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Wu D, Khan FA, Zhang K, Pandupuspitasari NS, Negara W, Guan K, Sun F, Huang C. Retinoic acid signaling in development and differentiation commitment and its regulatory topology. Chem Biol Interact 2024; 387:110773. [PMID: 37977248 DOI: 10.1016/j.cbi.2023.110773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
Retinoic acid (RA), the derivative of vitamin A/retinol, is a signaling molecule with important implications in health and disease. It is a well-known developmental morphogen that functions mainly through the transcriptional activity of nuclear RA receptors (RARs) and, uncommonly, through other nuclear receptors, including peroxisome proliferator-activated receptors. Intracellular RA is under spatiotemporally fine-tuned regulation by synthesis and degradation processes catalyzed by retinaldehyde dehydrogenases and P450 family enzymes, respectively. In addition to dictating the transcription architecture, RA also impinges on cell functioning through non-genomic mechanisms independent of RAR transcriptional activity. Although RA-based differentiation therapy has achieved impressive success in the treatment of hematologic malignancies, RA also has pro-tumor activity. Here, we highlight the relevance of RA signaling in cell-fate determination, neurogenesis, visual function, inflammatory responses and gametogenesis commitment. Genetic and post-translational modifications of RAR are also discussed. A better understanding of RA signaling will foster the development of precision medicine to improve the defects caused by deregulated RA signaling.
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Affiliation(s)
- Di Wu
- Institute of Reproductive Medicine, School of Medicine, Nantong University, Nantong, 226001, China
| | - Faheem Ahmed Khan
- Research Center for Animal Husbandry, National Research and Innovation Agency, Jakarta Pusat, 10340, Indonesia
| | - Kejia Zhang
- Institute of Reproductive Medicine, School of Medicine, Nantong University, Nantong, 226001, China
| | | | - Windu Negara
- Research Center for Animal Husbandry, National Research and Innovation Agency, Jakarta Pusat, 10340, Indonesia
| | - Kaifeng Guan
- School of Advanced Agricultural Sciences, Peking University, Beijing, 100871, China.
| | - Fei Sun
- Institute of Reproductive Medicine, School of Medicine, Nantong University, Nantong, 226001, China.
| | - Chunjie Huang
- Institute of Reproductive Medicine, School of Medicine, Nantong University, Nantong, 226001, China.
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2
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González-López TJ, Provan D, Bárez A, Bernardo-Gutiérrez A, Bernat S, Martínez-Carballeira D, Jarque-Ramos I, Soto I, Jiménez-Bárcenas R, Fernández-Fuertes F. Primary and secondary immune thrombocytopenia (ITP): Time for a rethink. Blood Rev 2023; 61:101112. [PMID: 37414719 DOI: 10.1016/j.blre.2023.101112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/07/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
There are not many publications that provide a holistic view of the management of primary and secondary ITP as a whole, reflecting the similarities and differences between the two. Given the lack of major clinical trials, we believe that comprehensive reviews are much needed to guide the diagnosis and treatment of ITP today. Therefore, our review addresses the contemporary diagnosis and treatment of ITP in adult patients. With respect to primary ITP we especially focus on establishing the management of ITP based on the different and successive lines of treatment. Life-threatening situations, "bridge therapy" to surgery or invasive procedures and refractory ITP are also comprehensively reviewed here. Secondary ITP is studied according to its pathogenesis by establishing three major differential groups: Immune Thrombocytopenia due to Central Defects, Immune Thrombocytopenia due to Blocked Differentiation and Immune Thrombocytopenia due to Defective Peripheral Immune Response. Here we provide an up-to-date snapshot of the current diagnosis and treatment of ITP, including a special interest in addressing rare causes of this disease in our daily clinical practice. The target population of this review is adult patients only and the target audience is medical professionals.
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Affiliation(s)
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Abelardo Bárez
- Department of Hematology. Complejo Asistencial de Ávila, Ávila, Spain
| | | | - Silvia Bernat
- Department of Hematology, Hospital Universitario de la Plana, Villarreal, Castellón, Spain
| | | | - Isidro Jarque-Ramos
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inmaculada Soto
- Department of Hematology, Hospital Central de Asturias, Oviedo, Asturias, Spain
| | | | - Fernando Fernández-Fuertes
- Department of Hematology, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
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3
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Lavudi K, Nuguri SM, Olverson Z, Dhanabalan AK, Patnaik S, Kokkanti RR. Targeting the retinoic acid signaling pathway as a modern precision therapy against cancers. Front Cell Dev Biol 2023; 11:1254612. [PMID: 37645246 PMCID: PMC10461636 DOI: 10.3389/fcell.2023.1254612] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/28/2023] [Indexed: 08/31/2023] Open
Abstract
Retinoic acid (RA) is a vital metabolite derived from vitamin A. RA plays a prominent role during development, which helps in embryological advancement and cellular differentiation. Mechanistically, RA binds to its definite nuclear receptors including the retinoic acid receptor and retinoid X receptor, thus triggering gene transcription and further consequences in gene regulation. This functional heterodimer activation later results in gene activation/inactivation. Several reports have been published related to the detailed embryonic and developmental role of retinoic acids and as an anti-cancer drug for specific cancers, including acute promyelocytic leukemia, breast cancer, and prostate cancer. Nonetheless, the other side of all-trans retinoic acid (ATRA) has not been explored widely yet. In this review, we focused on the role of the RA pathway and its downstream gene activation in relation to cancer progression. Furthermore, we explored the ways of targeting the retinoic acid pathway by focusing on the dual role of aldehyde dehydrogenase (ALDH) family enzymes. Combination strategies by combining RA targets with ALDH-specific targets make the tumor cells sensitive to the treatment and improve the progression-free survival of the patients. In addition to the genomic effects of ATRA, we also highlighted the role of ATRA in non-canonical mechanisms as an immune checkpoint inhibitor, thus targeting the immune oncological perspective of cancer treatments in the current era. The role of ATRA in activating independent mechanisms is also explained in this review. This review also highlights the current clinical trials of ATRA in combination with other chemotherapeutic drugs and explains the future directional insights related to ATRA usage.
