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Hamzah R, Yusof N, Tumian NR, Abdul Aziz S, Mohammad Basri NS, Leong TS, Ho KW, Selvaratnam V, Tan SM, Muhamad Jamil SA. Clinical Epidemiology, Treatment Outcome and Mortality Rate of Newly Diagnosed Immune Thrombocytopenia in Adult Multicentre Study in Malaysia. J Blood Med 2022; 13:337-349. [PMID: 35761846 PMCID: PMC9233512 DOI: 10.2147/jbm.s358993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Immune thrombocytopenia (ITP) is well characterized in Western, European and other Asia-Pacific countries. Nevertheless, the clinical epidemiology, treatment pattern and disease outcome of ITP in Malaysia are still limited and not well known. Objective This study aimed to describe the clinical epidemiology, treatment outcome and mortality of ITP patients in haematology tertiary multicentre in Malaysia. Methods Clinical and laboratory data of newly diagnosed adults with ITP by a platelet count <100 × 109/L from January 2010 to December 2020 were identified and analyzed. Results Out of 500 incident ITP, 71.8% were females with a striking age preponderance of both genders among those aged 18–29 years. The median age was 36 years. The median platelet count was 17.5 × 109/L, 23.0% had a secondary ITP, 34.6% had a Charlson’s score ≥1, 53.0% had bleeding symptoms including 2.2% intracranial bleedings (ICB). Helicobacter pylori screening was performed in <5% of cases. Persistency and chronicity rates were 13.6% and 41.8%, respectively. Most (80.6%) were treated at diagnosis onset and 31.2% needed second-line treatment. Throughout the course of ITP, 11.0% of patients died; 3.0% and 8.0% with bleeding and non-bleeding related ITP. Conclusion This study confirms the epidemiology of ITP is comparable with worldwide studies. Our incidence is high in the female, Malay ethnicity, primary ITP and events of cutaneous bleeding at ITP onset with 18–29 years predominance age group for both genders. The frequency of persistent and chronic ITP is inconsistent with published literature. Corticosteroids and immunotherapies are the most prescribed first-line and second-line pharmacological treatments. Thrombopoietin receptor agonist medications (TPO-RAs) usage is restricted and splenectomy is uncommon. Our mortality rate is similar but ITP related bleeding death is fourth-fold lower than previous studies. Mortality risks of our ITP patients include age ≥60 years, male, severe bleeding at presentation, CCI≥1 and secondary ITP.
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Affiliation(s)
- Roszymah Hamzah
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia.,Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Nurasyikin Yusof
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Nor Rafeah Tumian
- Haematology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Suria Abdul Aziz
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Nur Syahida Mohammad Basri
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Tze Shin Leong
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Kim Wah Ho
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Veena Selvaratnam
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Sen Mui Tan
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Siti Afiqah Muhamad Jamil
- Faculty of Computer and Mathematical Sciences, Universiti Teknologi Mara, Shah Alam, Selangor, Malaysia
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Sokal A, de Nadaï T, Maquet J, Comont T, Limal N, Michel M, Beyne-Rauzy O, Godeau B, Adoue D, Mahévas M, Moulis G. Primary immune thrombocytopenia in very elderly patients: particularities in presentation and management: results from the prospective CARMEN-France Registry. Br J Haematol 2021; 196:1262-1270. [PMID: 34738634 DOI: 10.1111/bjh.17935] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/19/2021] [Indexed: 02/04/2023]
Abstract
Data about the presentation and the management of primary immune thrombocytopenia (ITP) in very elderly patients (VEPs; aged ≥80 years) are lacking. The aim of the present study was to describe ITP in this subgroup. The data source was the prospective CARMEN-France registry. Patients included between 2013 and 2018 were selected. ITP presentation and management in VEPs was compared to elderly patients (EPs; aged 65-79 years). We assessed factors associated with bleeding at ITP onset in VEPs. Of 541 patients, 184 were included: 87 in the VEP group and 97 in the EP group. The mean age was 85·7 years in the VEP group. Comorbidities were more frequent in the VEP group (67·4% vs. 47·9%). The median platelet count at ITP onset was similar but severe bleeding tended to be more frequent in VEPs (10·3% vs. 4·1%, P = 0·1) as well as mortality. Exposure to ITP drugs, response to first-line treatment, need of second-line treatment, evolution towards persistency, occurrence of bleeding, infection and thrombosis did not differ between groups. In VEPs, factors associated to bleeding were female sex [odds ratio (OR) 4·75, 95% confidence interval (CI) 1·31-17·32] and platelet count of <20 × 109 /l (OR 10·05, 95% CI 4·83-67·39). Exposure to anticoagulants was strongly associated with severe bleeding (OR 7·61, 95% CI 1·77-32·83).
