1
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Shah S, Yadav R, Bhattarai A, Dahal K, Tharu S, Gautam S, Rawal L, Thapa S, Sah SK, Sharma S, Gundabolu K. Safety and efficacy of danazol in immune thrombocytopenia: a systematic review. Res Pract Thromb Haemost 2024; 8:102444. [PMID: 38988949 PMCID: PMC11234045 DOI: 10.1016/j.rpth.2024.102444] [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: 04/04/2024] [Accepted: 05/13/2024] [Indexed: 07/12/2024] Open
Abstract
Background The treatment landscape for relapsed or refractory immune thrombocytopenia (ITP) after corticosteroids is complex. Objectives We aimed to assess the efficacy of danazol in treating ITP and evaluate the safety and adverse events following its administration. Methods We searched the databases PubMed, EMBASE, and ClinicalTrials.gov for all published studies assessing danazol's efficacy and safety in treating ITP. The retrieved studies were screened by title and abstract, followed by full-text screening based on the eligibility requirements. The quality assessment was performed using a set of questionnaires. The data were extracted on the descriptive characteristics of the studies and participants, drug dosage, efficacy measures, and adverse effects, and the data were synthesized. Results A total of 17 studies consisting of 901 participants were included. The overall response rate is around 61% in this analysis. Among the participants, 315 (34.9%) were men. The age of participants ranged from 16 to 86 years. Danazol combined with other pharmacologic interventions, including all-trans-retinoic acid or glucocorticoids, generated better results. The most common side effects appear to be liver injury and elevation of liver enzymes, weight gain, oligomenorrhea, amenorrhea, and myalgia. Conclusion Danazol at low-to-medium doses was well tolerated and succeeded in improving ITP. Danazol therapy may be helpful in the treatment of chronic ITP that is corticosteroid refractory and when corticosteroids or splenectomy (or both) is contraindicated. Danazol can be considered for further research and development in treating primary immune thrombocytopenia.
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Affiliation(s)
- Sangam Shah
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Rukesh Yadav
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | | | - Krishna Dahal
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Sunraj Tharu
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Sandesh Gautam
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Laba Rawal
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Sangharsha Thapa
- Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | | | - Sumit Sharma
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Krishna Gundabolu
- Fred and Pamela Buffett Cancer Center, Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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2
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Crickx E, Mahévas M, Michel M, Godeau B. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging 2023; 18:115-130. [PMID: 36726813 PMCID: PMC9885884 DOI: 10.2147/cia.s369574] [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: 10/26/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
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Affiliation(s)
- Etienne Crickx
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris, Université Paris-Est-Créteil, Paris, France,INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Correspondence: Bertrand Godeau, Service de Médecine Interne, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), 51 avenue du maréchal de Lattre de Tassigny, Créteil, 94000, France, Tel +331 49 81 29 05, Fax +331 49 81 29 02, Email
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3
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Harsini S, Rezaei N. Autoimmune diseases. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00001-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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4
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Huang HE, Lin KM, Lin JC, Lin YT, He HR, Wang YW, Yu SF, Chen JF, Cheng TT. Danazol in Refractory Autoimmune Hemolytic Anemia or Immune Thrombocytopenia: A Case Series Report and Literature Review. Pharmaceuticals (Basel) 2022; 15:1377. [PMID: 36355549 PMCID: PMC9692819 DOI: 10.3390/ph15111377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 09/16/2023] Open
Abstract
Danazol is a treatment option for autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP). Three patients with AIHA and eight patients with ITP between 2008 and 2022 were enrolled in the Rheumatology Outpatient Clinic of Chang Gung Memorial Hospital, Kaohsiung. Those patients were refractory or intolerant to conventional therapy and were treated with danazol. All the patients received an initial dose of danazol (200-400 mg). The observation period was 6 months. Three patients (100%) with AIHA and six (75%) with ITP achieved treatment response after 6 months of danazol therapy. The dose of glucocorticoid for responders could be reduced to ≤5 mg/day of prednisolone, and the immunosuppressants, except hydroxychloroquine and azathioprine for systemic lupus erythematosus, could be discontinued. Adverse events were acne in two (18.2%) patients and transient dose-related liver function impairment in one (9.1%) patient in the current series. Danazol therapy appears to be a favorable alternative for refractory AIHA and ITP by altering the erythrocyte membrane to resist osmotic lysis and protecting platelets against complement-mediated lysis. In this report, we also performed a literature review and searched the PubMed/Cochrane Library for articles published from 1984 to January 2022 on danazol therapy for patients with AIHA and ITP.
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Affiliation(s)
- Hsu-En Huang
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Ko-Ming Lin
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Jing-Chi Lin
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
| | - Yu-Ting Lin
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Hsiao-Ru He
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Yu-Wei Wang
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Jia-Feng Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
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5
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Song F, Al-Samkari H. Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice. J Blood Med 2021; 12:653-664. [PMID: 34345191 PMCID: PMC8323851 DOI: 10.2147/jbm.s259101] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune process resulting in increased destruction and inadequate production of platelets that can result in bleeding, fatigue, and reduced health-related quality of life. While treatment is not required for many patients with ITP, the occurrence of bleeding manifestations, severe thrombocytopenia, and requirement for invasive procedures are among the reasons necessitating initiation of therapy. Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are typical first-line and rescue treatments, but these agents typically do not result in a durable remission in adult patients. Most patients requiring treatment therefore require subsequent line therapies, such as thrombopoietin receptor agonists (TPO-RAs), rituximab, fostamatinib, splenectomy, or a number of other immunosuppressive agents. In this focused review, we discuss management of adult ITP in the acute and chronic settings.
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Affiliation(s)
- Fei Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA.,Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
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6
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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: 655] [Impact Index Per Article: 163.8] [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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7
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Abstract
PURPOSE OF REVIEW Medical therapies for the treatment of immune thrombocytopenia (ITP) complicating SLE are increasingly being investigated as alternatives to splenectomy and IVIG. The purpose of this review is to highlight the therapies that are utilized in the treatment of primary ITP and ITP secondary to lupus. RECENT FINDINGS Corticosteroids are still the standard initial treatment of ITP, with the addition of IVIG when a rapid response is needed. There are few studies dedicated to assessing the efficacy of disease-modifying antirheumatic (DMARD), biologic, and nonimmunosuppressive agents as treatment for lupus thrombocytopenia/lupus ITP. Rituximab and thrombopoeitin mimetics have been the most extensively studied therapies for primary ITP in recent years. Results of trials show adequate initial responses; however, the duration of therapy and sustainability of responses are variable. Splenectomy is less often utilized. SUMMARY Although corticosteroids, intravenous immunoglobulin and splenectomy have proven to be effective measures to treat immune thrombocytopenia, newer studies have demonstrated positive outcomes of immunosuppressives and thrombopoeitin mimetics. In most cases, the reported duration of therapy was not prolonged. More studies are needed to fully assess the effect of medical therapy in lupus ITP and to determine how long to continue maintenance therapy.