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Affiliation(s)
- Kousalya Lavudi
- Department of Radiation Oncology, College of Medicine, The Ohio State University, Columbus, OH, United States
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
- School of Biotechnology, KIIT University, Bhubaneswar, Odisha, India
| | - Shreya Madhav Nuguri
- Department of Food Science and Technology, The Ohio State University, Columbus, OH, United States
| | - Zianne Olverson
- Department of Radiation Oncology, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Anantha Krishna Dhanabalan
- Centre for Advanced Study in Crystallography and Biophysics, University of Madras, Guindy Campus, Chennai, India
| | - Srinivas Patnaik
- School of Biotechnology, KIIT University, Bhubaneswar, Odisha, India
| | - Rekha Rani Kokkanti
- Department of Biotechnology, Sri Padmavati Mahila Visvavidyalayam, Tirupati, Andhra Pradesh, India
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Shen N, Qiao J, Jiang Y, Yin H, Li M, Zhu S, Li J. Safety of non‑peptide thrombopoietin receptor agonists in patients with immune thrombocytopenia: A systematic review and meta‑analysis of short‑term double‑blind randomized clinical trials. Exp Ther Med 2023; 26:393. [PMID: 37456173 PMCID: PMC10347292 DOI: 10.3892/etm.2023.12092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023] Open
Abstract
The aim of the present study was to analyze the safety of non-peptide thrombopoietin receptor agonists (TPO-RAs) for immune thrombocytopenia (ITP) treatment. All studies reporting adverse events (AEs) in relation to ITP treatment with eltrombopag, avatrombopag, and hetrombopag were retrieved from PubMed, Web of Science, and Embase databases. RevMan 5.4.1 was used for meta-analysis, heterogeneity and bias analyses. A total of 1,078 patients from seven eligible studies were enrolled. In the enrolled clinical trials, the double-blind period was between 6 weeks and 6 months. The results revealed that the chances of any AEs [relative risk (RR)=1.16; 95% confidence interval (CI), 0.90-1.51; I2=78%; P=0.26], grade 3/4 AEs (RR=1.07; 95% CI, 0.63-1.80; I2=0%; P=0.81), elevated transaminase levels (RR=1.09; 95% CI, 0.68-1.74; I2=0%; P=0.72), thrombosis (RR=1.92; 95% CI, 0.55-6.66; I2=0%; P=0.31) and cataracts (RR=0.83; 95% CI, 0.38-1.83; I2=0%; P=0.65) were not significantly higher in patients with ITP that received non-peptide TPO-RAs compared with patients with ITP treated with a placebo. The present study indicated that non-peptide TPO-RAs were relatively safe for patients with ITP, at least within 6 months of administration.
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Affiliation(s)
- Nan Shen
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
- Department of Hematology, The Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Jibing Qiao
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Yazhou Jiang
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Hanjun Yin
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Min Li
- Department of Hematology, The Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Suyue Zhu
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Jianqin Li
- Department of Hematology, The Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
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Yang J, Zhao L, Wang W, Wu Y. All-trans retinoic acid added to treatment of primary immune thrombocytopenia: a systematic review and meta-analysis. Ann Hematol 2023:10.1007/s00277-023-05263-w. [PMID: 37166528 DOI: 10.1007/s00277-023-05263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
All-trans retinoic acid (ATRA) application is a novel treatment approach for primary immune thrombocytopenia (ITP). This study aimed to evaluate the efficacy and safety of ATRA in the treatment of ITP. The databases of PubMed (MEDLINE), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and China National Knowledge Internet were searched on August 5, 2022, to find randomized controlled trials (RCTs) and observational studies. Five observational studies and four RCTs from China were included, and 760 Chinese patients were analyzed. In the five observational studies, the pooled overall response rate (ORR) and complete response rate (CRR) were 59.5% (95% confidence interval [CI], 52.4-66.4%) and 20.6% (95% CI, 14.3-27.6%), respectively. In the selected four RCTs, the pooled odds ratios for sustained response rate, ORR, and CRR were 3.00 (95% CI, 1.97-4.57; P < 0.01), 3.21 (95% CI, 2.15-4.78; P < 0.01), and 2.12 (95% CI, 1.17-3.86; P = 0.01), respectively. ATRA was associated with a reduction in relapse rate and salvage treatment rate (odds ratio, 0.30; 95% CI, 0.18-0.50; P < 0.01; 0.36; 95% CI, 0.23-0.56; P < 0.01, respectively). The pooled odds ratios for grade 1-2 dry skin, headache (or dizziness), and rash acneiform were 49.99 (95% CI, 16.05-155.67; P < 0.01), 1.75 (95% CI, 0.98-3.12; P = 0.06), and 0.37 (95% CI, 0.10-1.34; P = 0.13), respectively. This study suggests that ATRA may significantly improve the initial and long-term response of patients with ITP.
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Affiliation(s)
- Jinjun Yang
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Lei Zhao
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Wen Wang
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
| | - Yu Wu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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6
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Rodeghiero F. Recent progress in ITP treatment. Int J Hematol 2023; 117:316-330. [PMID: 36622549 DOI: 10.1007/s12185-022-03527-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 01/10/2023]
Abstract
In this review, the recently approved drugs avatrombopag and fostamatinib, which were not extensively covered within 2019 international recommendations for ITP, will be discussed in some detail. Avatrombopag appears more convenient than eltrombopag as it does not require dietary restrictions or subcutaneous administration like romiplostim. However, data on quality of life (QoL) are lacking and the rate of thromboembolic events in exposed patients is not negligible. Efficacy of fostamatinib, an inhibitor of macrophagic activity, is supported by placebo-controlled trials in patients refractory to several therapies, including TPO-RA. While hypertension and diarrhea have been reported, only one minor thrombotic event occurred in 146 exposed patients. In addition, several new treatment combinations and new agents entered clinical investigation in recent years. In a UK trial, combining mycophenolate mofetil with corticosteroids as first line therapy was more effective than corticosteroids alone, but at the cost of worse QoL. No combination, including oseltamivir or all-trans retinoic acid or danazol, resulted in convincing evidence of superior efficacy and safety when used in first or later lines of treatment. Agents targeting specific mechanisms are also discussed: sutimlimab (complement inhibitor); rilzabrutinib (BTK inhibitor) and efgartigimod (modified Fc fragment inhibiting FcRn). Only efgartigimod has completed phase 3 investigation.
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Affiliation(s)
- Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Hematology, "S. Bortolo" Hospital, Contrà San Francesco 41, 36100, Vicenza, Italy.
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Ou Y, Zhan Y, Zhuang X, Shao X, Xu P, Li F, Chen H, Ji L, Cheng Y. A bibliometric analysis of primary immune thrombocytopenia from 2011 to 2021. Br J Haematol 2023; 201:954-970. [PMID: 36807900 DOI: 10.1111/bjh.18692] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/22/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia. This bibliometric analysis was applied to identify the characteristics of global scientific output, the hotspots, and frontiers of ITP over the past 10 years. We retrieved publications from 2011 to 2021 from the Web of Science Core Collection (WoSCC). Bibliometrix package, VOSviewer, and Citespace were used to analyse and visualize the trend, distribution, and hotspots of research on ITP. Altogether, there were 2084 papers, written by 9080 authors from 410 organizations in 70 countries/regions, published in 456 journals with 37 160 co-cited references. In the last decades, the most productive journal was British Journal of Haematology, China was the most productive country. and the most cited journal was Blood. Shandong University was the most productive institution in the field of ITP. NEUNERT C, 2011, BLOOD, CHENG G, 2011, LANCET, and PATEL VL, 2012, BLOOD were the top three most cited documents. "Thrombopoietin receptor agonist", "regulatory T cell" and "sialic acid" were three hotspots of the last decade. And "immature platelet fraction", "Th17", and "fostamatinib" would be research frontiers in the feature. The present study provided a novel insight for future research directions and scientific decision-making.