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Affiliation(s)
- Aurélien Sokal
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Thomas de Nadaï
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Julien Maquet
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Thibault Comont
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse - Oncopôle, Toulouse, France
| | - Nicolas Limal
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Odile Beyne-Rauzy
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse - Oncopôle, Toulouse, France
| | - Bertrand Godeau
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Daniel Adoue
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse - Oncopôle, Toulouse, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Guillaume Moulis
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Centre d'Investigation Clinique 1436, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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Mezaache S, Derumeaux H, Ferraro P, Capdepon P, Steinbach JC, Abballe X, Palas D, Saichi N, Desboeuf K, Lapeyre-Mestre M, Sailler L, Moulis G. Validation of an algorithm identifying incident primary immune thrombocytopenia in the French national health insurance database. Eur J Haematol 2017; 99:344-349. [DOI: 10.1111/ejh.12926] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Salim Mezaache
- UMR 1027 INSERM-University of Toulouse; Toulouse France
- Toulouse University Hospital (CHU de Toulouse); CIC 1436; Toulouse France
| | - Helene Derumeaux
- Department of Medical Information; Toulouse University Hospital (CHU de Toulouse); Toulouse France
| | - Pierre Ferraro
- Department of Medical Information; Auch Hospital; Auch France
| | - Pascal Capdepon
- Department of Medical Information; Tarbes Hospital; Tarbes France
- Department of Medical Information; Lourdes Hospital; Lourdes France
| | | | - Xavier Abballe
- Department of Medical Information; Montauban Hospital; Montauban France
| | - Deborah Palas
- Department of Medical Information; Albi Hospital; Albi France
| | - Nabil Saichi
- Department of Medical Information; Val d'Ariege Hospital; Foix France
| | - Karine Desboeuf
- Department of Medical Information; Lavaur Hospital; Lavaur France
| | - Maryse Lapeyre-Mestre
- UMR 1027 INSERM-University of Toulouse; Toulouse France
- Toulouse University Hospital (CHU de Toulouse); CIC 1436; Toulouse France
- Department of Medical and Clinical Pharmacology; Toulouse University Hospital (CHU de Toulouse); Toulouse France
| | - Laurent Sailler
- UMR 1027 INSERM-University of Toulouse; Toulouse France
- Toulouse University Hospital (CHU de Toulouse); CIC 1436; Toulouse France
- Department of Internal Medicine; Toulouse University Hospital (CHU de Toulouse); Toulouse France
| | - Guillaume Moulis
- UMR 1027 INSERM-University of Toulouse; Toulouse France
- Toulouse University Hospital (CHU de Toulouse); CIC 1436; Toulouse France
- Department of Internal Medicine; Toulouse University Hospital (CHU de Toulouse); Toulouse France
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do Nascimento ACKV, Annichino-Bizzacchi JM, Maximo CDA, Minowa E, Julian GS, Dos Santos RF. Patterns of care and burden of chronic idiopathic thrombocytopenic purpura in Brazil. J Med Econ 2017; 20:884-892. [PMID: 28673116 DOI: 10.1080/13696998.2017.1341415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS Although several therapeutic options are available for chronic immune thrombocytopenic purpura (cITP), little is known about the treatment of cITP in Brazil. MATERIALS AND METHODS A multi-center, retrospective chart review, observational study was designed to describe the treatment patterns, clinical burden, resources use, and associated costs for adult patients diagnosed with cITP and treated in public and private institutions in Brazil. Patient charts were screened in reverse chronological order based on their last visit post January 1, 2012. (All costs were calculated using 1.00 USD = 3.9571 BRL, from February 2016.) Results: Of 340 patient charts screened, 50 patients were eligible for inclusion in the study. Single-drug therapy (prednisone, dexamethasone, or dapsone) was the most commonly used treatment, followed by combination therapies (azathioprine + prednisone, azathioprine + prednisone + danazol, and prednisone + dapsone). Splenectomy was performed in 22% of patients after at least first-line treatment. Platelet count and number of bleeding episodes at diagnosis were 31,561.1/mm3 (SD = ±26,396.1) and 40 episodes, respectively; in first-line, 92,631.1/mm3 (SD = ±79,955.3) and 19 episodes, respectively; in second-line, 96,950.0/mm3 (SD = ±76,476.4) and 17 episodes, respectively. Private system patients had a higher median cost compared to public system patients (USD 17.49/month, range = 0-2,020.77 vs USD 9.51/month, range = 0-192.64, respectively). LIMITATIONS This study does not allow conclusions for causal explanations due to the cohort study design, and treatment patterns represent only the practices of physicians who have agreed to participate in the study. CONCLUSIONS The data indicate that available therapeutic strategies for second- and third-line therapies appear to be limited.