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8
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Deshayes S, Godeau B. Second-line and beyond: treatment options for primary persistent and chronic immune thrombocytopenia. Platelets 2019; 31:291-299. [DOI: 10.1080/09537104.2019.1636018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Samuel Deshayes
- Service de Médecine Interne, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
- Service de Médecine Interne, Centre de Référence des Cytopénies Auto-Immunes de l’Adulte, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre de Référence des Cytopénies Auto-Immunes de l’Adulte, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
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9
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Aleem A, Al-Zahrani H, Mohareb F, Ahmed S, Al-Suliman A, Al Saeed H, Al-Ghamdi M, Al-Hashmi H. Management of adult immune thrombocytopenia: Recommendations by an expert Saudi panel. JOURNAL OF APPLIED HEMATOLOGY 2019. [DOI: 10.4103/joah.joah_51_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Lucchini E, Fanin R, Cooper N, Zaja F. Management of immune thrombocytopenia in elderly patients. Eur J Intern Med 2018; 58:70-76. [PMID: 30274902 DOI: 10.1016/j.ejim.2018.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/08/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Abstract
Despite the improvement in understanding its pathogenesis and the introduction of novel treatment options, the management of primary immune thrombocytopenia (ITP) still remains challenging. Considering its increased incidence with aging and prolonged life-expectancy, ITP is often diagnosed in elderly patients, a subset that deserves some special precautions. Ensure the diagnosis is a crucial step, and carefully attention must be given in excluding other causes of thrombocytopenia, especially among older people that frequently suffer from many comorbidities. When it comes to treatment decision, it is worth keeping into account that the elderly have an increased risk of bleeding, thrombosis and infections, that they often require many concomitant therapies, including antiplatelet or anticoagulant agents, and that treatment-related toxicities are often increased and sometimes more dangerous that the disease itself. There are not dedicated guidelines, and only few specific studies. Steroids with or without IVIG remain the first-line treatment. Splenectomy is less effective than in youngers and burdened by an increased thrombotic and infectious risk. Rituximab is a good option in non-immunocompromised patients, but long-term remissions are few. Eltrombopag and romiplostim have a good safety and efficacy profile, and have become a prominent drug in this subset, even if they are associated with a possible increased risk of thrombosis, and long-term toxicity is unknown. Other drugs, such as dapsone and danazol, have a well-known efficacy and safety profile, and still represent a valid option among elderly patients.
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Affiliation(s)
- Elisa Lucchini
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy.
| | - Renato Fanin
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy
| | | | - Francesco Zaja
- S.C. Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
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11
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Zimmer J. Danazol as a second‐line treatment for immune thrombocytopenic purpura. Eur J Haematol 2018; 102:97-98. [DOI: 10.1111/ejh.13184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jacques Zimmer
- Department of Infection and Immunity Luxembourg Institute of Health, House of BioHealth Esch‐sur‐Alzette Luxembourg
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12
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Palandri F, Catani L, Auteri G, Bartoletti D, Fatica S, Fusco A, Bacchi Reggiani ML, Cavo M, Vianelli N. Understanding how older age drives decision-making and outcome in Immune Thrombocytopenia. A single centre study on 465 adult patients. Br J Haematol 2018; 184:424-430. [DOI: 10.1111/bjh.15668] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/25/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Francesca Palandri
- Institute of Haematology “L. and A. Seràgnoli”; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Lucia Catani
- Institute of Haematology “L. and A. Seràgnoli”; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Giuseppe Auteri
- Institute of Haematology “L. and A. Seràgnoli”; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Daniela Bartoletti
- Institute of Haematology “L. and A. Seràgnoli”; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Sofia Fatica
- Institute of Haematology “L. and A. Seràgnoli”; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Alessio Fusco
- Institute of Haematology “L. and A. Seràgnoli”; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Maria L. Bacchi Reggiani
- Institute of Cardiology; Department of Experimental, Diagnostic and Specialty Medicine; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Michele Cavo
- Institute of Haematology “L. and A. Seràgnoli”; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Nicola Vianelli
- Institute of Haematology “L. and A. Seràgnoli”; Sant'Orsola-Malpighi University Hospital; Bologna Italy
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13
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Liu XG, Bai XC, Chen FP, Cheng YF, Dai KS, Fang MY, Feng JM, Gong YP, Guo T, Guo XH, Han Y, Hong LJ, Hu Y, Hua BL, Huang RB, Li Y, Peng J, Shu MM, Sun J, Sun PY, Sun YQ, Wang CS, Wang SJ, Wang XM, Wu CM, Wu WM, Yan ZY, Yang FE, Yang LH, Yang RC, Yang TH, Ye X, Zhang GS, Zhang L, Zheng CC, Zhou H, Zhou M, Zhou RF, Zhou ZP, Zhu HL, Zhu TN, Hou M. Chinese guidelines for treatment of adult primary immune thrombocytopenia. Int J Hematol 2018; 107:615-623. [PMID: 29619624 DOI: 10.1007/s12185-018-2445-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/22/2018] [Accepted: 03/22/2018] [Indexed: 02/05/2023]
Abstract
Primary immune thrombocytopenia (ITP) is a bleeding disorder commonly encountered in clinical practice. The International Working Group (IWG) on ITP has published several landmark papers on terminology, definitions, outcome criteria, bleeding assessment, diagnosis, and management of ITP. The Chinese consensus reports for diagnosis and management of adult ITP have been updated to the 4th edition. Based on current consensus positions and new emerging clinical evidence, the thrombosis and hemostasis group of the Chinese Society of Hematology issued Chinese guidelines for management of adult ITP, which aim to provide evidence-based recommendations for clinical decision making.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, 250012, China
| | - Xiao-Chuan Bai
- General Hospital of Ningxia Medical University, Yinchuan, China
| | - Fang-Ping Chen
- Xiangya Hospital, Centre South University, Changsha, China
| | | | - Ke-Sheng Dai
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Mei-Yun Fang
- The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | | | - Yu-Ping Gong
- West China Hospital, Sichuan University, Chengdu, China
| | - Tao Guo
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin-Hong Guo
- The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Yue Han
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | | | - Yu Hu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bao-Lai Hua
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Rui-Bing Huang
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yan Li
- The First Hospital of Chinese Medical University, Shenyang, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, 250012, China
| | - Mi-Mi Shu
- Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jing Sun
- Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - Pei-Yan Sun
- Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Beijing, China
| | - Chun-Sen Wang
- Sichuan Provincial People's Hospital, Chengdu, China
| | - Shu-Jie Wang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Min Wang
- People's Hospital of Xinjiang Uygur Autonomous Region, Ürümqi, China
| | - Cong-Ming Wu
- Hainan Provincial People's Hospital, Haikou, China
| | - Wen-Man Wu
- Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen-Yu Yan
- Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Feng-E Yang
- Union Hospital of Fujian Medical University, Fuzhou, China
| | - Lin-Hua Yang
- The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Ren-Chi Yang
- Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, Tianjin, China
| | - Tong-Hua Yang
- The First People's Hospital of Yunnan Province, Kunming, China
| | - Xu Ye
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guang-Sen Zhang
- The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lei Zhang
- Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, Tianjin, China
| | | | - Hu Zhou
- Henan Cancer Hospital, Zhengzhou, China
| | - Min Zhou
- Chengdu Women and Children's Hospital, Chengdu, China
| | | | - Ze-Ping Zhou
- The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hong-Li Zhu
- Chinese PLA General Hospital, Beijing, China
| | - Tie-Nan Zhu
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, 250012, China.