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Affiliation(s)
- Yang Ou
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yanxia Zhan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xibing Zhuang
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xia Shao
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pengcheng Xu
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China
| | - Hao Chen
- Zhongshan Hospital Xuhui Branch, Department of Thoracic Surgery, Fudan University, Shanghai, China
| | - Lili Ji
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yunfeng Cheng
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China.,Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai, China
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Liu XG, Hou Y, Hou M. How we treat primary immune thrombocytopenia in adults. J Hematol Oncol 2023; 16:4. [PMID: 36658588 PMCID: PMC9850343 DOI: 10.1186/s13045-023-01401-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an immune-mediated bleeding disorder characterized by decreased platelet counts and an increased risk of bleeding. Multiple humoral and cellular immune abnormalities result in accelerated platelet destruction and suppressed platelet production in ITP. The diagnosis remains a clinical exclusion of other causes of thrombocytopenia. Treatment is not required except for patients with active bleeding, severe thrombocytopenia, or cases in need of invasive procedures. Corticosteroids, intravenous immunoglobulin, and anti-RhD immunoglobulin are the classical initial treatments for newly diagnosed ITP in adults, but these agents generally cannot induce a long-term response in most patients. Subsequent treatments for patients who fail the initial therapy include thrombopoietic agents, rituximab, fostamatinib, splenectomy, and several older immunosuppressive agents. Other potential therapeutic agents, such as inhibitors of Bruton's tyrosine kinase and neonatal Fc receptor, are currently under clinical evaluation. An optimized treatment strategy should aim at elevating the platelet counts to a safety level with minimal toxicity and improving patient health-related quality of life, and always needs to be tailored to the patients and disease phases. In this review, we address the concepts of adult ITP diagnosis and management and provide a comprehensive overview of current therapeutic strategies under general and specific situations.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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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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10
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Systemic lupus erythematosus-complicating immune thrombocytopenia: From pathogenesis to treatment. J Autoimmun 2022; 132:102887. [PMID: 36030136 DOI: 10.1016/j.jaut.2022.102887] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022]
Abstract
Immune thrombocytopenia (ITP) is a common hematological manifestation of systemic lupus erythematosus (SLE). The heterogeneity of its clinical characteristics and therapeutic responses reflects a complex pathogenesis. A better understanding of its pathophysiological mechanisms and employing an optimal treatment regimen is therefore important to improve the response rate and prognosis, and avoid unwanted outcomes. Besides glucocorticoids, traditional immunosuppressants (i.e. cyclosporine, mycophenolate mofetil) and intravenous immunoglobulins, new therapies are emerging and promising for the treatment of intractable SLE-ITP, such as thrombopoietin receptor agonists (TPO-RAs), platelet desialylation inhibitors(i.e. oseltamivir), B-cell targeting therapy(i.e. rituximab, belimumab), neonatal Fc receptor(FcRn) inhibitor, spleen tyrosine kinase(Syk) inhibitor and Bruton tyrosine kinase(BTK) inhibitor et al., although more rigorous randomized controlled trials are needed to substantiate their efficacy. In this review, we update our current knowledge on the pathogenesis and treatment of SLE-ITP.
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Lv Y, Shi H, Liu H, Zhou L. Current therapeutic strategies and perspectives in refractory ITP: What have we learned recently? Front Immunol 2022; 13:953716. [PMID: 36003388 PMCID: PMC9393521 DOI: 10.3389/fimmu.2022.953716] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an acquired autoimmune bleeding disorder featured by increased platelet destruction and deficient megakaryocyte maturation. First-line treatments include corticosteroids, intravenous immunoglobulin and intravenous anti-D immunoglobulin. Second-line treatments consist of rituximab, thrombopoietin receptor agonists and splenectomy. Although most patients benefit from these treatments, an individualized treatment approach is warranted due to the large heterogeneity among ITP patients. In addition, ITP patients may relapse and there remains a subset of patients who become refractory to treatments. The management of these refractory patients is still a challenge. This review aims to summarize emerging therapeutic approaches for refractory ITP in several categories according to their different targets, including macrophages, platelets/megakaryocytes, T cells, B cells, and endothelial cells. Moreover, current management strategies and combination regimens of refractory ITP are also discussed.
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Affiliation(s)
- Yue Lv
- Department of Hematology, Affiliated Hospital and Medical School of Nantong University, Nantong, China
| | - Huiping Shi
- Soochow University Medical College, Suzhou, China
| | - Hong Liu
- Department of Hematology, Affiliated Hospital and Medical School of Nantong University, Nantong, China
- *Correspondence: Lu Zhou, ; Hong Liu,
| | - Lu Zhou
- Department of Hematology, Affiliated Hospital and Medical School of Nantong University, Nantong, China
- *Correspondence: Lu Zhou, ; Hong Liu,
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12
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Gómez-Almaguer D, Rojas-Guerrero EA, Gómez-De León A, Colunga-Pedraza PR, Jaime-Pérez JC. Alternatives for managing patients with newly diagnosed immune thrombocytopenia: a narrative review. Expert Rev Hematol 2022; 15:493-501. [PMID: 35615916 DOI: 10.1080/17474086.2022.2082936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is an acquired bleeding disorder. Conventionally, first-line ITP therapy aims to obtain a rapid response and stop or decrease the risk of bleeding by increasing the platelet count. At this point, the duration of the response, the tolerability, and the long-term safety of pharmacologic interventions are considered less of a priority. Combination treatments that simultaneously address multiple disease mechanisms are an attractive strategy to increase efficacy in acute ITP therapy. In this review, we discuss the treatment of newly diagnosed ITP patients, emphasizing the use of new combinations to benefit from their synergy. AREAS COVERED This article summarizes conventional treatment, recent and novel combinations, and COVID-19 management recommendations of newly diagnosed ITP patients. EXPERT OPINION The key areas for improvement consider the long-term effects of conventional first-line therapy, reducing relapse rates, and extending responses to achieve long-term remission. Although corticosteroids remain first-line therapy, restricting their use to avoid toxicity and the increasing use of rituximab and TPO-RAs in the first three months after diagnosis open the landscape for future interventions in frontline therapy for ITP. First-line therapy intensification or synergistic drug combination offers a potential and realistic shift in future treatment guidelines.
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Affiliation(s)
- David Gómez-Almaguer
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Edgar A Rojas-Guerrero
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Andrés Gómez-De León
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Perla R Colunga-Pedraza
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - José C Jaime-Pérez
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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13
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Al-Badr AA. Danazol. PROFILES OF DRUG SUBSTANCES, EXCIPIENTS, AND RELATED METHODOLOGY 2022; 47:149-326. [PMID: 35396014 DOI: 10.1016/bs.podrm.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A comprehensive profile of danazol describing the nomenclatures, formulae, elemental composition, appearance, uses and applications is presented. The profile contains the method which was utilized for the preparation of the drug substance and its respective scheme is outlined. The physical characteristics of the drug including the solubility, X-ray powder diffraction pattern, differential scanning calorimetry, thermal behavior and spectroscopic studies are described. The methods which were used for the analysis of the drug substance in bulk drug and/or in pharmaceutical formulations including the compendial, spectrophotometric, electrochemical and the chromatographic methods are reported. The stability, toxicity, pharmacokinetics, bioavailability, drug evaluation and monitoring, comparisons, pharmacology, in addition to several compiled reviews on the drug substance which were involved. Finally, two hundred and seventy-nine references are listed at the end of this profile.