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Affiliation(s)
- Ana Clara Kneese Virgilio do Nascimento
- a Departamento de Clínica Médica , Santa Casa de Misericórdia de São Paulo , São Paulo , SP , Brazil
- b Centro de Hematologia de São Paulo , São Paulo , SP , Brazil
| | | | | | - Eimy Minowa
- e Evidências - Kantar Health , São Paulo , SP , Brazil
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Moulis G, Lapeyre-Mestre M, Adoue D, Sailler L. Épidémiologie et pharmacoépidémiologie du purpura thrombopénique immunologique. Rev Med Interne 2017; 38:444-449. [DOI: 10.1016/j.revmed.2016.12.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/04/2016] [Accepted: 12/22/2016] [Indexed: 02/06/2023]
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Moulis G, Germain J, Comont T, Brun N, Dingremont C, Castel B, Arista S, Sailler L, Lapeyre-Mestre M, Beyne-Rauzy O, Godeau B, Adoue D. Newly diagnosed immune thrombocytopenia adults: Clinical epidemiology, exposure to treatments, and evolution. Results of the CARMEN multicenter prospective cohort. Am J Hematol 2017; 92:493-500. [PMID: 28240787 DOI: 10.1002/ajh.24702] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/21/2017] [Accepted: 02/21/2017] [Indexed: 12/27/2022]
Abstract
The clinical epidemiology of immune thrombocytopenia (ITP) is not well known in adults. This study was aimed at assessing the clinical epidemiology of incident ITP adults, the factors associated with chronicity and exposure to treatments. This study was conducted in the CARMEN registry, a multicentric prospective cohort aimed at including all newly diagnosed ITP adults in the French Midi-Pyrénées region, South of France (3 million inhabitants) from June 2013. Descriptive analyses and multivariate logistic regression models were conducted. Out of 121 newly diagnosed ITP until December 2014, 113 patients were followed in the region and gave informed consent. Median age was 65 years. Half of the patients were female, 20.3% had a secondary ITP, 50.4% had a Charlson's score ≥1, median platelet count was 17 × 109 /L; 50.9% had bleeding symptoms, including 2 severe gastrointestinal tract and 1 intracranial bleedings; 21.4% had another autoimmune disease and 20.3% experienced an infection within the six weeks before ITP onset. Persistency and chronicity rates were 68.2% and 58.7%, respectively. Antinuclear antibodies were associated with chronicity (OR: 2.89, 95% CI: 1.08-7.74). Sixty-eight (60.2%) patients were treated during the week following the diagnosis. Factors associated with the use of intravenous corticosteroids were secondary ITP and high bleeding score. Those associated with the use of intravenous immunoglobulin (IVIg) were a high bleeding score and low platelet count. In conclusion, severe bleeding is rare at ITP onset. Associated autoimmune diseases and recent infections were frequent. Antinuclear antibodies seem predictors of chronicity. Intravenous corticosteroids and IVIg were frequently used.