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14
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Ozelo MC, Colella MP, de Paula EV, do Nascimento ACKV, Villaça PR, Bernardo WM. Guideline on immune thrombocytopenia in adults: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. Project guidelines: Associação Médica Brasileira - 2018. Hematol Transfus Cell Ther 2018; 40:50-74. [PMID: 30057974 PMCID: PMC6001928 DOI: 10.1016/j.htct.2017.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 11/29/2017] [Indexed: 02/07/2023] Open
Affiliation(s)
| | | | | | | | - Paula Ribeiro Villaça
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Wanderley Marques Bernardo
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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15
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Estève C, Samson M, Guilhem A, Nicolas B, Leguy-Seguin V, Berthier S, Bonnotte B, Audia S. Efficacy and safety of dapsone as second line therapy for adult immune thrombocytopenia: A retrospective study of 42 patients. PLoS One 2017; 12:e0187296. [PMID: 29084292 PMCID: PMC5662230 DOI: 10.1371/journal.pone.0187296] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 10/17/2017] [Indexed: 01/19/2023] Open
Abstract
Dapsone is recommended as a second line therapy in immune thrombocytopenia (ITP), but is underused because of its potential side effects. The medical charts of 42 ITP patients treated with dapsone (100 mg/day) were retrospectively reviewed in order to assess its efficacy and safety in daily clinical practice. The overall response rate was 54.8% (n = 22, with a complete response in 38.1%) with a median time to response of 29 days (24-41 days). Patients with complete response had shorter disease duration whereas no difference was observed between responders and non-responders regarding age, sex or previous treatments received. Importantly, after dapsone withdrawal, a sustained response was observed in 5 patients, representing 12% of the whole cohort. Twenty percent of patients (n = 8) relapsed on therapy after 8.1 (6.5-13.6) months. Side effects occurred in 31% (n = 13) of patients, and required dapsone withdrawal in 22% (n = 9) or dosage reduction in 10% (n = 4) of the cases. Side effects resolved in all but one case. Overall, these data support dapsone as an interesting second line therapy in ITP, with a good safety and efficacy profile at a low cost.
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Affiliation(s)
- Clémentine Estève
- Université de Bourgogne Franche Comté, CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l’adulte, Dijon, France
| | - Maxime Samson
- Université de Bourgogne Franche Comté, CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l’adulte, Dijon, France
| | - Alexandre Guilhem
- Université de Bourgogne Franche Comté, CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l’adulte, Dijon, France
| | - Barbara Nicolas
- Université de Bourgogne Franche Comté, CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l’adulte, Dijon, France
| | - Vanessa Leguy-Seguin
- Université de Bourgogne Franche Comté, CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l’adulte, Dijon, France
| | - Sabine Berthier
- Université de Bourgogne Franche Comté, CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l’adulte, Dijon, France
| | - Bernard Bonnotte
- Université de Bourgogne Franche Comté, CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l’adulte, Dijon, France
| | - Sylvain Audia
- Université de Bourgogne Franche Comté, CHU Dijon Bourgogne, Service de Médecine Interne et Immunologie Clinique, Centre de Référence Constitutif des Cytopénies Auto-immunes de l’adulte, Dijon, France
- * E-mail:
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Weber E, Reynaud Q, Fort R, Durupt S, Cathébras P, Durieu I, Lega JC. Immunomodulatory treatments for persistent and chronic immune thrombocytopenic purpura: A PRISMA-compliant systematic review and meta-analysis of 28 studies. Medicine (Baltimore) 2017; 96:e7534. [PMID: 28906353 PMCID: PMC5604622 DOI: 10.1097/md.0000000000007534] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Corticosteroid sparing is required in 15% to 40% of adults with persistent or chronic primary immune thrombocytopenic purpura (ITP). Herein, the efficacy of immunomodulatory drugs (dapsone, interferon alpha, danazol, and hydroxychloroquine as second-third-line therapies in ITP is investigated. METHODS MEDLINE was searched for studies that included patients with persistent or chronic primary ITP and published before the end of December 2014. Two investigators independently extracted data regarding study design, patient characteristics, dosage schedule, time to response, and occurrence of adverse events. The pooled overall response rate (ORR; platelet count >30 × 10 L) and the complete response rate (CRR; platelet count >100 × 10 L) were evaluated to determine drug efficacy by calculating weighted mean proportion using a fixed or random-effects model according to heterogeneity (I > 50%). The study was performed following the MOOSE and PRISMA guidelines. RESULTS A total of 28 studies (415 patients) were included (dapsone: k = 7 studies, n = 80; danazol: k = 12, n = 224; interferon alpha: k = 8, n = 83; hydroxychloroquine: k = 1, n = 28). The mean patient age was 50 years (female sex 70%, splenectomy 47%). The ORR and CRR were 55% (95% CI: 44%-66%, I = 0%) and 21% (95% CI: 13%-31%, I = 0%), respectively, for dapsone; 42% (95% CI: 22%-65%, I = 63%) and 18% (95% CI: 10%-29%, I = 9%), respectively, for interferon alpha; and 58% (95% CI: 42%-72%, I = 67%) and 29% (95% CI: 19%-42%, I = 63%), respectively, for danazol. The ORR was 50% (95% CI: 32%-67%) for hydroxychloroquine (data not available for CRR). Meta-regression analysis found a correlation between the ORR for interferon alpha and the splenectomized status of the patient (P = .02) and between the CRR for danazol and disease duration (P < .001). In total, 73%, 51%, 30%, and 0% of patients who received danazol, dapsone, interferon alpha, and hydroxychloroquine experienced side effects, respectively. CONCLUSION The ORR was equivalent for hydroxychloroquine, danazol, and dapsone in ITP. Regarding their low CRR, patients at high risk of infection or at low risk of bleeding should benefit from these treatments. Thanks to their best efficacy and safety profiles, dapsone and hydroxychloroquine in patients with antinuclear antibodies should be preferred over danazol and interferon alpha.