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Affiliation(s)
- Abdullah A Al-Badr
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia
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14
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Vianelli N, Auteri G, Buccisano F, Carrai V, Baldacci E, Clissa C, Bartoletti D, Giuffrida G, Magro D, Rivolti E, Esposito D, Podda GM, Palandri F. Refractory primary immune thrombocytopenia (ITP): current clinical challenges and therapeutic perspectives. Ann Hematol 2022; 101:963-978. [PMID: 35201417 PMCID: PMC8867457 DOI: 10.1007/s00277-022-04786-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/01/2022] [Indexed: 01/19/2023]
Abstract
Chronic primary immune thrombocytopenia (ITP) can today benefit from multiple therapeutic approaches with proven clinical efficacy, including rituximab, thrombopoietin receptor agonists (TPO-RA), and splenectomy. However, some ITP patients are unresponsive to multiple lines of therapy with prolonged and severe thrombocytopenia. The diagnosis of refractory ITP is mainly performed by exclusion of other disorders and is based on the clinician's expertise. However, it significantly increases the risk of drug-related toxicity and of bleedings, including life-threatening events. The management of refractory ITP remains a major clinical challenge. Here, we provide an overview of the currently available treatment options, and we discuss the emerging rationale of new therapeutic approaches and their strategic combination. Particularly, combination strategies may target multiple pathogenetic mechanisms and trigger additive or synergistic effects. A series of best practices arising both from published studies and from real-life clinical experience is also included, aiming to optimize the management of refractory ITP.
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Affiliation(s)
- Nicola Vianelli
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Francesco Buccisano
- Dipartimento Di Biomedicina E Prevenzione, Università Tor Vergata, Rome, Italy
| | | | | | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | | | | | - Elena Rivolti
- Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniela Esposito
- Presidio Ospedaliero San G. Moscati Di Aversa - ASL Caserta, Caserta, Italy
| | - Gian Marco Podda
- Medicina III, Ospedale San Paolo, ASST Santi Paolo E Carlo, Dipartimento Di Scienze Della Salute, Università Degli Studi Di Milano, Milano, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.
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15
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Xiao M, Zhou P, Sun K. Effect of Therapeutically Related Drugs on Coagulation-Anticoagulation Balance in Acute Promyelocytic Leukemia. Clin Appl Thromb Hemost 2022; 28:10760296221080166. [PMID: 35187963 PMCID: PMC8864259 DOI: 10.1177/10760296221080166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute promyelocytic leukemia (APL) usually presents with a series of
coagulation-anticoagulation disturbance. Early administration of All-trans retinoic acid
(ATRA) can reduce the risk of bleeding, but the potential for thrombosis needs to be
addressed in some cases. The role of arsenic agent in correcting coagulation disorder
remains to be studied, but oral arsenic agent shows potential advantages in coagulation
recovery compared with intravenous agent, and chemotherapy can aggravate the progress of
coagulation disease. In addition to early application of ATRA, avoiding invasive
procedures and transfusion support can reduce the risk of bleeding. Whether the
administration of heparin, thrombomodulin, recombinant factor VIIa or antifibrinolytics
reduces the risk of bleeding and thrombosis associated with APL remains to be further
explored, and their routine use outside of clinical trials is not recommended. This
article reviews the effects of related drugs on coagulation-anticoagulation balance in APL
patients.
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Affiliation(s)
- Mengyu Xiao
- Department of Hematology, 12636Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Pan Zhou
- Department of Hematology, 12636Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Kai Sun
- Department of Hematology, 12636Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
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16
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Wu YJ, Liu H, Zeng QZ, Liu Y, Wang JW, Wang WS, Jia-Feng, Zhou HB, Huang QS, He Y, Fu HX, Zhu XL, Jiang Q, Jiang H, Chang YJ, Xu LP, Huang XJ, Zhang XH. All- trans retinoic acid plus low-dose rituximab vs low-dose rituximab in corticosteroid-resistant or relapsed ITP. Blood 2022; 139:333-342. [DOI: i:10.1182/blood.2021013393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Abstract
The study aimed to compare the efficacy and safety of all-trans retinoic acid (ATRA) plus low-dose rituximab (LD-RTX) with LD-RTX monotherapy in corticosteroid-resistant or relapsed immune thrombocytopenia (ITP) patients. Recruited patients were randomized at a ratio of 2:1 into 2 groups: 112 patients received LD-RTX plus ATRA, and 56 patients received LD-RTX monotherapy. Overall response (OR), defined as achieving a platelet count of ≥30 × 109/L confirmed on ≥2 separate occasions (≥7 days apart), at least a doubling of the baseline platelet count without any other ITP-specific treatment, and the absence of bleeding within 1 year after enrollment, was observed in more patients in the LD-RTX plus ATRA group (80%) than in the LD-RTX monotherapy group (59%) (between-group difference, 0.22; 95% CI, 0.07-0.36). Sustained response (SR), defined as maintenance of a platelet count >30 × 109/L, an absence of bleeding, and no requirement for any other ITP-specific treatment for 6 consecutive months after achievement of OR during 1 year following enrollment, was achieved by 68 (61%) patients in the combination group and 23 (41%) patients in the monotherapy group (between-group difference, 0.20; 95% CI, 0.04-0.35). The 2 most common adverse events (AEs) for the combination group were dry skin and headache or dizziness. Our findings demonstrated that ATRA plus LD-RTX significantly increased the overall and sustained response, indicating a promising treatment option for corticosteroid-resistant or relapsed adult ITP. This study is registered at www.clinicaltrials.gov as #NCT03304288.
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Affiliation(s)
- Ye-Jun Wu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hui Liu
- Department of Hematology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Qiao-Zhu Zeng
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yi Liu
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wen-Sheng Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Jia-Feng
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China; and
| | - He-Bing Zhou
- Department of Hematology, The Affiliated Beijing Luhe Hospital of Capital Medical University, Beijing, China
| | - Qiu-Sha Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yun He
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hai-Xia Fu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Lu Zhu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qian Jiang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hao Jiang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ying-Jun Chang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lan-Ping Xu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Jun Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
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17
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Bussel J, Cooper N, Boccia R, Zaja F, Newland A. Immune thrombocytopenia. Expert Rev Hematol 2021; 14:1013-1025. [PMID: 34720027 DOI: 10.1080/17474086.2021.1995347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a low platelet count (<100 × 109/L) with an increased risk of bleeding. Recent (2019) guidelines from the International Consensus Report (ICR) expert panel and the American Society of Hematology (ASH) provide updated recommendations for the diagnosis and management of ITP. AREAS COVERED The 2019 ICR and ASH guidelines are reviewed, and differences and similarities highlighted. Clinical approaches to the treatment of ITP are discussed, including the role of fostamatinib which is an approved treatment option in adult patients who are refractory to other treatments. EXPERT OPINION The 2019 ICR and ASH guidelines reflect recent changes in the management of ITP. Current treatment approaches for ITP are more rational and evidence-based than in the past. Patients should be treated based on their needs rather than on disease stage, and patient-specific outcomes, (e.g. quality of life) should be considered. Whilst corticosteroids are the mainstay of initial ITP treatment their use should be limited. For subsequent treatment, the use of thrombopoietin receptor agonist (TPO-RA) agents, fostamatinib and rituximab in adults is supported by robust evidence. Rituximab and recently approved fostamatinib offer viable alternatives to splenectomy.
