100,000/μL) occurred 3 and 5 months after starting a gluten-free diet, respectively. Conclusion: We think that screening for CD should be considered in children with ITP regardless of the presence of gastrointestinal symptoms. Furthermore, some patients may recover from ITP after starting a gluten-free diet.
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Affiliation(s)
- Angela Guarina
- U.O.C. Oncoematologia Pediatrica, ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
| | - Maddalena Marinoni
- Pediatria-DH Oncoematologico Pediatrico, SSD Oncoematologia Pediatrica-Ospedale Filippo Del Ponte, Varese ASST Settelaghi, Varese, Italy
| | - Giuseppe Lassandro
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro,” Bari, Italy
| | - Paola Saracco
- SC Pediatria Specialistica Universitaria, AOU Città della Salute e della Scienza, Presidio Ospedale Infantile Regina Margherita, Torin, Italy
| | - Silverio Perrotta
- U.O. S.D. Ematologia e Oncologia Pediatrica Dai Materno Infantile - Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Elena Facchini
- Clinica Pediatrica Oncologia Ed Ematologia Pediatrica “Lalla Seràgnoli - Policlinico Sant’Orsola Malpighi,” Bologna, Italy
| | - Lucia Dora Notarangelo
- U.O. Oncoematologia Pediatrica, Presidio Ospedale dei Bambini, Spedali Civili, Brescia, Italy
| | - Giovanna Russo
- UOC Ematologia ed Oncologia Pediatrica con TMO - AOU Policlinico “Rodolico-San Marco,” Università di Catania, Catania, Italy
| | - Paola Giordano
- Department of Biomedical Sciences and Human Oncology, University of Bari “Aldo Moro,” Bari, Italy
| | - Francesca Romano
- SC Pediatria Specialistica Universitaria, AOU Città della Salute e della Scienza, Presidio Ospedale Infantile Regina Margherita, Torin, Italy
| | - Elisa Bertoni
- U.O. Oncoematologia Pediatrica, Presidio Ospedale dei Bambini, Spedali Civili, Brescia, Italy
| | - Chiara Gorio
- U.O. Oncoematologia Pediatrica, Presidio Ospedale dei Bambini, Spedali Civili, Brescia, Italy
| | | | - Milena Motta
- UOC Ematologia ed Oncologia Pediatrica con TMO - AOU Policlinico “Rodolico-San Marco,” Università di Catania, Catania, Italy
| | - Marco Spinelli
- Fondazione MBBM/AO San Gerardo Clinica Pediatrica Universitaria, Monza, Italy
| | | | - Marco Zecca
- SC Oncoematologia Pediatrica - Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | - Francesca Compagno
- SC Oncoematologia Pediatrica - Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | - Saverio Ladogana
- UOC Oncoematologia Pediatrica - IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Angela Maggio
- UOC Oncoematologia Pediatrica - IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Maurizio Miano
- Dipartimento di Scienze Pediatriche Generali e Specialistiche, U.O.C. Oncologia IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gianluca Dell'Orso
- Dipartimento di Scienze Pediatriche Generali e Specialistiche, U.O.C. Oncologia IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Elena Chiocca
- Oncologia, Ematologia e TCSE - Centro di Eccellenza di Oncologia ed Ematologia - AOU A. Mayer, Firenze, Italy
| | - Ilaria Fotzi
- Oncologia, Ematologia e TCSE - Centro di Eccellenza di Oncologia ed Ematologia - AOU A. Mayer, Firenze, Italy
| | | | | | - Irene D'Alba
- S.O.S.D., Oncomematologia Pediatrica, A.O.U. Azienda Ospedali Riuniti, Ospedale Pediatrico Salesi, Ancona, Italy
| | - Silvia Salvatore
- Dipartimento di Pediatria, Università degli Studi dell’Insubria, Varese, Italy
| | - Maddalena Casale
- U.O. S.D. Ematologia e Oncologia Pediatrica Dai Materno Infantile - Università degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Giuseppe Puccio
- U.O.C. Oncoematologia Pediatrica, ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
| | - Ugo Ramenghi
- SC Pediatria Specialistica Universitaria, AOU Città della Salute e della Scienza, Presidio Ospedale Infantile Regina Margherita, Torin, Italy
| | - Piero Farruggia