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Affiliation(s)
- Emmanuelle Weber
- Department of Internal and Vascular Medicine, Centre Hospitalier Lyon-Sud, Pierre-Bénite
| | - Quitterie Reynaud
- Department of Internal and Vascular Medicine, Centre Hospitalier Lyon-Sud, Pierre-Bénite
- Equipe d’Accueil HESPER 7425, Claude Bernard University Lyon 1, Villeurbanne
| | - Romain Fort
- Department of Internal and Vascular Medicine, Centre Hospitalier Lyon-Sud, Pierre-Bénite
| | - Stéphane Durupt
- Department of Internal and Vascular Medicine, Centre Hospitalier Lyon-Sud, Pierre-Bénite
| | - Pascal Cathébras
- Department of Internal Medicine, Hôpital Nord, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Priest-en-Jarez
| | - Isabelle Durieu
- Department of Internal and Vascular Medicine, Centre Hospitalier Lyon-Sud, Pierre-Bénite
- Equipe d’Accueil HESPER 7425, Claude Bernard University Lyon 1, Villeurbanne
| | - Jean-Christophe Lega
- Department of Internal and Vascular Medicine, Centre Hospitalier Lyon-Sud, Pierre-Bénite
- UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Villeurbanne, France
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Giudice V, Rosamilio R, Serio B, Di Crescenzo RM, Rossi F, De Paulis A, Pilone V, Selleri C. Role of Laparoscopic Splenectomy in Elderly Immune Thrombocytopenia. Open Med (Wars) 2017; 11:361-368. [PMID: 28352821 PMCID: PMC5329853 DOI: 10.1515/med-2016-0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/19/2016] [Indexed: 12/17/2022] Open
Abstract
The management of older patients with chronic primary immune thrombocytopenia (ITP) is still very challenging because of the fragility of older patients who frequently have severe comorbidities and/or disabilities. Corticosteroid-based first-line therapies fail in most of the cases and patients require a second-line treatment, choosing between rituximab, thrombopoietin-receptor agonists and splenectomy. The choice of the best treatment in elderly patients is a compromise between effectiveness and safety and laparoscopic splenectomy may be a good option with a complete remission rate of 67% at 60 months. But relapse and complication rates remain higher than in younger splenectomized ITP patients because elderly patients undergo splenectomy with unfavorable conditions (age >60 year-old, presence of comorbidities, or multiple previous treatments) which negatively influence the outcome, regardless the hematological response. For these reasons, a good management of concomitant diseases and the option to not use the splenectomy as the last possible treatment could improve the outcome of old splenectomized patients.
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Affiliation(s)
- Valentina Giudice
- Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Rosa Rosamilio
- Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Bianca Serio
- Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | | | - Francesca Rossi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Amato De Paulis
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Vincenzo Pilone
- Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Carmine Selleri
- Hematology and Transplant Center, Department of Medicine and Surgery, University of Salerno, Salerno, 84131, Italy
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Rattanathammethee T, Theerajangkhaphichai W, Rattarittamrong E, Hantrakool S, Chai-Adisaksopha C, Norasetthada L, Tantiworawit A. The Efficacy of Colchicine and Dapsone Combination Therapy in Relapsed Immune Thrombocytopenia. Hematol Rep 2017; 9:7034. [PMID: 28286634 PMCID: PMC5337828 DOI: 10.4081/hr.2017.7034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 01/26/2017] [Accepted: 02/05/2017] [Indexed: 11/23/2022] Open
Abstract
The aim of the present paper is to evaluate the efficacy and safety of colchicine and dapsone combination therapy in cases of steroid-dependent, relapsed and refractory immune thrombocytopenia (ITP). This is a retrospective study of ITP patients who attended the Hematology Clinic at Chiang Mai University Hospital (Thailand) from 1 January 2008 to 30 September 2014. Medical records and clinical data were reviewed for efficacy and adverse effects. Sixty-four ITP patients received the combination therapy. The median age was 46 years and 70.3% were female. The majority (65.6%) were relapsed ITP patients. Median platelet count before starting treatment was 22.6×109/L. The response rate was 82.8%, with 75.0% of patients having a complete response. Median time to response was 8 weeks. The response rate was higher in relapsed patients (90.4%) compared to refractory (61.5%) and steroid-dependent patients (77.8%). Steroid treatment was discontinued in 30 patients (50%) following combination therapy. The most common side effect was hemolysis due to dapsone which was found in eight patients (12.5%). We can therefore conclude that combination therapy with colchicine and dapsone is an alternative second-line therapy option in relapsed ITP cases with acceptable side effects.
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Affiliation(s)
- Thanawat Rattanathammethee
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University , Chiang Mai, Thailand
| | - Wasan Theerajangkhaphichai
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University , Chiang Mai, Thailand
| | - Ekarat Rattarittamrong
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University , Chiang Mai, Thailand
| | - Sasinee Hantrakool
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University , Chiang Mai, Thailand
| | - Chatree Chai-Adisaksopha
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University , Chiang Mai, Thailand
| | - Lalita Norasetthada
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University , Chiang Mai, Thailand
| | - Adisak Tantiworawit
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University , Chiang Mai, Thailand
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Moukhadder HM, Chaya BF, Bazarbachi AHA, Taher AT. Immune thrombocytopenia: a comprehensive review from pathophysiology to promising treatment modalities. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1247691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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20
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How I treat refractory immune thrombocytopenia. Blood 2016; 128:1547-54. [DOI: 10.1182/blood-2016-03-603365] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/04/2016] [Indexed: 01/19/2023] Open
Abstract
Abstract
This article summarizes our approach to the management of children and adults with primary immune thrombocytopenia (ITP) who do not respond to, cannot tolerate, or are unwilling to undergo splenectomy. We begin with a critical reassessment of the diagnosis and a deliberate attempt to exclude nonautoimmune causes of thrombocytopenia and secondary ITP. For patients in whom the diagnosis is affirmed, we consider observation without treatment. Observation is appropriate for most asymptomatic patients with a platelet count of 20 to 30 × 109/L or higher. We use a tiered approach to treat patients who require therapy to increase the platelet count. Tier 1 options (rituximab, thrombopoietin receptor agonists, low-dose corticosteroids) have a relatively favorable therapeutic index. We exhaust all Tier 1 options before proceeding to Tier 2, which comprises a host of immunosuppressive agents with relatively lower response rates and/or greater toxicity. We often prescribe Tier 2 drugs not alone but in combination with a Tier 1 or a second Tier 2 drug with a different mechanism of action. We reserve Tier 3 strategies, which are of uncertain benefit and/or high toxicity with little supporting evidence, for the rare patient with serious bleeding who does not respond to Tier 1 and Tier 2 therapies.
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Mahévas M, Michel M, Godeau B. How we manage immune thrombocytopenia in the elderly. Br J Haematol 2016; 173:844-56. [PMID: 27062054 DOI: 10.1111/bjh.14067] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
With prolonged life expectancy, immune thrombocytopenia (ITP) is frequent in elderly people. In this setting, ITP diagnosis is challenging because of the concern about an underlying myelodysplastic syndrome. Studies of older adults are lacking, and recommendations for treatment are based mainly on expert opinion. The therapeutic strategy differs from that for younger patients and must take into account the greater risk of bleeding and thrombosis, presence of comorbidities, possible impaired cognitive performance or poor life expectancy and concomitant medications, such as anticoagulant and antiplatelet therapy. Steroids and intravenous immunoglobulin (IVIg) therapy remain the first-line treatments in elderly patients, but prolonged treatment with steroids should be avoided and IVIg treatment may lead to renal failure. Splenectomy is less effective than in young patients and risk of thrombosis is increased. Severe co-morbidities can also contraindicate surgery. Therefore, other second-line treatments are frequently preferred. Danazol and dapsone can be an option for the less severe ITP form. Rituximab is a good option except in patients with a history of infection or with hypogammaglobulinaemia. Thrombopoietin agonists are attractive, especially for patients with severe comorbidities or with limited life expectancy but the risk of thrombosis is a concern.