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Affiliation(s)
- James Bussel
- Professor Emeritus, Weill Cornell Medicine, New York, USA
| | - Nichola Cooper
- Senior Lecturer and Honorary Consultant Haematologist, Imperial College, London, UK
| | - Ralph Boccia
- Clinical Associate Professor of Medicine, Georgetown University, Washington DC and Medical Director, Center for Cancer and Blood Disorders, Bethesda, USA
| | - Francesco Zaja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Sc Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Adrian Newland
- Professor of Haematology, Barts and the London School of Medicine and Dentistry, London, UK
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18
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All-trans retinoic acid plus low-dose rituximab vs low-dose rituximab in corticosteroid-resistant or relapsed ITP. Blood 2021; 139:333-342. [PMID: 34665865 DOI: 10.1182/blood.2021013393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
The study aimed to compare the efficacy and safety of all-trans retinoic acid (ATRA) plus low-dose rituximab (LD-RTX) with LD-RTX monotherapy in corticosteroid-resistant or relapsed immune thrombocytopenia (ITP) patients. Recruited patients were randomized at a ratio of 2:1 into 2 groups: 112 patients received LD-RTX plus ATRA and 56 patients received LD-RTX monotherapy. Overall response (OR), defined as achieving a platelet count of ≥ 30 × 109/L confirmed on at least two separate occasions (at least 7 days apart), at least a doubling of the baseline platelet count without any other ITP-specific treatment and the absence of bleeding within 1 year after enrollment, was observed in more patients in the LD-RTX plus ATRA group (80%) than in the LD-RTX monotherapy group (59%) (between-group difference, 0.22; 95% CI, 0.07 to 0.36). Sustained response (SR), defined as maintenance of a platelet count > 30 x 109/L, an absence of bleeding, and no requirement for any other ITP-specific treatment for 6 consecutive months after achievement of OR during 1 year following enrollment, was achieved by 68 (61%) patients in the combination group and 23 (41%) patients in the monotherapy group (between-group difference, 0.20; 95% CI, 0.04 to 0.35). The 2 most common AEs for the combination group were dry skin and headache or dizziness. Our findings demonstrated that ATRA plus LD-RTX significantly increased the overall and sustained response, indicating a promising treatment option for corticosteroid-resistant or relapsed adult ITP. This study is registered at www.clinicaltrials.gov as #NCT03304288.
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19
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Gabarin N, Arnold DM. All-trans retinoic acid for treating immune thrombocytopenia: new purpose for an old drug? LANCET HAEMATOLOGY 2021; 8:e672-e673. [PMID: 34560008 DOI: 10.1016/s2352-3026(21)00269-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Nadia Gabarin
- Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; McMaster Center for Transfusion Research, McMaster University, Hamilton, ON L8N 3Z5, Canada.
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20
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Huang QS, Liu Y, Wang JB, Peng J, Hou M, Liu H, Feng R, Wang JW, Xu LP, Wang Y, Huang XJ, Zhang XH. All-trans retinoic acid plus high-dose dexamethasone as first-line treatment for patients with newly diagnosed immune thrombocytopenia: a multicentre, open-label, randomised, controlled, phase 2 trial. LANCET HAEMATOLOGY 2021; 8:e688-e699. [PMID: 34560012 DOI: 10.1016/s2352-3026(21)00240-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/26/2021] [Accepted: 07/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND High-dose dexamethasone is the standard initial treatment for patients with immune thrombocytopenia, but many patients still relapse and require further treatments. All-trans retinoic acid has been shown to exert immunomodulatory effects and promote thrombopoiesis, and so we aimed to assess the activity and safety of all-trans retinoic acid plus high-dose dexamethasone as a first-line treatment for newly diagnosed patients with immune thrombocytopenia. METHODS This multicentre, open-label, randomised, controlled, phase 2 trial was done at six different tertiary medical centres in China. Eligible participants were adults (aged >18 years) with treatment-naive, newly diagnosed, primary immune thrombocytopenia who had either a platelet count of less than 30 × 109 platelets per L or a platelet count of less than 50 × 109 platelets per L and clinically significant bleeding. We randomly assigned (1:1) participants to receive either all-trans retinoic acid (10 mg orally twice daily for 12 weeks) plus high-dose dexamethasone (40 mg/day intravenously for 4 consecutive days) or high-dose dexamethasone alone using a central, web-based randomisation system. If patients did not respond by day 14, the 4-day course of dexamethasone was repeated. The primary endpoint was 6-month sustained response, defined as the maintenance of a platelet count of at least 30 × 109 platelets per L and at least 2-times higher than the baseline count and the absence of bleeding, with no need for rescue medication at this time. The primary endpoint was analysed by intention-to-treat and safety was assessed in all participants who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov, NCT04217148, and is now completed. FINDINGS Between Jan 1, 2020, and June 30, 2020, 132 patients were randomly assigned to either all-trans retinoic acid plus high-dose dexamethasone (n=66) or high-dose dexamethasone alone (n=66). Three patients did not receive their allocated treatment, leaving 129 in the safety analysis set. At 6 months, a significantly higher proportion of participants in the all-trans retinoic acid plus high-dose dexamethasone group (45 [68%] of 66) than in the high-dose dexamethasone monotherapy group (27 [41%] of 66) had a sustained response (OR 3·095, 95% CI 1·516-6·318; p=0·0017). The most common adverse events were dry skin (31 [48%] of 64 patients), headaches (12 [19%]), and insomnia (12 [19%]) in the combination group, and insomnia (ten [15%] of 65 patients) and anxiety or mood disorders (eight [12%]) in the monotherapy group. Both treatments were well tolerated and no grade 4 or worse adverse events occurred. There were no treatment-related deaths. INTERPRETATION The combination of all-trans retinoic acid and high-dose dexamethasone was safe and active in newly diagnosed patients with primary immune thrombocytopenia, providing a sustained response. This regimen represents a potential first-line treatment in this setting, but further studies are needed to validate its efficacy and safety. FUNDING The Beijing Municipal Science and Technology Commission, the National Natural Science Foundation of China, the Beijing Natural Science Foundation, the National Key Research and Development Program of China, and the Foundation for Innovative Research Groups of the National Natural Science Foundation of China.
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Affiliation(s)
- Qiu-Sha Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yi Liu
- Department of Hematology, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Jing-Bo Wang
- Department of Hematology, Beijing Aerospace General Hospital, Beijing, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Hui Liu
- Department of Hematology, National Centre of Gerontology, Beijing Hospital, Beijing, China
| | - Ru Feng
- Department of Hematology, National Centre of Gerontology, Beijing Hospital, Beijing, China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Beijing, China
| | - Lan-Ping Xu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yang Wang
- Biological Information and Statistics Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Jun Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China.