- U.O.C. Oncoematologia Pediatrica, ARNAS Civico, Di Cristina, Benfratelli, Palermo, Italy
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20
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Harris EM, Hillier K, Al‐Samkari H, Berbert L, Grace RF. Response to rituximab in children and adults with immune thrombocytopenia (ITP). Res Pract Thromb Haemost 2021; 5:e12587. [PMID: 34466770 PMCID: PMC8385184 DOI: 10.1002/rth2.12587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/02/2021] [Accepted: 08/02/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Rituximab is a monoclonal anti-CD20 antibody used as a second-line treatment for immune thrombocytopenia (ITP). As additional treatments for ITP emerge, identifying the most appropriate patients and optimal timing for rituximab are important but challenging without established predictors of response to therapy. OBJECTIVES The purpose of this study was to describe demographic, clinical, and laboratory characteristics of pediatric and adult patients with ITP to identify differences in evaluation before rituximab administration and correlates of platelet response. METHODS This is a retrospective cohort study describing the characteristics of patients with ITP treated with rituximab from 2010 to 2020 at two academic tertiary care centers. RESULTS A total of 64 patients met criteria for inclusion. Complete rituximab response (56%) was not significantly different between children (58%, n = 24) and adults (55%, n = 40). Response rate was similar in those with primary versus secondary ITP (53% vs 62%). Among patients treated with rituximab, Evans Syndrome was more common in children than adults (42% vs 18%). Immunologic labs assessed before rituximab varied by age and were more commonly evaluated in children (lymphocyte subsets 88% vs 22%). Immunologic markers, including antinuclear antibody, direct antiglobulin testing, immunoglobulin levels, and lymphocyte subsets, did not predict response to rituximab in pediatric or adult patients with ITP. CONCLUSIONS Pre-rituximab immunologic evaluation varied significantly between adults and children, which could represent institution-specific practice patterns or a more general practice difference. If the latter, underlying immunodeficiency in adults with ITP may be underrecognized. Standardized guidance for pre-rituximab immunologic evaluation is needed.
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Affiliation(s)
- Emily M. Harris
- Department of PediatricsBoston Children's HospitalBoston Combined Residency ProgramBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Kirsty Hillier
- Harvard Medical SchoolBostonMAUSA
- Dana‐Farber/Boston Children’s Cancer and Blood Disorders CenterBoston Children's HospitalBostonMAUSA
| | - Hanny Al‐Samkari
- Harvard Medical SchoolBostonMAUSA
- Division of HematologyMassachusetts General HospitalBostonMAUSA
| | - Laura Berbert
- Clinical Research CenterBoston Children's HospitalBostonMAUSA
| | - Rachael F. Grace
- Harvard Medical SchoolBostonMAUSA
- Dana‐Farber/Boston Children’s Cancer and Blood Disorders CenterBoston Children's HospitalBostonMAUSA
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21
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Shah RM, Trehan A. ASH 2019 guidelines for immune thrombocytopenia: “Old wine in a new bottle with added spices”. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2021. [DOI: 10.1016/j.phoj.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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22