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Affiliation(s)
- Matthieu Mahévas
- Service de Médecine Interne, Centre de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France
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22
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Neunert C, Farah R, Yacobovich J, Neufeld E. Refractory autoimmune disease: an overview of when first-line therapy is not enough. Semin Hematol 2016; 53 Suppl 1:S35-8. [PMID: 27312162 DOI: 10.1053/j.seminhematol.2016.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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23
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Idiopathic Thrombocytopenic Purpura Misdiagnosed as Hereditary Angioedema. Case Rep Dermatol Med 2016; 2015:934247. [PMID: 26819784 PMCID: PMC4706890 DOI: 10.1155/2015/934247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/05/2015] [Accepted: 12/15/2015] [Indexed: 12/03/2022] Open
Abstract
Hereditary angioedema is a rare, but potentially life-threatening genetic disorder that results from an autosomal dominant trait. It is characterized by acute, recurrent attacks of severe local edema, most commonly affecting the skin and mucosa. Swelling in hereditary angioedema patients does however not always have to be caused by angioedema but can relate to other concomitant disorders. In this report we are focusing on misdiagnosis in a patient with known hereditary angioedema, whose bleeding episode caused by idiopathic thrombocytopenic purpura was mistaken for an acute attack of hereditary angioedema. The case illustrates how clinicians can have difficulties in handling patients with rare diseases, especially in the emergency care setting.
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Podhorecka M, Macheta A, Chocholska S, Bojarska-Junak A, Szymczyk A, Goracy A, Dmoszynska A, Hus M. Danazol induces apoptosis and cytotoxicity of leukemic cells alone and in combination with purine nucleoside analogs in chronic lymphocytic leukemia. Ann Hematol 2015; 95:425-35. [PMID: 26692089 PMCID: PMC4742499 DOI: 10.1007/s00277-015-2579-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/09/2015] [Indexed: 01/26/2023]
Abstract
Recently, great progress has been achieved in the treatment of chronic lymphocytic leukemia (CLL). However, some patients, particularly older patients with comorbidities or with relapsed/refractory leukemia, still have limited therapeutic options. There is an urgent need to discover less toxic and more effective drugs for CLL patients. Applying new modalities or substances that are widely used for the treatment of other diseases has been reported to improve results in CLL treatment. This study aimed to assess the non-chemotherapeutic drug danazol for its potential to destroy leukemic cells. Leukemic cells, obtained from the peripheral blood and bone marrow of 23 CLL patients, were cultured in the presence of danazol and its combination with the purine nucleoside analogs fludarabine and cladribine and bendamustine. After 24 h of incubation, the rate of apoptosis indicated by active caspase-3 expression, and cytotoxicity indicated by forward light scatter and light scatter analysis, was assessed by flow cytometry. We also measured expression of apoptosis-regulating proteins of BCL family and active caspase 9 and active caspase 8 expressions in leukemic cells. Danazol had a caspase-dependent pro-apoptotic and cytotoxic effect on leukemic cells in a tumor-specific manner. The mechanisms of its action appear to be complex and should be precisely established; however, induction of apoptosis involving both mitochondrial and receptor cascades appears to be most probable. Danazol showed a synergic effect with cladribine, an additive effect with fludarabine, and an infra-additive effect with bendamustine. The rate of danazol-induced apoptosis and cytotoxicity did not differ between patients with better and worse prognostic markers. Our results indicate that danazol may be a potential therapeutic agent for CLL patients alone and in combination with purine analogs.
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Affiliation(s)
- Monika Podhorecka
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Staszica 11, 20-081, Lublin, Poland.
| | - Arkadiusz Macheta
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Staszica 11, 20-081, Lublin, Poland
| | - Sylwia Chocholska
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Staszica 11, 20-081, Lublin, Poland
| | | | - Agnieszka Szymczyk
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Staszica 11, 20-081, Lublin, Poland
| | - Aneta Goracy
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Staszica 11, 20-081, Lublin, Poland
| | - Anna Dmoszynska
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Staszica 11, 20-081, Lublin, Poland
| | - Marek Hus
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Staszica 11, 20-081, Lublin, Poland
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25
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Liu W, Gu X, Fu R, Li Y, Lv M, Sun T, Lv C, Liu X, Xue F, Zhang L, Yang R. The Effect of Danazol in Primary Immune Thrombocytopenia: An Analysis of a Large Cohort From a Single Center in China. Clin Appl Thromb Hemost 2015; 22:727-733. [PMID: 26681745 DOI: 10.1177/1076029615622002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM This study assessed the long-term benefits and side effects of low-to-medium dose of danazol therapy in primary immune thrombocytopenia (ITP). METHODS The retrospective analysis included 319 patients with ITP who accepted danazol therapy. Patients accepted danazol alone or in combination with glucocorticoids. Clinical outcome and tolerance were assessed in all patients. RESULTS Among patients with persistent or chronic ITP, the overall response rate of danazol therapy was 65.0%. Sixty-five (63.1%) of the 103 patients reached remission with danazol alone, and 93 (48.7%) of the 191 patients who accepted combination therapies acquired remission and discontinued glucocorticoids successfully. Age and previous treatments were 2 risk factors for response rate. In newly diagnosed patients with ITP, the response rate and median response time did not differ significantly with or without danazol. However, the relapse rate was significantly lower in patients administered danazol combined with glucocorticoids than those accepted glucocorticoids alone. Totally, 21.1% of the patients experienced mild or moderate side effects, and 1.2% of the patients discontinued treatment due to intolerable side effects. CONCLUSION Low-to-medium dosage of danazol is better tolerated and effective in patients with ITP, even in those refractory to other treatments. Combination of danazol and glucocorticoids for initial treatment may decrease relapse rates to achieve well-tolerated long-term remission.
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Affiliation(s)
- Wenjie Liu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Xueping Gu
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yang Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Mingen Lv
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Tiantian Sun
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Cuicui Lv
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
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Audia S, Godeau B, Bonnotte B. Is there still a place for "old therapies" in the management of immune thrombocytopenia? Rev Med Interne 2015; 37:43-9. [PMID: 26422785 DOI: 10.1016/j.revmed.2015.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/13/2015] [Indexed: 02/07/2023]
Abstract
New molecules such as rituximab or thrombopoietin receptor agonists (romiplostim and eltrombopag) have changed the management of immune thrombocytopenia. Therefore, old drugs which are less expensive and with a well-known benefit/risk ratio are being underused. We aim to define the place of dapsone, danazol, hydroxychloroquine and vinca-alkaloids at the era of targeted therapy in immune thrombocytopenia. With a response rate around 30% to 50%, dapsone is an interesting second-line therapy to be used just after corticosteroids. Patients with positive antinuclear antibodies can benefit from hydroxychloroquine with a 50% response rate. Because of its side effects, mostly virilization, danazol will be preferentially used in the elderly. Vinca-alkaloids could be temporarily used in patients that do not respond to intravenous immunoglobulins or to limit their use to avoid shortage periods.