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Affiliation(s)
- Guillaume Moulis
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse; Toulouse F-31059 France
- UMR1027, Inserm, Université de Toulouse; Toulouse F-31073 France
- CIC 1436, Centre Hospitalier Universitaire de Toulouse; Toulouse F-31073 France
| | - Johanne Germain
- CIC 1436, Centre Hospitalier Universitaire de Toulouse; Toulouse F-31073 France
| | - Thibault Comont
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse-Oncopole; Toulouse F-31100 France
| | - Natacha Brun
- Centre Hospitalier de Rodez; Service de Médecine Interne; Rodez F-12000 France
| | - Claire Dingremont
- Centre Hospitalier de Bigorre; Service de Médecine Interne; Tarbes F-65000 France
| | - Brice Castel
- Centre Hospitalier de Lourdes; Service de Médecine Interne; Lourdes F-65107 France
| | - Sophie Arista
- Centre Hospitalier d'Auch; Service de Médecine Interne; Auch F-32000 France
| | - Laurent Sailler
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse; Toulouse F-31059 France
- UMR1027, Inserm, Université de Toulouse; Toulouse F-31073 France
- CIC 1436, Centre Hospitalier Universitaire de Toulouse; Toulouse F-31073 France
| | - Maryse Lapeyre-Mestre
- UMR1027, Inserm, Université de Toulouse; Toulouse F-31073 France
- CIC 1436, Centre Hospitalier Universitaire de Toulouse; Toulouse F-31073 France
- Service de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire de Toulouse; Toulouse F-31059 France
| | - Odile Beyne-Rauzy
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse-Oncopole; Toulouse F-31100 France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre National de Référence pour les Cytopénies Auto-Immunes de l'Adulte, Centre Hospitalier Universitaire Henri Mondor; Assistance Publique-Hôpitaux de Paris Créteil F-94010 France
| | - Daniel Adoue
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse-Oncopole; Toulouse F-31100 France
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Audia S, Mahévas M, Samson M, Godeau B, Bonnotte B. Pathogenesis of immune thrombocytopenia. Autoimmun Rev 2017; 16:620-632. [DOI: 10.1016/j.autrev.2017.04.012] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 03/17/2017] [Indexed: 01/19/2023]
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Moulis G, Lapeyre-Mestre M, Palmaro A, Sailler L. Infections in non-splenectomized persistent or chronic primary immune thrombocytopenia adults: risk factors and vaccination effect. J Thromb Haemost 2017; 15:785-791. [PMID: 28078756 DOI: 10.1111/jth.13622] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Indexed: 01/01/2023]
Abstract
Essentials The risk factors for infection in immune thrombocytopenia are not well known. We conducted a national pharmacoepidemiological study. Pulmonary disease, corticosteroids and rituximab were the main risk factors for infections. Pneumococcal and influenza vaccines were protective against infections. SUMMARY Introduction Risk factors for infection and protective effect of vaccines in immune thrombocytopenia (ITP) patients in the era of rituximab therapy are unknown. Objectives To assess the risk factors for serious and non-serious infections (respectively, SIs and NSIs) in non-splenectomized adults treated for persistent or chronic primary ITP, including the effect of pneumococcal and influenza vaccines. Patients/Methods The population was the 2009-2012 FAITH cohort (n = 1805), which is the cohort of all incident (newly diagnosed) primary ITP adults treated > 3 months in France built into the national health insurance database (SNIIRAM). SIs were hospitalizations with any infection as the primary diagnosis code. NSIs were identified using out-of-hospital antibiotic dispensing. Cox models were performed. Results Incidence rates were 6.3/100 patient-years (95% confidence interval [CI], 5.4-7.4) for SIs (lower respiratory tract in 42.8% of the cases) and 100.5/100 patient-years (95% CI, 95.0-106.3) for NSIs. In multivariate analyses, increasing age and chronic pulmonary disease were associated with both SI and NSI occurrence. The hazard ratios (HRs) for corticosteroids and rituximab were, respectively, 3.83 (95% CI, 2.76-5.31) and 2.60 (95% CI, 1.67-4.03) for SIs and 2.46 (95% CI, 2.19-2.76) and 1.49 (95% CI, 1.28-1.74) for NSIs. Pneumococcal vaccine showed a protective effect for both SIs and NSIs (0.38 [95% CI, 0.20-0.73] and 0.52 [95% CI, 0.43-0.65], respectively), as did influenza vaccine (0.42 [95% CI, 0.27-0.64] and 0.49 [95% CI, 0.41-0.59], respectively). Conclusions Chronic pulmonary disease, corticosteroids and rituximab are the main risk factors for infections, whereas pneumococcal and influenza vaccines are protective against SIs and NSIs.