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Bussel JB, Soff G, Balduzzi A, Cooper N, Lawrence T, Semple JW. A Review of Romiplostim Mechanism of Action and Clinical Applicability. Drug Des Devel Ther 2021; 15:2243-2268. [PMID: 34079225 PMCID: PMC8165097 DOI: 10.2147/dddt.s299591] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Thrombocytopenia results from a variety of conditions, including radiation, chemotherapy, autoimmune disease, bone marrow disorders, pathologic conditions associated with surgical procedures, hematopoietic stem cell transplant (HSCT), and hematologic disorders associated with severe aplastic anemia. Immune thrombocytopenia (ITP) is caused by immune reactions that accelerate destruction and reduce production of platelets. Thrombopoietin (TPO) is a critical component of platelet production pathways, and TPO receptor agonists (TPO-RAs) are important for the management of ITP by increasing platelet production and reducing the need for other treatments. Romiplostim is a TPO-RA approved for use in patients with ITP in the United States, European Union, Australia, and several countries in Africa and Asia, as well as for use in patients with refractory aplastic anemia in Japan and Korea. Romiplostim binds to and activates the TPO receptor on megakaryocyte precursors, thus promoting cell proliferation and viability, resulting in increased platelet production. Through this mechanism, romiplostim reduces the need for other treatments and decreases bleeding events in patients with thrombocytopenia. In addition to its efficacy in ITP, studies have shown that romiplostim is effective in improving platelet counts in various settings, thereby highlighting the versatility of romiplostim. The efficacy of romiplostim in such disorders is currently under investigation. Here, we review the structure, mechanism, pharmacokinetics, and pharmacodynamics of romiplostim. We also summarize the clinical evidence supporting its use in ITP and other disorders that involve thrombocytopenia, including chemotherapy-induced thrombocytopenia, aplastic anemia, acute radiation syndrome, perisurgical thrombocytopenia, post-HSCT thrombocytopenia, and liver disease.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Gerald Soff
- Department of Medicine, Hematology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | | | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
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23
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Chen M, Fang JP, Zhou CX, Li XY, Lin SF, Xu LH. Efficacy and safety of eltrombopag in the treatment of Chinese children with chronic immune thrombocytopenia. ACTA ACUST UNITED AC 2021; 26:31-36. [PMID: 33357172 DOI: 10.1080/16078454.2020.1856511] [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: 10/22/2022]
Abstract
OBJECTIVES Our aim is to evaluate initial efficacy, safety, and durable response of eltrombopag in the treatment of Chinese children with chronic immune thrombocytopenia (cITP). METHODS This was a retrospective, single-center cohort study including 30 pediatric patients with cITP administered eltrombopag between 1 July 2017 and 1 January 2019. Patients with at least 12 weeks of eltrombopag treatment and available follow-up data were included. Initial response rate, durable response rate, bleeding events, and adverse events were assessed during the follow-up period. RESULTS The median duration of eltrombopag administration was 6 months (range 3-8 months). The initial response rate was 73.3%. Patients with megakaryocyte count ≥100/slide or Treg <4.5% were more likely to achieve initial response. The median follow-up period was 10 months (range 6-20 months). A total of 53.2% of pediatric patients had a durable response of up to 20 months. Patients with megakaryocyte count ≥100/slide and Treg<4.5% had more than 60% durable response rates compared with individuals with megakaryocyte count<100/slide and Treg≥4.5%, respectively. No serious bleeding events or serious adverse events occurred during the study period. CONCLUSION Eltrombopag not only shows excellent initial response but also has continued efficacy and safety. Patients with megakaryocyte count ≥100/slide and Treg<4.5% achieve increased initial response and more frequent durable response.