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Affiliation(s)
- S Audia
- Service de Médecine Interne et Immunologie Clinique, Centre de Compétences des cytopénies auto-immunes de l'adulte, Hôpital Bocage Central, 14, rue Paul-Gaffarel, 21000 Dijon, France; CR INSERM 1098, Bâtiment B3, rue Angélique-Ducoudray, 21000 Dijon, France.
| | - B Godeau
- Service de Médecine Interne, Centre de Référence des cytopénies auto-immunes, Hôpital Henri-Mondor, AP-HP, UPEC, 94000 Créteil, France
| | - B Bonnotte
- Service de Médecine Interne et Immunologie Clinique, Centre de Compétences des cytopénies auto-immunes de l'adulte, Hôpital Bocage Central, 14, rue Paul-Gaffarel, 21000 Dijon, France; CR INSERM 1098, Bâtiment B3, rue Angélique-Ducoudray, 21000 Dijon, France
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27
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Abstract
Primary immune thrombocytopenia is an autoimmune disorder of unknown cause affecting both children and adults. The low peripheral blood platelet count is caused by premature platelet destruction by self-reacting antibodies in addition to an impairment of platelet production. The disease is heterogeneous in its pathophysiology, clinical features and responses to treatment. To date, most of the treatments used have been immune-modulating drugs and these contribute to increased morbidity and mortality in patients. A new class of drugs, the thrombopoietin receptor agonists, has been developed for use in ITP. These have gone through randomised controlled trials in large numbers of patients with ITP. These drugs have high efficacy and are well tolerated. In addition, around 30% of patients receiving these drugs are able to stop them and maintain a safe or normal platelet count. Older treatments such as splenectomy are being used less than before, largely because of the introduction of the thrombopoietin receptor agonists. Currently there are trials underway evaluating novel therapies for ITP that will become available over the next few years once the trials are complete.
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Affiliation(s)
- Drew Provan
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Whitechapel, London, UK.
| | - Adrian C Newland
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Whitechapel, London, UK
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Moulis G, Lapeyre-Mestre M, Montastruc JL, Sailler L. Exposure to non-corticosteroid treatments in adult primary immune thrombocytopenia before the chronic phase in the era of thrombopoietin receptor agonists in France. A nationwide population-based study. Autoimmun Rev 2015; 14:168-73. [DOI: 10.1016/j.autrev.2014.10.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/09/2014] [Indexed: 12/25/2022]
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Rodeghiero F, Ruggeri M. ITP and international guidelines: What do we know, what do we need? Presse Med 2014; 43:e61-7. [DOI: 10.1016/j.lpm.2014.02.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 02/11/2014] [Indexed: 01/12/2023] Open
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Hallam S, Provan D, Newland AC. Immune thrombocytopenia – what are the new treatment options? Expert Opin Biol Ther 2013; 13:1173-85. [DOI: 10.1517/14712598.2013.801451] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Cheng G. Eltrombopag, a thrombopoietin- receptor agonist in the treatment of adult chronic immune thrombocytopenia: a review of the efficacy and safety profile. Ther Adv Hematol 2013; 3:155-64. [PMID: 23556122 DOI: 10.1177/2040620712442525] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Chronic immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a low platelet count that has persisted for more than 12 months. Patients may be asymptomatic but those with severe disease may have significant morbidity and require treatment. Corticosteroids and intravenous immunoglobulin are recommended as first-line treatments. Recently, two thrombopoietin-receptor agonists, romiplostim and eltrombopag have been licensed for the treatment of chronic ITP. The current indications for thrombopoietin-receptor agonists are for splenectomized adult patients with chronic ITP who are refractory to other treatments and adult nonsplenectomized patients in whom splenectomy is contraindicated. This article reviews data on the pharmacology, clinical efficacy and safety profile of eltrombopag in the treatment of ITP.
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Affiliation(s)
- Gregory Cheng
- Dr Stanley Ho Medical Development Foundation, 9/F ICBC Tower, Macau Landmark, 555 Avenida da Amizade, Macau
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Andrès E, Mecili M, Fothergill H, Zimmer J, Vogel T, Maloisel F. Gender-related analysis of the clinical presentation, treatment response and outcome in patients with immune thrombocytopenia. Presse Med 2012; 41:e426-31. [PMID: 22459990 DOI: 10.1016/j.lpm.2012.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 01/24/2012] [Accepted: 02/13/2012] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Immune thrombocytopenia (idiopathic thrombocytopenic purpura [ITP]) frequently occurs in young adults, particularly women in their third or fourth decade. The female predominance suggests that sex hormones may play a role in the different aspects of ITP. In this paper, we report a gender-related analysis of patients with ITP, specifically examining the clinical manifestations, responses to treatment and overall outcomes of the patients. METHODS We included patients with "ITP" attending the departments of onco-hematology or internal medicine B (university hospital of Strasbourg, France) between 1990 and December 2010 The gender-related analysis was retrospective. RESULTS We studied in 225 consecutive cases of established ITP with a follow-up period of 1.7 to 112 months The mean age of the patients was 44 years; 156 patients were female. The analysis revealed no significant statistical differences regarding patient characteristics between the female and male groups, with the exception of the following characteristics: the bleeding score, which altered in the presence of meno- and/or metrorrhagia and hematuria in female patients (P=0.03); the presence of anemia (P=0.04); and the detection of antinuclear and/or antiphospholipid antibodies (P=0.02). During the follow-up, no statistically significant difference was found regarding outcome or treatment response in relation to gender among these 225 patients (all P>0.05). DISCUSSION Gender does not appear to affect the manifestation of immune thrombocytopenia, the outcome or response to treatment. However, further large-scale randomized trials are needed to confirm these findings.
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Affiliation(s)
- Emmanuel Andrès
- University hospital of Strasbourg, department of internal medicine B, 67091 Strasbourg cedex, France.
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Aggarwal P, Mittal S, Malhotra N, Bahadur A. Idiopathic thrombocytopenic purpura managed by intravenous anti-D. J OBSTET GYNAECOL 2012; 32:195-8. [PMID: 22296443 DOI: 10.3109/01443615.2011.609924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- P Aggarwal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
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Nakamura RK, Tompkins E, Bianco D. Therapeutic options for immune-mediated thrombocytopenia. J Vet Emerg Crit Care (San Antonio) 2012; 22:59-72. [DOI: 10.1111/j.1476-4431.2011.00705.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 11/25/2011] [Indexed: 01/15/2023]
Affiliation(s)
| | | | - Domenico Bianco
- Internal Medicine Department; Veterinary Specialists of the Valley; Woodland Hills; CA; 91364
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Khellaf M. Prise en charge du purpura thrombopénique immunologique de l’adulte. Rev Med Interne 2010; 31 Suppl 3:S329-32. [DOI: 10.1016/j.revmed.2010.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Palau J, Jarque I, Sanz MA. Long-term management of chronic immune thrombocytopenic purpura in adults. Int J Gen Med 2010; 3:305-11. [PMID: 21042569 PMCID: PMC2962326 DOI: 10.2147/ijgm.s4722] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Chronic immune thrombocytopenic purpura (ITP) is generally a more benign disease than previously thought. Currently it is recommended that only those patients with severe and/or symptomatic thrombocytopenia definitely require treatment. Additional factors, such as age, lifestyle, and uremia can also influence the hemorrhagic risk and should be carefully assessed before decision-making on the appropriate management of patients with less severe forms of ITP. The recent introduction of new classes of therapeutic agents such as rituximab and the thrombopoietic growth factors has had a major impact on the management of ITP. Updated treatment guidelines have recently been made available but they are based largely on expert opinion rather than on high-quality clinical trial evidence. This structured review is focused on the management of adults with chronic ITP, including the use of new classes of agents.