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Affiliation(s)
- G Moulis
- UMR 1027, INSERM, Université de Toulouse III, Toulouse, France
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Centre d'Investigation Clinique 1436, axe pharmacoépidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - M Lapeyre-Mestre
- UMR 1027, INSERM, Université de Toulouse III, Toulouse, France
- Centre d'Investigation Clinique 1436, axe pharmacoépidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - A Palmaro
- UMR 1027, INSERM, Université de Toulouse III, Toulouse, France
- Centre d'Investigation Clinique 1436, axe pharmacoépidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - L Sailler
- UMR 1027, INSERM, Université de Toulouse III, Toulouse, France
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Centre d'Investigation Clinique 1436, axe pharmacoépidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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Affiliation(s)
- Abdulgabar Salama
- Charité - Universitätsmedizin Berlin, Germany - Institute of Transfusion Medicine, Berlin, Germany
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Palandri F, Polverelli N, Sollazzo D, Romano M, Catani L, Cavo M, Vianelli N. Have splenectomy rate and main outcomes of ITP changed after the introduction of new treatments? A monocentric study in the outpatient setting during 35 years. Am J Hematol 2016; 91:E267-72. [PMID: 26799593 DOI: 10.1002/ajh.24310] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/12/2016] [Accepted: 01/14/2016] [Indexed: 01/19/2023]
Abstract
In the last years, rituximab (RTX) and agonists of the thrombopoietin receptor (TPO-R) eltrombopag and romiplostim have provided new treatment options in persistent and chronic immune thrombocytopenia (ITP). Here, we analyzed the changes in therapeutic choices over time and their impact on clinical outcomes in a cohort of 557 ITP outpatients followed at the "L. and A. Seràgnoli" Institute of Hematology, Bologna, Italy, from 1980 to 2015. Overall 397 patients (71%) required front-line corticosteroids, mainly prednisone. Over the decades, splenectomy was delayed from second to third-line, but was steadily used in around 15-25% of patients refractory or relapsing after first-line treatment. Consensually, RTX and TPO-R agonists emerged as second and third-line therapy of choice, respectively. Splenectomy was associated with the best response rates and the lower incidences of relapse, while the relapse rate after RTX was comparable to that observed with corticosteroids and other immunosuppressive agents. The introduction of TPO-R agonists gave an alternative to the administration of immunosuppressive drugs and probably contributed to moderate the incidence of infectious complications that remained stable over the decades, despite an increasing use of RTX from the 2000s onwards. Overall responses were similar over time, with over 97% achieving a response in all time-periods. However, the cumulative risk of bleeding significantly decreased [14.3% (1980-89) vs. 7% (1990-99) vs. 5.6% (2000-09) vs. 0.2% (2010-15)] (P < 0.001), mainly thanks to the optimization of front-line corticosteroids therapy and to the wider availability of second and third-line therapies.
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Affiliation(s)
- Francesca Palandri
- Institute of Hematology “L. E A. Seràgnoli,” Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italy
| | - Nicola Polverelli
- Institute of Hematology “L. E A. Seràgnoli,” Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italy
| | - Daria Sollazzo
- Institute of Hematology “L. E A. Seràgnoli,” Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italy
| | - Marco Romano
- Institute of Hematology “L. E A. Seràgnoli,” Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italy
| | - Lucia Catani
- Institute of Hematology “L. E A. Seràgnoli,” Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italy
| | - Michele Cavo
- Institute of Hematology “L. E A. Seràgnoli,” Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italy
| | - Nicola Vianelli
- Institute of Hematology “L. E A. Seràgnoli,” Department of Experimental, Diagnostic and Specialty Medicine; University of Bologna; Italy
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Moulis G, Audemard-Verger A, Arnaud L, Luxembourger C, Montastruc F, Gaman AM, Svenungsson E, Ruggeri M, Mahévas M, Gerfaud-Valentin M, Brainsky A, Michel M, Godeau B, Lapeyre-Mestre M, Sailler L. Risk of thrombosis in patients with primary immune thrombocytopenia and antiphospholipid antibodies: A systematic review and meta-analysis. Autoimmun Rev 2016; 15:203-9. [DOI: 10.1016/j.autrev.2015.11.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/03/2015] [Indexed: 02/02/2023]
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12
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Corticosteroid Risk Function of Severe Infection in Primary Immune Thrombocytopenia Adults. A Nationwide Nested Case-Control Study. PLoS One 2015; 10:e0142217. [PMID: 26559054 PMCID: PMC4641733 DOI: 10.1371/journal.pone.0142217] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 10/19/2015] [Indexed: 12/02/2022] Open