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Affiliation(s)
- Mo Chen
- Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Pediatrics, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, People's Republic of China
| | - Jian-Pei Fang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Chuan-Xin Zhou
- Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Pediatrics, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, People's Republic of China
| | - Xin-Yu Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Shao-Fen Lin
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Lu-Hong Xu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
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24
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Elalfy MS, Eltonbary KYEM, El Ghamry IR, Elalfy O, Wahid M, Badr M, Hassan T, Mansour A, Meabed M, El-Hawy M, Youssry I, Abd Elhady M, Elshanshory M, Elsayh K, Hassab HM. Intracranial hemorrhage in primary immune thrombocytopenia (ITP): 20 years' experience in pediatrics. Eur J Pediatr 2021; 180:1545-1552. [PMID: 33452569 DOI: 10.1007/s00431-020-03923-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/25/2020] [Accepted: 12/28/2020] [Indexed: 11/25/2022]
Abstract
Incidence of intracranial hemorrhage (ICH) among children with primary immune thrombocytopenia (ITP) varies among different studies. We published data during the period of 1997-2007 of ICH in children with primary ITP, addressing risk factors and outcome. The aim of this study is to assess changes in incidence, risk factors, and outcome of ICH in children with ITP from last decade and to report the overall 20 years' experience. We compared 2008-2018 with the decade before it. Data of children with ITP and ICH during study period and ITP control cases were analyzed. Neurosurgical intervention and outcome were also reported. A total of 4340 children with primary ITP were evaluated. Twenty-five (0.63%) ICH events were reported over 2 decades. Head trauma, hematuria, and platelet counts < 10 × 109/L were the risk factors mostly associated with ICH. Overall mortality was 24%, and a further 28% had neurologic sequelae. Neurosurgical intervention was done in 12% of cases with good outcome.Conclusion: Persistent platelet counts < 10 × 109/L were a significant risk factor for ICH in both time periods, while head trauma and hematuria were more reported in the period of 2008-2018 as significant risk factors for ICH. Outcome was comparable in both periods. What is Known: • ICH is a rare complication of ITP; however, early recognition of risk factors and aggressive treatment might lead to complete recovery without sequalae. Platelet counts less than < 10 × 109/L are the main risk factor for ICH. Few studies reported other significant risk factors. What is New: • Hematuria and head trauma are significant risk factors for ICH in ITP, in addition to having a persistently low platelet count < 10 × 109/L. (more than 90 days in chronic ITP, 45 days in persistent and 21 days in acute ITP) • Combined treatment with IVIG and HDMP followed by platelet transfusion was associated with complete recovery without sequelae in almost 50% of patients.
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Affiliation(s)
- Mohsen Saleh Elalfy
- Department of Pediatric Hematology/Oncology, Ain Shams University, Cairo, Egypt
| | | | - Islam R El Ghamry
- Department of Pediatric Hematology/Oncology, Ain Shams University, Cairo, Egypt
| | - Omar Elalfy
- Department of Complementary Medicine, National Research Center, Cairo, Egypt
| | - Marwa Wahid
- Department of Pediatric Hematology/Oncology, Ain Shams University, Cairo, Egypt
| | - Mohamed Badr
- Department of Pediatric Hematology/Oncology, Zagazig University, Zagazig, Egypt
| | - Tamer Hassan
- Department of Pediatric Hematology/Oncology, Zagazig University, Zagazig, Egypt
| | - Ahmed Mansour
- Department of Pediatric Hematology/Oncology, Mansoura University, Mansoura, Egypt
| | - Mohamed Meabed
- Department of Pediatric Hematology/Oncology, Beni Suef University, Beni Suef, Egypt
| | - Mahmoud El-Hawy
- Department of Pediatric Hematology/Oncology, Menoufia University, Shibin Al Kawm, Menoufia, Egypt
| | - Ilham Youssry
- Department of Pediatric Hematology/Oncology, Cairo University, Cairo, Egypt
| | - Marwa Abd Elhady
- Department of Pediatric Hematology/Oncology, Cairo University, Cairo, Egypt
| | | | - Khalid Elsayh
- Department of Pediatric Hematology/Oncology, Assiut University, Assiut, Egypt
| | - Hoda M Hassab
- Department of Pediatric Hematology/Oncology, Alexandria University, Alexandria, Egypt
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25
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Immune thrombocytopenia: A review of upfront treatment strategies. Blood Rev 2021; 49:100822. [PMID: 33736875 DOI: 10.1016/j.blre.2021.100822] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/06/2021] [Accepted: 02/24/2021] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP), resulting from antibody-mediated platelet destruction combined with impaired platelet production, is a rare cause of thrombocytopenia in both children and adults. The decision to treat newly diagnosed patients is based on several factors, including the desire to increase platelet count to prevent bleeding, induce remission, and improve health-related quality of life (HRQoL). At present, standard first-line therapy is corticosteroids. While this treatment does increase the platelet count in many patients, a high percentage still relapse after discontinuation of therapy. For this reason, alteration or intensification of first-line therapy that results in superior long-term remission rates is desirable. The objective of this review is to outline different upfront strategies for newly diagnosed patients with ITP in an effort to potentially enhance remission rates and prevent relapse, taking into account an assessment of the risks and benefits of each approach. We primarily focus on adults with ITP, highlighting pediatric data and practice when applicable.