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Affiliation(s)
- Javier Palau
- Department of Hematology, Hospital, Universitario La Fe, Valencia, Spain.
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Should medical treatment options be exhausted before splenectomy is performed in adult ITP patients? A debate. Ann Hematol 2010; 89:1185-95. [DOI: 10.1007/s00277-010-1066-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/22/2010] [Indexed: 12/23/2022]
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Chouhan JD, Herrington JD. Treatment Options for Chronic Refractory Idiopathic Thrombocytopenic Purpura in Adults: Focus on Romiplostim and Eltrombopag. Pharmacotherapy 2010; 30:666-83. [DOI: 10.1592/phco.30.7.666] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Audia S, Lakomy D, Guy J, Leguy-Seguin V, Berthier S, Aho S, Lorcerie B, Bonnotte B. Traitement du purpura thrombopénique immunologique : étude rétrospective de 40 patients. Rev Med Interne 2010; 31:337-44. [DOI: 10.1016/j.revmed.2009.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 10/06/2009] [Accepted: 11/25/2009] [Indexed: 01/06/2023]
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41
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International consensus report on the investigation and management of primary immune thrombocytopenia. Blood 2009; 115:168-86. [PMID: 19846889 DOI: 10.1182/blood-2009-06-225565] [Citation(s) in RCA: 1219] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Previously published guidelines for the diagnosis and management of primary immune thrombocytopenia (ITP) require updating largely due to the introduction of new classes of therapeutic agents, and a greater understanding of the disease pathophysiology. However, treatment-related decisions still remain principally dependent on clinical expertise or patient preference rather than high-quality clinical trial evidence. This consensus document aims to report on new data and provide consensus-based recommendations relating to diagnosis and treatment of ITP in adults, in children, and during pregnancy. The inclusion of summary tables within this document, supported by information tables in the online appendices, is intended to aid in clinical decision making.
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Viallard JF. Prise en charge diagnostique et thérapeutique du Purpura Thrombopénique Idiopathique. Rev Med Interne 2009; 30:9-12. [DOI: 10.1016/s0248-8663(09)72467-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Abstract
Immune thrombocytopenic purpura (ITP) is a relatively common autoimmune disorder in which antibodies are produced to circulating platelets. Symptoms can be mild, but for most patients the risk of severe bleeding is unacceptable and treatment is required. Glucocorticoids followed by splenectomy had been the mainstays of therapy. High dose intravenous immunoglobulin and anti-RhD therapy are available for patients with severe illness, but produce only temporary benefit. Rituximab may provide more durable responses, danazol may be underutilized, and immunosuppressants and cytotoxic agents are less often required. Recently the pathophysiology of ITP has been more clearly elucidated, particularly the importance of decreased production of platelets in most patients and the very blunted rise that occurs in serum thrombopoietin (TPO). The isolation of TPO and better understanding of its role in thrombopoiesis has led to the development of new highly effective treatments. TPO analogs had some successes in treating highly refractory ITP patients but were taken out of development due to TPO-antibody induction. Two second-generation TPO-mimetics, romiplostim and the orally available eltrombopag, have recently been licensed in some territories for the treatment of ITP. Approval of eltrombopag was based on results from Phase II and III placebo-controlled clinical trials and a long-term extension study. About 80% of patients achieve significant increases in platelet count (11% of placebo patients), with reduced bleeding and reduced use of concomitant medications; responses are often durable with no tachyphylaxis. The side effects of eltrombopag are generally mild and not worse than placebo, although there are concerns about hepatic dysfunction, and the potentials for thromboses, marrow reticulin fibrosis, rebound thrombocytopenia and cataracts. This is an important new option for highly refractory patients, and its niche in earlier treatment (and for other thrombocytopenic disorders) is yet to be defined.
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Affiliation(s)
- Lawrence Rice
- Weill Cornell Medical College, Methodist Hospital, Houston, Texas, USA.
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Perreault S, Burzynski J. Romiplostim: a novel thrombopoiesis-stimulating agent. Am J Health Syst Pharm 2009; 66:817-24. [PMID: 19386944 DOI: 10.2146/ajhp080524] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE The pharmacology, pharmacokinetics, dosage and administration, efficacy, safety, effects on quality of life, and place in therapy of romiplostim are reviewed. SUMMARY Romiplostim is a second- generation thrombopoietic agent that stimulates the thrombopoietin receptor and platelet production without inducing production of autoantibodies. Romiplostim, a peptibody, bears no structural resemblance to endogenous thrombopoietin, thus minimizing the risk for development of thrombopoietin autoantibodies. Clinical trials have shown that romiplostim increases platelet counts compared with placebo in both splenectomized and non-splenectomized adult patients with chronic idiopathic thrombocytopenic purpura (ITP). Clinical trials with romiplostim are ongoing for patients with myelodysplastic syndrome and those receiving chemotherapy for treatment of malignancies. Romiplostim may confer an increased risk of bone marrow reticulin formation or fibrosis, malignancy, thrombosis, and thrombocytopenia that is more severe than the level present before initiation of romiplostim. While all patients receiving romiplostim in clinical trials experienced at least one adverse event, most were mild to moderate in severity. The most frequent adverse effects were ecchymosis, headache, and petechiae. Romiplostim is initiated at a dosage of 1 microg/kg subcutaneously once weekly and titrated to achieve platelet counts between 50 and 200 x 10(9) platelets/L, with a maximum dose of 10 microg/kg. Romiplostim is only available through the manufacturer's risk-management program. The current wholesale price of romiplostim is $1,062.50 for a single-use vial of 250 microg or $2,125 for a single-use vial of 500 microg. The extrapolated drug cost for weekly dosing for one year is approximately $55,250. CONCLUSION Romiplostim is a novel thrombopoietic-stimulating agent for use in patients with chronic ITP who have not responded to other therapies.
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Affiliation(s)
- Sarah Perreault
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55901, USA.