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21
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Cuker A, Liebman HA. Corticosteroid overuse in adults with immune thrombocytopenia: Cause for concern. Res Pract Thromb Haemost 2021; 5:e12592. [PMID: 34466771 PMCID: PMC8387601 DOI: 10.1002/rth2.12592] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/20/2021] [Accepted: 08/02/2021] [Indexed: 01/20/2023] Open
Abstract
Corticosteroids remain a crucial component of first-line therapy for immune thrombocytopenia (ITP) due to low cost, high initial response rates, and acceptable short-term tolerability. However, extended and recurrent use of corticosteroids is associated with substantial toxicity. Survey studies indicate that >95% of patients with ITP treated with corticosteroids report adverse effects, more than one-third of whom require reduction or discontinuation of treatment. In light of the heavy treatment burden of prolonged corticosteroid exposure, clinical practice guidelines recommend limiting corticosteroid treatment to no more than 6 weeks in adults with ITP receiving initial therapy. For patients who require subsequent therapy, clinical practice guidelines recommend treatments more suitable for long-term disease control such as thrombopoietin receptor agonists, rituximab, other immune-modulating medications, or splenectomy, rather than repeated courses of corticosteroids. Despite these recommendations, real-world evidence suggests that corticosteroids remain the most frequently used treatment for adults with ITP, not only in the first line, but also in the second and third line. In this review, we summarize evidence on the efficacy, safety, and tolerability of corticosteroids; discuss the problem of overuse; and suggest strategies for curtailing the excessive use of corticosteroids in adults with ITP.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Howard A. Liebman
- Jane Anne Nohl Division of HematologyDepartment of MedicineNorris Cancer CenterUniversity of Southern California‐Keck School of MedicineLos AngelesCAUSA
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22
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Dixit K, Chaudhari D, Dhotre D, Shouche Y, Saroj S. Restoration of dysbiotic human gut microbiome for homeostasis. Life Sci 2021; 278:119622. [PMID: 34015282 DOI: 10.1016/j.lfs.2021.119622] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/08/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023]
Abstract
The human microbiome is a complex and dynamic ecosystem, and the imbalance of its microbial community structure from the normal state is termed dysbiosis. The dysbiotic gut microbiome has been proved to be related to several pathological conditions like Inflammatory Bowel Disease (IBD), Irritable Bowel Syndrome (IBS), Colorectal Cancer (CRC), etc., and several other extra-intestinal conditions like Type 1 & 2 diabetes, obesity, etc. The complex gut microbial ecosystem starts to build before the birth of an individual. It is known to get affected by several factors such as birth mode, individual lifestyle, dietary practices, medications, and antibiotics. A dysbiotic microbiome can potentially hamper host homeostasis due to its role in immune modulation, metabolism, nutrient synthesis, etc. Restoration of the dysbiotic gut microbiome has emerged as a promising aid and a better therapeutic approach. Several approaches have been investigated to achieve this goal, including prebiotics and probiotics, Fecal Microbiota Transplantation (FMT), extracellular vesicles, immune modulation, microbial metabolites, dietary interventions, and phages. This review discusses the various factors that influence the human microbiome with respect to their cause-effect relationship and the effect of gut microbiome compositional changes on the brain through the gut-brain axis. We also discuss the practices used globally for gut microbiome restoration purposes, along with their effectiveness.
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Affiliation(s)
- Kunal Dixit
- Symbiosis School of Biological Sciences (SSBS), Symbiosis International (Deemed University), Pune, India
| | - Diptaraj Chaudhari
- National Center for Microbial Resource (NCMR), National Center for Cell Science (NCCS), Pune, India
| | - Dhiraj Dhotre
- Innovative Technology Group, Reliance Life Sciences Pvt Ltd., Navi-Mumbai, India
| | - Yogesh Shouche
- National Center for Microbial Resource (NCMR), National Center for Cell Science (NCCS), Pune, India
| | - Sunil Saroj
- Symbiosis School of Biological Sciences (SSBS), Symbiosis International (Deemed University), Pune, India.
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Jaime-Pérez JC, Ramos-Dávila EM, Meléndez-Flores JD, Gómez-De León A, Gómez-Almaguer D. Insights on chronic immune thrombocytopenia pathogenesis: A bench to bedside update. Blood Rev 2021; 49:100827. [PMID: 33771403 DOI: 10.1016/j.blre.2021.100827] [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] [Received: 01/21/2021] [Revised: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 12/17/2022]
Abstract
Immune thrombocytopenia (ITP) is a heterogeneous disease with an unpredictable course. Chronicity can develop in up to two-thirds of adults and 20-25% of children, representing a significant burden on patients' quality of life. Despite acceptable responses to treatment, precise etiology and pathophysiology phenomena driving evolution to chronicity remain undefined. We analyzed reported risk factors for chronic ITP and associated them with proposed underlying mechanisms in its pathogenesis, including bone marrow (BM) microenvironment disturbances, clinical features, and immunological markers. Their understanding has diagnostic implications, such as screening for the presence of specific antibodies or BM examination employing molecular tools, which could help predict prognosis and recognize main pathogenic pathways in each patient. Identifying these underlying mechanisms could guide the use of personalized therapies such as all-trans retinoic acid, mTor inhibitors, FcRn inhibitors, oseltamivir, and others. Further research should lead to tailored treatments and chronic course prevention, improving patients' quality of life.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico.
| | - Eugenia M Ramos-Dávila
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Jesús D Meléndez-Flores
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Andrés Gómez-De León
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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24
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[Chinese guideline on the diagnosis and management of adult primary immune thrombocytopenia (version 2020)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 41:617-623. [PMID: 32942813 PMCID: PMC7525165 DOI: 10.3760/cma.j.issn.0253-2727.2020.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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25
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Roşca AE, Vlădăreanu AM, Mititelu A, Popescu BO, Badiu C, Căruntu C, Voiculescu SE, Onisâi M, Gologan Ş, Mirica R, Zăgrean L. Effects of Exogenous Androgens on Platelet Activity and Their Thrombogenic Potential in Supraphysiological Administration: A Literature Review. J Clin Med 2021; 10:jcm10010147. [PMID: 33406783 PMCID: PMC7795962 DOI: 10.3390/jcm10010147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 02/04/2023] Open
Abstract
Anabolic androgenic steroids (AAS), simply called “androgens”, represent the most widespread drugs used to enhance performance and appearance in a sporting environment. High-dosage and/or long-term AAS administration has been associated frequently with significant alterations in the cardiovascular system, some of these with severe endpoints. The induction of a prothrombotic state is probably the most life-threatening consequence, suggested by numerous case reports in AAS-abusing athletes, and by a considerable number of human and animal studies assessing the influence of exogenous androgens on hemostasis. Despite over fifty years of research, data regarding the thrombogenic potential of exogenous androgens are still scarce. The main reason is the limited possibility of conducting human prospective studies. However, human observational studies conducted in athletes or patients, in vitro human studies, and animal experiments have pointed out that androgens in supraphysiological doses induce enhanced platelet activity and thrombopoiesis, leading to increased platelet aggregation. If this tendency overlaps previously existing coagulation and/or fibrinolysis dysfunctions, it may lead to a thrombotic diathesis, which could explain the multitude of thromboembolic events reported in the AAS-abusing population. The influence of androgen excess on the platelet activity and fluid–coagulant balance remains a subject of debate, urging for supplementary studies in order to clarify the effects on hemostasis, and to provide new compelling evidence for their claimed thrombogenic potential.