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26
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Gruhn B, Ehrnsperger A, Willy C, Fröhlich B. Successful Use of Eltrombopag in a Young Child With Chronic Immune Thrombocytopenia. Cureus 2021; 13:e12723. [PMID: 33614326 PMCID: PMC7883557 DOI: 10.7759/cureus.12723] [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: 11/23/2022] Open
Abstract
The disease course in a young girl with chronic immune thrombocytopenia (ITP) at the initial age of 19 months, treated with eltrombopag, was evaluated retrospectively and is presented as a case record and discussed against the background of the available literature. A stable response and reduction in clinical symptoms, over several years and without frequent dose changes, was achieved. Bleeding symptoms were mild to moderate and occurred particularly frequently in combination with low platelet counts. Raising the platelet count, in turn, was accompanied by a decreased bleeding tendency. Eltrombopag was tolerated well. No new safety signals were observed during the treatment. Based on a follow-up of more than 2.5 years, our case confirms that a child with chronic ITP can benefit from treatment with eltrombopag in the regular care setting. We assume that early treatment with a thrombopoietin receptor agonist could save many children from repeated and lengthy hospitalizations with intravenous immunoglobulins and prolonged administration of corticosteroids.
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Affiliation(s)
- Bernd Gruhn
- Department of Pediatrics, Jena University Hospital, Jena, DEU
| | - Achim Ehrnsperger
- Translational Clinical Oncology & Mature Products, Novartis Pharma GmbH, Nürnberg, DEU
| | - Claudia Willy
- Translational Clinical Oncology & Mature Products, Novartis Pharma GmbH, Nürnberg, DEU
| | - Birgit Fröhlich
- Department of Pediatrics, Münster University Hospital, Münster, DEU
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27
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American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv 2020; 3:3829-3866. [PMID: 31794604 DOI: 10.1182/bloodadvances.2019000966] [Citation(s) in RCA: 617] [Impact Index Per Article: 154.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/21/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Despite an increase in the number of therapies available to treat patients with immune thrombocytopenia (ITP), there are minimal data from randomized trials to assist physicians with the management of patients. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the management of ITP. METHODS In 2015, ASH formed a multidisciplinary guideline panel that included 8 adult clinical experts, 5 pediatric clinical experts, 2 methodologists with expertise in ITP, and 2 patient representatives. The panel was balanced to minimize potential bias from conflicts of interest. The panel reviewed the ASH 2011 guideline recommendations and prioritized questions. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence (up to May 2017) and formulate recommendations. RESULTS The panel agreed on 21 recommendations covering management of ITP in adults and children with newly diagnosed, persistent, and chronic disease refractory to first-line therapy who have non-life-threatening bleeding. Management approaches included: observation, corticosteroids, IV immunoglobulin, anti-D immunoglobulin, rituximab, splenectomy, and thrombopoietin receptor agonists. CONCLUSIONS There was a lack of evidence to support strong recommendations for various management approaches. In general, strategies that avoided medication side effects were favored. A large focus was placed on shared decision-making, especially with regard to second-line therapy. Future research should apply standard corticosteroid-dosing regimens, report patient-reported outcomes, and include cost-analysis evaluations.
