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Rovó A, Gavillet M, Drexler B, Keller P, Schneider JS, Colucci G, Beauverd Y, van Dorland HA, Pollak M, Schmidt A, De Gottardi A, Bissig M, Lehmann T, Duchosal MA, Zeerleder S. Swiss Survey on current practices and opinions on clinical constellations triggering the search for PNH clones. Front Med (Lausanne) 2023; 10:1200431. [PMID: 37564039 PMCID: PMC10410560 DOI: 10.3389/fmed.2023.1200431] [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: 04/04/2023] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
This national survey investigated the current practice in Switzerland by collecting participants' opinions on paroxysmal nocturnal hemoglobinuria (PNH) clone assessment and clinical practice. Aim This study aimed to investigate clinical indications prompting PNH clones' assessment and physician's accessibility of a flow cytometry facility, and also to understand clinical attitudes on the follow-up (FU) of patients with PNH clones. Methods The survey includes 16 multiple-choice questions related to PNH and targets physicians with a definite level of experience in the topic using two screener questions. Opinion on clinical management was collected using hypothetical clinical situations. Each participant had the option of being contacted to further discuss the survey results. This was an online survey, and 264 physicians were contacted through email once a week for 5 weeks from September 2020. Results In total, 64 physicians (24.2%) from 23 institutions participated (81.3% hematologists and 67.2% from university hospitals). All had access to flow cytometry for PNH clone testing, with 76.6% having access within their own institution. The main reasons to assess for PNH clones were unexplained thrombosis and/or hemolysis, and/or aplastic anemia (AA). Patients in FU for PNH clones were more likely to be aplastic anemia (AA) and symptomatic PNH. In total, 61% of the participants investigated PNH clones repetitively during FU in AA/myelodysplastic syndromes patients, even when there was no PNH clone found at diagnosis, and 75% of the participants tested at least once a year during FU. Opinions related to clinical management were scattered. Conclusion The need to adhere to guidelines for the assessment, interpretation, and reporting of PNH clones emerges as the most important finding, as well as consensus for the management of less well-defined clinical situations. Even though there are several international guidelines, clear information addressing specific topics such as the type of anticoagulant to use and its duration, as well as the indication for treatment with complement inhibitors in some borderline situations are needed. The analysis and the discussion of this survey provide the basis for understanding the unmet needs of PNH clone assessment and clinical practice in Switzerland.
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Affiliation(s)
- Alicia Rovó
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Mathilde Gavillet
- Service and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Beatrice Drexler
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Jenny Sarah Schneider
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Yan Beauverd
- Division of Hematology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - Matthias Pollak
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Adrian Schmidt
- Department of Internal Medicine, Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zürich, Switzerland
| | - Andrea De Gottardi
- Servizio di Gastroenterología e Epatologia, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano, Switzerland
| | - Marina Bissig
- Department of Medical Oncology and Hematology, University Hospital of Zürich, Zürich, Switzerland
| | - Thomas Lehmann
- Kantonsspital St. Gallen, Clinic for Medical Oncology and Hematology, St. Gallen, Switzerland
| | - Michel A. Duchosal
- Service and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Sacha Zeerleder
- Department of Hematology, Kantonsspital Luzern, Lucerne and University of Bern, Bern, Switzerland
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Fattizzo B, Serpenti F, Giannotta JA, Barcellini W. Difficult Cases of Paroxysmal Nocturnal Hemoglobinuria: Diagnosis and Therapeutic Novelties. J Clin Med 2021; 10:jcm10050948. [PMID: 33804461 PMCID: PMC7957780 DOI: 10.3390/jcm10050948] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/14/2021] [Accepted: 02/20/2021] [Indexed: 11/16/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an intriguing disease that can pose many difficulties to physicians, as well as to hematologists, who are unfamiliar with it. Research regarding its pathophysiologic, diagnostic, and therapeutic aspects is still ongoing. In the last ten years, new flow cytometry techniques with high sensitivity enabled us to detect PNH clones as small as <1% of a patient's hematopoiesis, resulting in increasing incidence but more difficult data interpretation. Particularly, the clinical significance of small PNH clones in patients with bone marrow failures, including aplastic anemia and myelodysplastic syndromes, as well as in uncommon associations, such as myeloproliferative disorders, is still largely unknown. Besides current treatment with the anti-C5 eculizumab, which reduced PNH-related morbidity and mortality, new complement inhibitors will likely fulfill unmet clinical needs in terms of patients' quality of life and better response rates (i.e., responses in subjects with C5 polymorphisms; reduction of extravascular hemolysis and breakthrough hemolysis episodes). Still, unanswered questions remain for these agents regarding their use in mono- or combination therapy, when to treat, and which drug is the best for which patient. Lastly, long-term safety needs to be assessed in real-life studies. In this review, we describe some clinical vignettes illustrating practical aspects of PNH diagnosis and management; moreover, we discuss recent advances in PNH diagnostic and therapeutic approaches.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy; (F.S.); (J.A.G.); (W.B.)
- Department of Oncology and Oncohematology, University of Milan, 20122 Milan, Italy
- Correspondence: ; Tel.: +39-025-5033-345
| | - Fabio Serpenti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy; (F.S.); (J.A.G.); (W.B.)
| | - Juri Alessandro Giannotta
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy; (F.S.); (J.A.G.); (W.B.)
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy; (F.S.); (J.A.G.); (W.B.)
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Skeith L. Anticoagulating patients with high-risk acquired thrombophilias. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:439-449. [PMID: 30504344 PMCID: PMC6246016 DOI: 10.1182/asheducation-2018.1.439] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Antiphospholipid syndrome (APS), heparin-induced thrombocytopenia, and paroxysmal nocturnal hemoglobinuria are 3 acquired thrombophilias that carry a high risk of venous and arterial thromboembolism. Management of these conditions has largely included anticoagulation with a vitamin K antagonist after an initial period of a parenteral anticoagulant, for as long as the thrombotic risk is still present. The available evidence for the use of direct oral anticoagulants (DOACs) is limited and primarily consists of case series and cohort studies, which are summarized in this chapter. Randomized trials evaluating DOACs in patients with APS are reviewed. Further research is needed prior to widely adopting DOACs for use in these high-risk acquired thrombophilias; however, there may be selected low-risk subgroups where DOAC use is possible after careful consideration and patient discussion.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada; and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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Anticoagulating patients with high-risk acquired thrombophilias. Blood 2018; 132:2219-2229. [DOI: 10.1182/blood-2018-05-848697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 08/07/2018] [Indexed: 01/19/2023] Open
Abstract
Abstract
Antiphospholipid syndrome (APS), heparin-induced thrombocytopenia, and paroxysmal nocturnal hemoglobinuria are 3 acquired thrombophilias that carry a high risk of venous and arterial thromboembolism. Management of these conditions has largely included anticoagulation with a vitamin K antagonist after an initial period of a parenteral anticoagulant, for as long as the thrombotic risk is still present. The available evidence for the use of direct oral anticoagulants (DOACs) is limited and primarily consists of case series and cohort studies, which are summarized in this chapter. Randomized trials evaluating DOACs in patients with APS are reviewed. Further research is needed prior to widely adopting DOACs for use in these high-risk acquired thrombophilias; however, there may be selected low-risk subgroups where DOAC use is possible after careful consideration and patient discussion.
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