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Sobota A, Neufeld EJ, Lapsia S, Bennett CM. Response to mercaptopurine for refractory autoimmune cytopenias in children. Pediatr Blood Cancer 2009; 52:80-4. [PMID: 18726904 PMCID: PMC2585152 DOI: 10.1002/pbc.21729] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Several treatment strategies are available for children with severe immune thrombocytopenic purpura (ITP) and other immune cytopenias refractory to initial therapies. 6-Mercaptopurine (6MP) is one option, however it has not been well studied in children, especially as a single agent, and no pediatric case series have been reported since 1970. PATIENTS AND METHODS We reviewed the experience at our institution over 8 years, using 6MP as a steroid sparing treatment for children with ITP, auto-immune hemolytic anemia (AIHA) or Evans syndrome. A total of 29 pediatric patients were treated with 6MP from 2000 to 2007. RESULTS Response was defined as a rise in hemoglobin by at least 1.5 g/dl and to a level of 10 g/dl or greater in patients treated for anemia, or a platelet count >or=50 x 10(9)/L in patients treated for thrombocytopenia. We found an overall response rate of 83% among all patients. Fourteen percent of patients stopped drug because of side effects. CONCLUSIONS These results suggest that 6MP can be an effective single-agent treatment for refractory immune cytopenias in children. Prospective studies are warranted to determine long-term efficacy and toxicity and to more clearly define patient populations most likely to respond.
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Affiliation(s)
- Amy Sobota
- Division of Hematology/Oncology, Children's Hospital Boston, Boston, MA 02115, USA.,Dana Farber Cancer Institute, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
| | - Ellis J. Neufeld
- Division of Hematology/Oncology, Children's Hospital Boston, Boston, MA 02115, USA.,Dana Farber Cancer Institute, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
| | - Sameer Lapsia
- Division of Hematology/Oncology, Children's Hospital Boston, Boston, MA 02115, USA
| | - Carolyn M Bennett
- Division of Hematology/Oncology, Children's Hospital Boston, Boston, MA 02115, USA.,Dana Farber Cancer Institute, Boston, MA 02115, USA.,Harvard Medical School, Boston, MA 02115, USA
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Daou S, Federici L, Zimmer J, Maloisel F, Serraj K, Andrès E. Idiopathic thrombocytopenic purpura in elderly patients: a study of 47 cases from a single reference center. Eur J Intern Med 2008; 19:447-51. [PMID: 18848179 DOI: 10.1016/j.ejim.2007.07.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Revised: 06/12/2007] [Accepted: 07/22/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Idiopathic thrombocytopenic purpura (ITP) is often diagnosed in the elderly, but no specific guidelines exist for such patients. We describe our experience with ITP management in elderly patients and analyze the therapeutic response. METHODS We retrospectively reviewed a cohort of 47 consecutive elderly ITP patients (> or =60 years old) followed in a single reference center. We specifically analyzed the clinical characteristics, therapies used, patient response rates, and side effects. RESULTS The mean age of the 47 patients was 66 (range 60-82) years; 31 patients were female. Their initial presentation included bleeding limited to the skin (n=10, 21%) and bleeding at one or more other sites (n=26, 56%); 11 patients (23%) were asymptomatic. The mean platelet count was 52 x 10(9)/L (range 1-120 x 10(9)/L). After 1 and 6 months, the overall response rate was: 61% and 33% with corticosteroids (n=43), 80% and 50% with splenectomy (n=10), and 14% and 60% with danazol (n=15), respectively. Side effects of these therapies were reported in 100% of these elderly ITP patients, 60% and 50% with these drugs, respectively. No response was reported using IVIg. One case of fatal sepsis was noted after splenectomy. CONCLUSIONS The results confirm (1) that age influences the hemorrhagic pattern of ITP expression, response, and adverse effects of conventional ITP therapies, and (2) that danazol has the potential to be an effective therapeutic alternative to splenectomy in elderly ITP patients.
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Affiliation(s)
- Samira Daou
- Department of Internal Medicine, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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Godeau B, Bierling P. [Treatment of idiopathic thrombocytopenic purpura in adults]. Presse Med 2008; 37:1292-8. [PMID: 18644317 DOI: 10.1016/j.lpm.2008.01.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Accepted: 01/07/2008] [Indexed: 11/30/2022] Open
Abstract
The lack of controlled studies of the treatment of idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenic purpura, means that no evidence-based recommendations are available. ITP is a benign disease and severe hemorrhages are rare. Oral prednisone remains the first-line treatment. In patients with very low platelet counts and significant bleeding, intravenous immunoglobulins and high-dose oral dexamethasone may be an alternative. A validated bleeding score would help physicians use these treatments more effectively. Splenectomy remains the best curative treatment for adults with chronic ITP and platelet counts <30 x 10(9)/L after failure of the first-line treatments. Rituximab is probably the single most effective agent, as well as the least toxic, when splenectomy fails: the short-term response rate is 50% and the sustained-response rate more than 30%. Cytotoxic or other immunosuppressive agents should be reserved for patients with severe disease refractory to both splenectomy and rituximab. Thrombopoietin receptor agonists are a class of new investigational drugs for which promising results have been reported, but more data regarding long-term safety are needed.
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Affiliation(s)
- Bertrand Godeau
- Centre de référence labellisé pour la prise en charge des cytopénies auto-immunes de l'adulte, Service de médecine interne, Assistance-Publique Hôpitaux de Paris APHP, Université Paris 12, Hôpital Henri Mondor, Créteil, France.
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Badawi MA, Salih F, Al-Humaidi AA, El Khalifa MY, Elhadd TA. Bone marrow hypoplasia responsive to testosterone therapy in a patient with panhypopituitarism: need for adherence to androgen replacement. Endocr Pract 2008; 14:229-32. [PMID: 18308664 DOI: 10.4158/ep.14.2.229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the case of a young Saudi male patient with long-term panhypopituitarism and pancytopenia attributable to poor adherence to androgen replacement therapy, which resolved after institution of testosterone treatment and recurred after another interval of poor adherence to recommended therapy. METHODS We present the clinical and laboratory data before and after treatment with testosterone. In addition, the corresponding histologic changes in the bone marrow are illustrated. RESULTS After resection of a hypothalamic glioma, panhypopituitarism developed in a 14-year-old Saudi boy. At age 22 years, he had shunt-related meningitis. He was then noted to have pancytopenia, with a platelet count of 54 x 10(3)/microL, a hemoglobin concentration of 6.9 g/dL, and a leukocyte count of 2.7 x 10(3)/microL. After treatment of sepsis, the pancytopenia persisted. No underlying cause was detected. Bone marrow biopsy showed a hypocellular marrow with dysplastic megakaryocytes. The patient's family indicated that he had not been taking his testosterone therapy. Testosterone decanoate (250 mg) was administered intramuscularly daily for 3 days. His platelet count increased to 74 x 10(3)/microL. Maintenance therapy with testosterone once weekly for 3 weeks and then once every 3 weeks resulted in improved hematologic findings. Repeated bone marrow biopsy after 6 weeks showed normocellular marrow, with disappearance of the megakaryocytic dysplasia. The patient again discontinued his testosterone treatment, and the hematologic abnormalities recurred but were again corrected after supervised testosterone therapy. CONCLUSION This case emphasizes the importance of androgen replacement therapy in patients with hypopituitarism, not only for sexual potency, bone strength, and quality of life but also for normal bone marrow function.
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Affiliation(s)
- Manal A Badawi
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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Combined therapy with danazol, pegilated interferon, and ribavirin improves thrombocytopenia and liver injury in rats with fibrosis. Ann Hepatol 2007. [DOI: 10.1016/s1665-2681(19)31904-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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