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28
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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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29
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Why do patients with immune thrombocytopenia (ITP) experience lower bleeding events despite thrombocytopenia? Thromb Res 2020; 187:154-158. [PMID: 32004875 DOI: 10.1016/j.thromres.2020.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/08/2020] [Accepted: 01/14/2020] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia is an autoimmune condition characterized by an isolated thrombocytopenia. Despite the low platelet levels, severe bleeding episodes are relatively rare suggesting that patients with ITP may have a protective factor against bleeding. Platelet microparticles (PMP) are thought to play a role in clot formation and some studies have demonstrated higher levels of circulating PMP in patients with ITP. This article provides a review of the epidemiology, mechanism, clinical presentation, management, and prognosis of ITP as well as a review of the literature and discussion regarding PMP and bleeding risk in ITP patients.
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30
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Gilbert MM, Grimes AB, Kim TO, Despotovic JM. Romiplostim for the Treatment of Immune Thrombocytopenia: Spotlight on Patient Acceptability and Ease of Use. Patient Prefer Adherence 2020; 14:1237-1250. [PMID: 32801654 PMCID: PMC7383044 DOI: 10.2147/ppa.s192481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/28/2020] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an immune-mediated disorder resulting in platelet destruction and subsequent thrombocytopenia. Bleeding symptoms range from mild cutaneous bleeding to life-threatening hemorrhage. Romiplostim, a peptide-antibody fusion product, is a thrombopoietin receptor agonist (TPO-RA) indicated for use in patients with ITP. Romiplostim is US Food and Drug Administration (FDA) approved in children ≥1 year of age with ITP of >6 months' duration who have had an inadequate response to first-line therapies or splenectomy. FDA approval in adults with chronic ITP was expanded in October 2019 to include adults with newly diagnosed (<3 months' duration) and persistent (3-12 months' duration) ITP who demonstrated an inadequate response to first-line therapies, including corticosteroids and immunoglobulins, or splenectomy. The newly published 2019 American Society of Hematology ITP Guidelines place TPO-RAs, including romiplostim, as second-line therapies in both children and adults. Here, we review the use of romiplostim as second-line therapy with a spotlight on health-related quality of life, ease of use, and patient preference.
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Affiliation(s)
- Megan M Gilbert
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
- Correspondence: Megan M Gilbert Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Suite 1510, Houston, TX77030, USATel +1 (832) 824-4736Fax +1 (832) 825-4846 Email
| | - Amanda B Grimes
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Taylor Olmsted Kim
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Jenny M Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
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31
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Grace RF, Shimano KA, Bhat R, Neunert C, Bussel JB, Klaassen RJ, Lambert MP, Rothman JA, Breakey VR, Hege K, Bennett CM, Rose MJ, Haley KM, Buchanan GR, Geddis A, Lorenzana A, Jeng M, Pastore YD, Crary SE, Neier M, Neufeld EJ, Neu N, Forbes PW, Despotovic JM. Second-line treatments in children with immune thrombocytopenia: Effect on platelet count and patient-centered outcomes. Am J Hematol 2019; 94:741-750. [PMID: 30945320 DOI: 10.1002/ajh.25479] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 04/01/2019] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder with isolated thrombocytopenia and hemorrhagic risk. While many children with ITP can be safely observed, treatments are often needed for various reasons, including to decrease bleeding, or to improve health related quality of life (HRQoL). There are a number of available second-line treatments, including rituximab, thrombopoietin-receptor agonists, oral immunosuppressive agents, and splenectomy, but data comparing treatment outcomes are lacking. ICON1 is a prospective, multi-center, observational study of 120 children starting second-line treatments for ITP designed to compare treatment outcomes including platelet count, bleeding, and HRQoL utilizing the Kids ITP Tool (KIT). While all treatments resulted in increased platelet counts, romiplostim had the most pronounced effect at 6 months (P = .04). Only patients on romiplostim and rituximab had a significant reduction in both skin-related (84% to 48%, P = .01 and 81% to 43%, P = .004) and non-skin-related bleeding symptoms (58% to 14%, P = .0001 and 54% to 17%, P = .0006) after 1 month of treatment. HRQoL significantly improved on all treatments. However, only patients treated with eltrombopag had a median improvement in KIT scores at 1 month that met the minimal important difference (MID). Bleeding, platelet count, and HRQoL improved in each treatment group, but the extent and timing of the effect varied among treatments. These results are hypothesis generating and help to improve our understanding of the effect of each treatment on specific patient outcomes. Combined with future randomized trials, these findings will help clinicians select the optimal second-line treatment for an individual child with ITP.
