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Mishra K, Jandial A, Sandal R, Meshram A, Lad D, Prakash G, Khadwal A, Kapoor R, Ahluwalia J, Varma N, Varma S, Dhiman RK, Malhotra P. Bleeding risk assessment in immune thrombocytopenia. Ann Hematol 2023; 102:3007-3014. [PMID: 37740064 DOI: 10.1007/s00277-023-05466-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/18/2023] [Indexed: 09/24/2023]
Abstract
The bleeding risk in immune thrombocytopenia (ITP) is related not only to low platelet count but also to the presence of platelet dysfunction. However, diagnosing a concomitant platelet dysfunction is challenging as most of the available platelet function assays (PFAs) require a platelet count of greater than 100,000/μL. Sonoclot coagulation and platelet function analyzer works on the principle of viscoelastometry, and results remain unaffected by the platelet counts. To assess the platelet function in adult acute ITP patients with the help of sonoclot coagulation and platelet function analyzer and correlate it with the risk of bleeding. Newly diagnosed acute ITP patients with a platelet count less than 20,000/μL were divided into two groups based on WHO bleeding grade: ITP non-bleeder (ITP-NB) group (WHO bleeding grade ≤1) and ITP bleeder (ITP-B) group (WHO bleeding grade ≥2). Platelet function was assessed by sonoclot in both groups. The patients without significant bleeding (ITP-NB) were followed up monthly for six months with the assessment of platelet function during each contact. Eighty patients (30 ITP-B and 50 ITP-NB) were prospectively included in this study. The median age of patients in the two groups was 37 years and 30 years, respectively. The female-to-male ratio was 4:1 and 1:1 in ITP-B and ITP-NB groups. The median platelet count in ITP-B and ITP-NB was 12000/μL (range 1000-19000/μL) and 8000/μL (range 1000-19000/μL), respectively. Mean platelet functions by sonoclot in both groups were lower than the normal cut-off (>1.6). However, the mean platelet function in the ITP-B group (0.2 + 0.17) was significantly lower than the ITP-NB group (1.2 ± 0.52) (p = 0.01). During the follow-up period of 6 months, patients in ITP-NB with a normal platelet function (>1.6) on sonoclot had lesser episodes (one episode) of clinically significant bleeding than patients with a low platelet function (4 episodes). Patients with acute severe thrombocytopenia and bleeding phenotype have a greater abnormality on platelet function by sonoclot than patients with non-bleeding phenotype. This information may help in taking therapeutic decisions in patients with acute ITP.
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Affiliation(s)
- Kundan Mishra
- Department of Clinical Hematology and Medical Oncology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
- Department of Clinical Hematology, Army Hospital (Research and Referral), New Delhi, 110010, India.
| | - Aditya Jandial
- Department of Clinical Hematology and Medical Oncology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Rajeev Sandal
- Department of Clinical Hematology and Medical Oncology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
- Regional Cancer Centre, Indira Gandhi Medical College, Shimla, 171001, India
| | - Ashok Meshram
- Department of Clinical Hematology and Medical Oncology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Gaurav Prakash
- Department of Clinical Hematology and Medical Oncology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Alka Khadwal
- Department of Clinical Hematology and Medical Oncology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Rajan Kapoor
- Department of Clinical Hematology, Army Hospital (Research and Referral), New Delhi, 110010, India
| | - Jasmina Ahluwalia
- Department of Hematology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Neelam Varma
- Department of Hematology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Subhash Varma
- Department of Clinical Hematology and Medical Oncology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - R K Dhiman
- Department of Hepatology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Post-Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Sandal R, Mishra K, Jandial A, Sahu KK, Siddiqui AD. Update on diagnosis and treatment of immune thrombocytopenia. Expert Rev Clin Pharmacol 2021; 14:553-568. [PMID: 33724124 DOI: 10.1080/17512433.2021.1903315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a heterogeneous acquired disorder characterized by isolated thrombocytopenia whose exact pathogenesis is not yet clear. Depending upon the presence or absence of an underlying treatable cause, ITP can be categorized as primary or secondary. Primary ITP is a diagnosis of exclusion and there is no gold standard test for its confirmation. Recent drug intake, infections, lymphoproliferative disorders, and connective tissue disorders should be ruled out before labeling a patient as primary ITP. AREA COVERED This review summarizes a comprehensive update on the diagnostic and therapeutic modalities for ITP. We reviewed the literature using GOOGLE SCHOLAR, PUBMED and ClinicalTrial.gov databases as needed to support the evidence. We searched the literature using the following keywords: 'immune thrombocytopenia,' 'idiopathic thrombocytopenic purpura,' 'thrombocytopenia,' 'immune thrombocytopenic purpura,' and 'isolated thrombocytopenia'. EXPERT OPINION We believe that more detailed studies are required to understand the exact pathophysiology behind ITP. The first-line drugs like corticosteroids have both short-term and long-term adverse effects. This brings the need to explore effective alternative medications and to reconsider their role in ITP treatment algorithm if guidelines can be modified based on new studies.
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Affiliation(s)
- Rajeev Sandal
- Dept of Clinical Hematology, IGMC, Shimla, Himachal Pradesh, India
| | - Kundan Mishra
- Department of Internal Medicine (Adult Clinical Hematology Division), Postgraduate Institute of Medical Education and Research, Chandigarh (Union Territory), India
| | - Aditya Jandial
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), Delhi, India
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Ahmad Daniyal Siddiqui
- Division of Hematology and Oncology, Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
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