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Affiliation(s)
- Adrian Eugen Roşca
- Division of Physiology and Neuroscience, Department of Functional Sciences, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.E.V.); (L.Z.)
- Victor Babeş National Institute of Research-Development in the Pathology Domain, 050096 Bucharest, Romania;
- Department of Cardiology, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania
- Correspondence: (A.E.R.); (A.-M.V.)
| | - Ana-Maria Vlădăreanu
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania; (A.M.); (M.O.)
- Correspondence: (A.E.R.); (A.-M.V.)
| | - Alina Mititelu
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania; (A.M.); (M.O.)
| | - Bogdan Ovidiu Popescu
- Victor Babeş National Institute of Research-Development in the Pathology Domain, 050096 Bucharest, Romania;
- Department of Neurology, Carol Davila University of Medicine and Pharmacy, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Corin Badiu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology, 11863 Bucharest, Romania;
| | - Constantin Căruntu
- Division of Physiology, Department of Fundamental Disciplines, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Dermatology, “Prof. N.C. Paulescu” National Institute of Diabetes, Nutrition and Metabolic Diseases, 011233 Bucharest, Romania
| | - Suzana Elena Voiculescu
- Division of Physiology and Neuroscience, Department of Functional Sciences, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.E.V.); (L.Z.)
| | - Minodora Onisâi
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania; (A.M.); (M.O.)
| | - Şerban Gologan
- Department of Gastroenterology, Carol Davila University of Medicine and Pharmacy, Elias Clinical Hospital, 011461 Bucharest, Romania;
| | - Radu Mirica
- Department of Surgery, Carol Davila University of Medicine and Pharmacy, “Sf. Ioan” Clinical Hospital, 042122 Bucharest, Romania;
| | - Leon Zăgrean
- Division of Physiology and Neuroscience, Department of Functional Sciences, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (S.E.V.); (L.Z.)
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26
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Bussel JB. Early combination treatment of immune thrombocytopenia: Is this the way? Am J Hematol 2020; 95:1452-1453. [PMID: 33068015 DOI: 10.1002/ajh.26024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022]
Affiliation(s)
- James B. Bussel
- Division of Hematology/Oncology Weill Cornell Medicine New York New York USA
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27
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Zeng Q, Zhang X. Current and emerging treatments based on novel mechanisms for immune thrombocytopenia. SCIENCE CHINA-LIFE SCIENCES 2020; 63:1597-1599. [PMID: 32789725 DOI: 10.1007/s11427-020-1757-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 06/16/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Qiaozhu Zeng
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, 100044, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China.,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, 100044, China. .,Collaborative Innovation Center of Hematology, Peking University, Beijing, 100044, China. .,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, 100044, China. .,National Clinical Research Center for Hematologic Disease, Beijing, 100044, China.
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28
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Cirasino L, Robino AM, Podda G, Andrès E, Despotovic JM, Elalfy M, Holbro A, Kondo T, Lambert MP, Loggetto SR, McCrae KR, Lee JW, Cattaneo M. Report of a 'consensus' on the lines of therapy for primary immune thrombocytopenia in adults, promoted by the Italian Gruppo di Studio delle Piastrine. Platelets 2020; 31:461-473. [PMID: 32314933 DOI: 10.1080/09537104.2020.1751105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Despite the publication in 2009 of a paper on 'terms and definitions of immune thrombocytopenia' (ITP), some unresolved issues remain and are reflected by the disagreement in the treatment suggested for primary ITP in adults. Considering that these disagreements could be ascribed to non-shared goals, we generated a 'consensus' on some terms, definitions, and assertions useful for classifying the different lines of treatment for primary ITP in adults according to their indications and goals. Agreement on the appropriateness of the single assertions was obtained by consensus for the following indicators: 1. classification of four 'lines of therapy'; 2. acceptance of the expression 'sequences of disease' for the indications of the respective four lines of treatment; 3I . practicability of splenectomy; 3Ib . acceptance, with only some exceptions, of a 'timing for elective splenectomy of 12 months'; and 4a-d . 'goals of the four lines of therapy.' On the basis of the consensus, a classification of four lines of treatment for primary ITP in adults was produced. In our opinion, this classification, whose validity is not influenced by the recently published new guidelines of the American Society of Hematology (ASH) and reviews, could reduce the disagreement that still exists regarding the treatment of the disease.
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Affiliation(s)
| | - Anna M Robino
- Medicina B3, Ospedale Niguarda Ca' Granda , Milano, Italy
| | - GianMarco Podda
- Medicina 2 ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano , Milano, Italy
| | - Emmanuel Andrès
- Clinique Médicale B Hôpitaux Universitaires de Strasbourg (HUS) , Strasbourg, France
| | | | - Mohsen Elalfy
- Faculty of Medicine, Ain Shams University Hospitals Cairo , Egypt
| | - Andreas Holbro
- Blood Transfusion Center SRC and Hematology, University Hospital Basel, Swiss Red Cross , Basel, Switzerland
| | - Tadakazu Kondo
- Department of Hematology/Oncology, Graduate School of Medicine, Kyoto University , Kyoto, Japan
| | - Michele P Lambert
- The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA, USA
| | - Sandra R Loggetto
- Department of Pediatric Hematology, Sabara Pediatric Hospital , Sao Paulo, Brazil
| | - Keith R McCrae
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic Lerner College of Medicine , Cleveland, OH, USA
| | - Jong Wook Lee
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea , Seoul, Korea
| | - Marco Cattaneo
- Medicina 2 ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano , Milano, Italy
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29
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Wang Y, Zhang J, Su Y, Wang C, Zhang G, Liu X, Chen Q, Lv M, Chang Y, Peng J, Hou M, Huang X, Zhang X. miRNA-98-5p Targeting IGF2BP1 Induces Mesenchymal Stem Cell Apoptosis by Modulating PI3K/Akt and p53 in Immune Thrombocytopenia. MOLECULAR THERAPY. NUCLEIC ACIDS 2020; 20:764-776. [PMID: 32428701 PMCID: PMC7232042 DOI: 10.1016/j.omtn.2020.04.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/15/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023]
Abstract
Immune thrombocytopenia (ITP) is a common hematological autoimmune disease, in which defective mesenchymal stem cells (MSCs) are potentially involved. Our previous study suggested that MSCs in ITP patients displayed enhanced apoptosis. MicroRNAs (miRNAs) play important roles in ITP by affecting megakaryopoiesis, platelet production and immunoregulation, whereas the roles of miRNAs in ITP-MSCs remain unknown. In a previous study, we performed microarray analysis to obtain mRNA and miRNA profiles of ITP-MSCs. In the present study, we reanalyze the data and identify miR-98-5p as a candidate miRNA contributing to MSC deficiency in ITP. miR-98-5p acts through targeting insulin-like growth factor 2 mRNA-binding protein 1 (IGF2BP1), and the subsequent downregulation of insulin-like growth factor 2 (IGF-2) causes inhibition of the phosphatidylinositol 3-kinase (PI3K)/Akt pathway, which is involved in the process of MSC deficiency. Furthermore, miR-98-5p upregulates p53 by inhibiting β-transducin repeat-containing protein (β-TrCP)-dependent p53 ubiquitination. Moreover, miR-98-5p overexpression impairs the therapeutic effect of MSCs in ITP mice. All-trans retinoic acid (ATRA) protects MSCs from apoptosis by downregulating miR-98-5p, thus providing a potential therapeutic approach for ITP. Our findings demonstrate that miR-98-5p is a critical regulator of ITP-MSCs, which will help us thoroughly understand the pathogenesis of ITP.