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Affiliation(s)
- Rachael F. Grace
- Division of Hematology/OncologyDana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston Massachusetts
| | - Kristin A. Shimano
- Division of Pediatric Allergy, Immunology, and Bone Marrow TransplantationUCSF Benioff Children's Hospital San Francisco California
| | - Rukhmi Bhat
- Center for Cancer & Blood Disorders, Ann and Robert H. Lurie Childrens Hospital of ChicagoFeinberg School of Medicine, Northwestern University Chicago Illinois
| | - Cindy Neunert
- Division of Hematology, Oncology, and Stem Cell TransplantColumbia University Medical School New York New York
| | - James B. Bussel
- Department of PediatricsWeill Cornell Medicine New York New York
| | - Robert J. Klaassen
- Division of Hematology/OncologyChildren's Hospital of Eastern Ontario Ottawa Ontario Canada
| | - Michele P. Lambert
- Division of HematologyThe Children's Hospital of Philadelphia Philadelphia Pennsylvania
| | - Jennifer A. Rothman
- Division of Pediatric Hematology/OncologyDuke University Medical Center Durham North Carolina
| | - Vicky R. Breakey
- Division of Pediatric Hematology/OncologyMcMaster University Hamilton Ontario Canada
| | - Kerry Hege
- Division of Pediatric Hematology/Oncology, Riley Hospital at IU HealthIndiana University School of Medicine Indianapolis Indiana
| | - Carolyn M. Bennett
- Division of Hematology/Oncology, Aflac Cancer and Blood Disorders CenterEmory University School of Medicine, Children's Healthcare of Atlanta Atlanta Georgia
| | - Melissa J. Rose
- Division of Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's HospitalThe Ohio State University College of Medicine Columbus Ohio
| | - Kristina M. Haley
- Division of Pediatric HematologyOregon Health & Science University Portland Oregon
| | - George R. Buchanan
- Division of Hematology‐OncologyUniversity of Texas Southwestern Medical Center Dallas Texas
| | - Amy Geddis
- Division of Pediatric Hematology/OncologyUniversity of Washington, Seattle Children's Hospital Seattle Washington
| | - Adonis Lorenzana
- Division of Pediatric Hematology/OncologySt. John Ascension Hospital Detroit Michigan
| | - Michael Jeng
- Department of PediatricsStanford School of Medicine Palo Alto California
| | - Yves D. Pastore
- Division of Hematology/OncologyCHU Sainte‐Justine Montreal Québec Canada
| | - Shelley E. Crary
- Department of PediatricsUniversity of Arkansas for Medical Sciences Little Rock Arkansas
| | - Michelle Neier
- Division of Pediatric Hematology/OncologyGoryeb Children's Hospital Morristown New Jersey
| | - Ellis J. Neufeld
- Division of HematologySt. Jude Children's Research Hospital Memphis Tennessee
| | - Nolan Neu
- Division of Hematology/OncologyDana‐Farber/Boston Children's Cancer and Blood Disorder Center Boston Massachusetts
| | - Peter W. Forbes
- Clinical Research CenterBoston Children's Hospital Boston Massachusetts
| | - Jenny M. Despotovic
- Department of PediatricsHematology/Oncology Section, Baylor College of Medicine Houston Texas
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32
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Tarantino MD, Bussel JB, Blanchette VS, Beam D, Roy J, Despotovic J, Raj A, Carpenter N, Mehta B, Eisen M. Long-term treatment with romiplostim and treatment-free platelet responses in children with chronic immune thrombocytopenia. Haematologica 2019; 104:2283-2291. [PMID: 30846500 PMCID: PMC6821612 DOI: 10.3324/haematol.2018.202283] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 03/06/2019] [Indexed: 01/19/2023] Open
Abstract