Abstract
Corticosteroid (CS)-related infection risk in immune thrombocytopenia (ITP) is unknown. The aim of this study was to assess the adjusted CS risk function of severe infection in persistent or chronic primary ITP adults. We designed a nested case-control study in the FAITH cohort. This cohort is built through the French national health insurance database named SNIIRAM and includes all treated incident persistent or chronic primary ITP adults in France (ENCePP n°4574). Patients who entered the FAITH cohort between 2009 and 2012 were eligible (n = 1805). Cases were patients with infection as primary diagnosis code during hospitalization. Index date was the date of first hospitalization for infection. A 2:1 matching was performed on age and entry date in the cohort. Various CS exposure time-windows were defined: current user, exposure during the 1/3/6 months preceding index date and from the entry date. CS doses were converted in prednisone equivalent (PEQ). The cumulative CS doses were averaged in each time-window to obtain daily PEQ dosages. Each CS exposure definition was assessed using multivariate conditional regression models. During the study period, 161 cases (9 opportunistic) occurred. The model with the best goodness of fit was CS exposure during the month before the index date (OR: 2.48, 95% CI: 1.61–3.83). The dose-effect relation showed that the risk existed from averaged daily doses ≥5 mg PEQ (vs. <5 mg: 2.09, 95% CI: 1.17–3.71). The risk of infection was mainly supported by current or recent exposure to CS, even with low doses.
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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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14
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Roccatello D, Sciascia S, Baldovino S, Rossi D, Alpa M, Naretto C, Di Simone D, Simoncini M, Menegatti E. A 4-year observation in lupus nephritis patients treated with an intensified B-lymphocyte depletion without immunosuppressive maintenance treatment-Clinical response compared to literature and immunological re-assessment. Autoimmun Rev 2015; 14:1123-30. [PMID: 26244817 DOI: 10.1016/j.autrev.2015.07.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/29/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND B cells (BC) play a critical role in systemic lupus erythematosus (SLE). BC depletion therapy still remains an attractive option, despite the disappointing results of randomized controlled trials (RTCs). METHODS Twelve patients with SLE [3 males, mean age 43.8 yrs (25-55)] with severe multiorgan involvement all including kidney (3 patients with Class IV, 4 with Class III/V and 5 with Class V, according to the International Society of Nephrology/Renal Pathology Society glomerulonephritis classification), skin lesions [10], severe polyarthralgias with arthritis [10], polyserositis [2], and lymphadenopathy [5] have been prospectively treated with an intensified B cell depletion therapy (IBCDT) protocol due to their resistance or intolerance to previous therapy (six cases) or as a front line immunosuppressive treatment in 6 women with unsatisfactory therapeutic compliance or as a specific request of a short-time immunosuppression for gestational perspectives. PROTOCOL Rituximab (RTX) 375 mg/sm on days 1, 8, 15, 22, and 2 more doses after 1 and 2 months, associated with 2 IV administrations of 10mg/kg of cyclophosphamide and 3 methylprednisolone pulses (15mg/kg) followed by oral prednisone (0.8 mg/kg/day, rapidly tapered to 5mg/day by the end of the 3rd month after RTX). No further immunosuppressive maintenance therapy has been given. RESULTS Patients had been followed-up for a mean of 44.5 (24-93)months. Significant decreases (p<0.05) were found in the levels of ESR (baseline mean value: 55.0mm; 3 months: 36; end of follow-up: 13), anti-dsDNA antibodies (baseline: 185 U; 3 months: 107; end of follow-up: 15), and proteinuria (baseline: 4.9 g/24h; 3 months: 0.97; end of follow-up: 0.22). C4 values (baseline 11 mg/dl) significantly increased (p<0.05) after 3 months (22 mg/dl) and at the end of the follow-up (20mg/dl). Of the 12 patients, 9 (75%) have remained well after one cycle of IBCDT, with no flare (mean 51.6 months [25-93]). Three patients relapsed after 36, 41, and 72 months, respectively. Following re-treatment, they again showed complete remission over 18-48 months of observation. CONCLUSIONS A promising role of RTX in an intensified protocol of induction therapy can be envisaged in patients for whom avoiding immunosuppressive maintenance therapy and sparing steroids are particularly appealing. Moreover, our data confirm in one of the longest follow-up available, the opportunity to reconsider the regimens of BL depletion in the treatment of the most severe or refractory forms of SLE despite the disappointing results of RCTs.