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Affiliation(s)
- Yanan Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Jiamin Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Yan Su
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Chencong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Gaochao Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Xiao Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Qi Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Meng Lv
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Yingjun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan 250012, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan 250012, China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China.
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30
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Miltiadous O, Hou M, Bussel JB. Identifying and treating refractory ITP: difficulty in diagnosis and role of combination treatment. Blood 2020; 135:472-490. [PMID: 31756253 PMCID: PMC7484752 DOI: 10.1182/blood.2019003599] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 11/08/2019] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is the most common acquired thrombocytopenia after chemotherapy-induced thrombocytopenia. Existing guidelines describe the management and treatment of most patients who, overall, do well, even if they present with chronic disease, and they are usually not at a high risk for bleeding; however, a small percentage of patients is refractory and difficult to manage. Patients classified as refractory have a diagnosis that is not really ITP or have disease that is difficult to manage. ITP is a diagnosis of exclusion; no specific tests exist to confirm the diagnosis. Response to treatment is the only affirmative confirmation of diagnosis. However, refractory patients do not respond to front-line or other treatments; thus, no confirmation of diagnosis exists. The first section of this review carefully evaluates the diagnostic considerations in patients with refractory ITP. The second section describes combination treatment for refractory cases of ITP. The reported combinations are divided into the era before thrombopoietin (TPO) and rituximab and the current era. Current therapy appears to have increased effectiveness. However, the definition of refractory, if it includes insufficient response to TPO agents, describes a group with more severe and difficult-to-treat disease. The biology of refractory ITP is largely unexplored and includes oligoclonality, lymphocyte pumps, and other possibilities. Newer treatments, especially rapamycin, fostamatinib, FcRn, and BTK inhibitors, may be useful components of future therapy given their mechanisms of action; however, TPO agents, notwithstanding failure as monotherapy, appear to be critical components. In summary, refractory ITP is a complicated entity in which a precise specific diagnosis is as important as the development of effective combination treatments.
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Affiliation(s)
- Oriana Miltiadous
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
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31
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Zhu X, Wang Y, Jiang Q, Jiang H, Lu J, Wang Y, Kong Y, Chang Y, Xu L, Peng J, Hou M, Huang X, Zhang X. All- trans retinoic acid protects mesenchymal stem cells from immune thrombocytopenia by regulating the complement-interleukin-1β loop. Haematologica 2019; 104:1661-1675. [PMID: 30679324 PMCID: PMC6669169 DOI: 10.3324/haematol.2018.204446] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/21/2019] [Indexed: 12/11/2022] Open
Abstract
Enhanced peripheral complement activation has long been considered as one of the major pathogenic elements of immune thrombocytopenia. A dysfunctional bone marrow microenvironment, especially with regards to mesenchymal stem cells, has been observed in patients with immune thrombocytopenia. However, the potential role of the complement system in the dysfunctional bone marrow microenvironment remains poorly understood. In this study, bone marrow samples from patients with immune thrombocytopenia were divided into two groups based on whether or not complement components were deposited on the surfaces of their mesenchymal stem cells. The mesenchymal cells from the group with complement deposition were less numerous, dysfunctional, had a reduced capacity to proliferate, and showed increased apoptosis as well as abnormal secretion of interleukin-1β and C-X-C motif chemokine ligand 12. In vitro treatment with all-trans retinoic acid increased the number and improved the function of the complement-positive bone marrow mesenchymal stem cells by upregulating DNA hypermethylation of the interleukin-1β promoter. In vivo studies showed that all-trans retinoic acid could rescue the impaired mesenchymal stem cells to support the thrombopoietic niche in both patients with immune thrombocytopenia and a murine model of this disease. Taken together, these results indicate that impairment of mesenchymal stem cells, mediated by the complement-interleukin-1β loop, plays a role in the pathogenesis of immune thrombocytopenia. All-trans retinoic acid represents a promising therapeutic approach in patients with immune thrombocytopenia through its effect of repairing mesenchymal stem cell impairment.
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Affiliation(s)
- Xiaolu Zhu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Yanan Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Hao Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Yazhe Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Yuan Kong
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Yingjun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Lanping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, P.R. China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, P.R. China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing
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Descamps HC, Herrmann B, Wiredu D, Thaiss CA. The path toward using microbial metabolites as therapies. EBioMedicine 2019; 44:747-754. [PMID: 31201140 PMCID: PMC6606739 DOI: 10.1016/j.ebiom.2019.05.063] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 12/26/2022] Open
Abstract
Metabolites have emerged as the quintessential effectors mediating the impact of the commensal microbiome on human physiology, both locally at the sites of microbial colonization and systemically. The endocrine activity of the microbiome and its involvement in a multitude of complex diseases has made microbiome-modulated metabolites an attractive target for the development of new therapies. Several properties make metabolites uniquely suited for interventional strategies: natural occurrence in a broad range of concentrations, functional pleiotropy, ease of administration, and tissue bioavailability. Here, we provide an overview of recently discovered physiological effects of microbiome-associated small molecules that may serve as the first examples of metabolite-based therapies. We also highlight challenges and obstacles that the field needs to overcome on the path toward successful clinical trials of microbial metabolites for human disease.
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Affiliation(s)
- Hélène C Descamps
- Microbiology Department, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Beatrice Herrmann
- Microbiology Department, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daphne Wiredu
- Microbiology Department, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christoph A Thaiss
- Microbiology Department, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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33
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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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Atorvastatin enhances bone marrow endothelial cell function in corticosteroid-resistant immune thrombocytopenia patients. Blood 2018; 131:1219-1233. [PMID: 29288170 DOI: 10.1182/blood-2017-09-807248] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/18/2017] [Indexed: 12/15/2022] Open
Abstract
Key Points
Impaired BM EPCs were found in corticosteroid-resistant ITP patients. Atorvastatin improved BM EPC quantity and function, representing a novel therapy approach for corticosteroid-resistant ITP patients.
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Panzer S, Pabinger I. Is oral all-trans retinoic acid plus danazol a refinement of second-line therapy for primary immune thrombocytopenia in adults? LANCET HAEMATOLOGY 2017; 4:e457-e458. [PMID: 28917656 DOI: 10.1016/s2352-3026(17)30167-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/22/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna 1090, Austria.
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna 1090, Austria
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