Children with immune thrombocytopenia for ≥6 months completing a romiplostim study received weekly subcutaneous romiplostim (1-10 μg/kg targeting platelet counts of 50-200×109/L) in this extension to examine romiplostim’s long-term safety and efficacy. Sixty-five children received romiplostim for a median of 2.6 years (range: 0.1-7.0 years). Median baseline age was 11 years (range: 3-18 years) and platelet count was 28×109/L (range: 2-458×109/L). No patient discontinued treatment for an adverse event. Median average weekly dose was 4.8 mg/kg (range: 0.1-10 mg/kg); median platelet counts remained >50×109/L, starting at week 2. Nearly all patients (94%) had ≥1 platelet response (≥50×109/L, no rescue medication in the previous 4 weeks), 72% had responded at ≥75% of visits, and 58% had responded at ≥90% of visits. Treatment-free response (platelets ≥50×109/L ≥24 weeks without immune thrombocytopenia treatment) was seen in 15 of 65 patients while withholding romiplostim doses. At onset of treatment-free response, the nine girls and six boys had a median immune thrombocytopenia duration of four years (range: 1-12 years) and had received romiplostim for two years (range: 1-6 years). At last observation, treatment-free responses lasted for a median of one year (range: 0.4-2.1 years), with 14 of 15 patients still in treatment-free response. Younger age at first dose and platelet count >200×109/L in the first four weeks were associated with treatment-free responses. In this 7-year open-label extension, three-quarters of the patients responded ≥75% of the time, and romiplostim was well tolerated, with no substantial treatment-related adverse events. Importantly, 23% of children maintained treatment-free platelet responses while withholding romiplostim and all other immune thrombocytopenia medications for ≥6 months. (Registered at clinicaltrials.gov identifier: 01071954)
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Affiliation(s)
- Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, University of Illinois College of Medicine-Peoria, Peoria, IL, USA
| | - James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Victor S Blanchette
- Department of Pediatrics, University of Toronto, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Donald Beam
- Cook Children's Medical Center, Fort Worth, TX, USA
| | - John Roy
- Children's Health Queensland and Pathology Queensland, South Brisbane, Queensland, Australia and The University of Queensland, Saint Lucia, Queensland, Australia
| | | | - Ashok Raj
- Pediatric Cancer and Blood Disorders Clinic, Louisville, KY, USA
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33
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Despotovic JM, Grimes AB. Pediatric ITP: is it different from adult ITP? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:405-411. [PMID: 30504339 PMCID: PMC6246008 DOI: 10.1182/asheducation-2018.1.405] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Immune thrombocytopenia (ITP) has historically been thought to occur in 2 distinct forms: childhood ITP and adult ITP. This division is based largely on the presumption that childhood ITP is often benign and self-limited, whereas ITP in adults tends to be more chronic and difficult to treat. Although data exist to justify a different approach to the diagnosis and treatment in young children and the elderly, ITP in older children, adolescents, and younger adults is likely to share more similar pathology. This article will highlight the most recent data describing the natural history, diagnostic approach, management strategies, and disease-related outcomes in children and adults with ITP. These data reveal many unexpected similarities between the 2 groups, while confirming some of the more well-described differences. Discussion of these findings aims to highlight similarities and differences between ITP in children and adults, which will underscore important areas of future research and/or changes in management guidelines.
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Affiliation(s)
- Jenny M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, TX
| | - Amanda B Grimes
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, TX
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