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Affiliation(s)
- Dario Roccatello
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy; SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Turin, Italy.
| | - Savino Sciascia
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Simone Baldovino
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Daniela Rossi
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Mirella Alpa
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Carla Naretto
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Debora Di Simone
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Matteo Simoncini
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Elisa Menegatti
- Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
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15
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Moulis G, Lapeyre-Mestre M, Mahévas M, Montastruc JL, Sailler L. Need for an improved vaccination rate in primary immune thrombocytopenia patients exposed to rituximab or splenectomy. A nationwide population-based study in France. Am J Hematol 2015; 90:301-5. [PMID: 25557586 DOI: 10.1002/ajh.23930] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 12/17/2014] [Accepted: 12/22/2014] [Indexed: 01/19/2023]
Abstract
International guidelines on immune thrombocytopenia (ITP) management recommend vaccination against Streptococcus pneumoniae (S.p.), Haemophilus influenza b (Hib) and Neisseiria meningitidis (N.m.) before splenectomy. French guidelines also recommend these vaccinations before rituximab. The aim of this study was to assess the application of these recommendations. The French Adult ITP: a French pHarmacoepidemiological study (FAITH, n°ENCEPP 4574) is aimed at following in the French national health insurance system database (SNIIRAM) the cohort of all incident and persistent or chronic primary ITP adults treated in France. We assessed vaccine exposure in the 1,106 patients who entered the FAITH cohort between 2009 and 2011. Vaccination was said "recommended" if performed at least 2 weeks before rituximab or splenectomy accordingly with French guidelines. Among the 423 non-splenectomized patients exposed to rituximab, vaccination rates against S.p., Hib and N.m. were respectively 32.4%, 18.9%, and 3.8%. It was recommended in 12.8%, 6.6%, and 1.2% of the patients, respectively. Among the 178 splenectomized patients, vaccination rates were 70.2%, 47.0%, and 11.9%, respectively (recommended: 60.1%, 35.7%, and 9.5%). Among the splenectomized patients previously exposed to rituximab (n = 67), 53.3% of the vaccinations occurred during the semester following a rituximab infusion that is during the maximal B-cell depletion period. In multivariate analyses, a disease duration exceeding 3 months was the sole factor associated to recommended vaccination in rituximab-treated patients as well as in splenectomized patients. This study stresses the need of better and earlier vaccination of ITP patients.
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Affiliation(s)
- Guillaume Moulis
- Service De Médecine Interne; CHU De Toulouse; Toulouse F-31000 France
- Inserm; UMR1027; Toulouse; F-31000 France; Université De Toulouse III, UMR1027; Toulouse F-31000 France
| | - Maryse Lapeyre-Mestre
- Inserm; UMR1027; Toulouse; F-31000 France; Université De Toulouse III, UMR1027; Toulouse F-31000 France
- Service De Pharmacologie Médicale Et Clinique; CHU De Toulouse; Toulouse F-31000 France
| | - 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; F-94000 France; Etablissement Français Du Sang Ile De France, Inserm U955, Créteil, Hôpital Henri Mondor; Paris F-94000 France
| | - Jean-Louis Montastruc
- Inserm; UMR1027; Toulouse; F-31000 France; Université De Toulouse III, UMR1027; Toulouse F-31000 France
- Service De Pharmacologie Médicale Et Clinique; CHU De Toulouse; Toulouse F-31000 France
- Centre Midi-Pyrénées De PharmacoVigilance; De Pharmacoépidémiologie Et D'informations Sur Le Médicament; CHU De Toulouse; Toulouse F-31000 France
| | - Laurent Sailler
- Service De Médecine Interne; CHU De Toulouse; Toulouse F-31000 France
- Inserm; UMR1027; Toulouse; F-31000 France; Université De Toulouse III, UMR1027; Toulouse F-31000 France
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