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Fattizzo B, Cantoni S, Giannotta JA, Bandiera L, Zavaglia R, Bortolotti M, Barcellini W. Efficacy and safety of cyclosporine A treatment in autoimmune cytopenias: the experience of two Italian reference centers. Ther Adv Hematol 2022; 13:20406207221097780. [PMID: 35585968 PMCID: PMC9109490 DOI: 10.1177/20406207221097780] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/13/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Immune thrombocytopenia (ITP) and autoimmune hemolytic anemia (AIHA) show
good responses to frontline steroids. About two-third of cases relapse and
require second-line treatment, including rituximab, mainly effective in
AIHA, and thrombopoietin-receptor agonists (TPO-RAs) in ITP, while the use
of splenectomy progressively decreased due to concerns for
infectious/thrombotic complications. For those failing second line,
immunosuppressants may be considered. Objectives: The aim of this study was to evaluate the efficacy of cyclosporine treatment
in patients with ITP and AIHA. Design: In this retrospective study, we evaluated the efficacy and safety of
cyclosporine A (CyA) in ITP (N = 29) and AIHA
(N = 10) patients followed at two reference centers in
Milan, Italy. Methods: Responses were classified as partial [Hb > 10 or at least 2 g/dl increase
from baseline, platelets (PLT) > 30 × 109/l with at least
doubling from baseline] and complete (Hb > 12 g/dl or
PLT > 100 × 109/l) and evaluated at 3, 6, and 12 months.
Treatment emergent adverse events were also registered. Results: The median time from diagnosis to CyA was 35 months (3–293), and patients had
required a median of 4 (1–8) previous therapy lines. Median duration of CyA
was 28 (2–140) months and responses were achieved in 86% of ITP and 50% of
AIHA subjects. Responders could reduce or discontinue concomitant treatment
and resolved PLT fluctuations on TPO-RA. CyA was generally well tolerated,
and only two serious infectious complications in elderly patients on
concomitant steroids suggesting caution in this patient population. Conclusion: CyA may be advisable in ITP, which is not well controlled under TPO-RA, and
in AIHA failing rituximab, particularly if ineligible in clinical trial.
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Affiliation(s)
- Bruno Fattizzo
- Hematology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, via F. Sforza 35, 20100 Milan, Italy
| | - Silvia Cantoni
- Hematology Unit, Hematology & Oncology Department, Niguarda Cancer Center, ASST Ospedale Niguarda, Milan, Italy
| | | | - Laura Bandiera
- Pathology Unit, Hematology & Oncology Department, Niguarda Cancer Center, ASST Ospedale Niguarda, Milan, Italy
| | - Rachele Zavaglia
- Department of Oncology and Hemato-Oncologyilan, University of Milan, Italy
| | - Marta Bortolotti
- Department of Oncology and Hemato-Oncologyilan, University of Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
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2
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Liu APY, Cheuk DKL, Lee AHY, Lee PPW, Chiang AKS, Ha SY, Tsoi WC, Chan GCF. Cyclosporin A for persistent or chronic immune thrombocytopenia in children. Ann Hematol 2016; 95:1881-6. [PMID: 27525725 DOI: 10.1007/s00277-016-2791-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/05/2016] [Indexed: 11/28/2022]
Abstract
Twenty percent of children with immune thrombocytopenia (ITP) develop a chronic course where treatment strategy is less established. Cyclosporin A (CSA) has been shown to be effective in small series of children with chronic ITP and might reduce the need for chronic steroid therapy and/or splenectomy. We reviewed consecutive patients below 18 years old with persistent or chronic ITP treated with CSA in our unit between January 1998 and June 2015. Thirty patients (14 boys and 16 girls) were included. The median age at initial diagnosis of ITP was 5 years (range 0.5-16.2 years). CSA was started at a median of 13.9 months (range 3.4-124 months) after initial diagnosis and given for a median duration of 9.3 months (range 0.2-63.9 months). The median platelet count before commencement was 12 × 10(9)/L (range 4-199 × 10(9)/L). The median dose of CSA was 6 mg/kg/day (range 2.4-7.5 mg/kg/day). Complete response (CR) or response (R) was achieved in 17 patients (57 %), and 7 (23 %) had sustained response. Side effects (most commonly hirsutism) were tolerable and reversible. CSA appeared effective in about half of persistent or chronic ITP patients and safe as a second-line agent in managing these children.
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Affiliation(s)
- Anthony P Y Liu
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China.
| | - Daniel K L Cheuk
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Ana H Y Lee
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Pamela P W Lee
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Alan K S Chiang
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - S Y Ha
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - W C Tsoi
- Hong Kong Red Cross Blood Transfusion Service, Hong Kong Special Administrative Region, China
| | - Godfrey C F Chan
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
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3
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Liebman HA. Immune modulation for autoimmune disorders: evolution of therapeutics. Semin Hematol 2016; 53 Suppl 1:S23-6. [DOI: 10.1053/j.seminhematol.2016.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Xu J, Lu S, Tao J, Zhou Z, Chen Z, Huang Y, Yang R. CD72 polymorphism associated with child-onset of idiopathic thrombocytopenic purpura in Chinese patients. J Clin Immunol 2008; 28:214-9. [PMID: 18071878 DOI: 10.1007/s10875-007-9158-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Accepted: 11/21/2007] [Indexed: 11/30/2022]
Abstract
Idiopathic thrombocytopenic purpura (ITP) is a disease putatively relating to abnormal immune function and auto-antiplatelet immunoglobulin. We examined whether polymorphism of CD72, an inhibitory receptor of B cells, affect the susceptibility to ITP, or associated with the clinical characteristics of ITP. A case-control study was carried out in 206 Chinese ITP patients and 169 healthy controls. The detection of variable number of tandem repeats in CD72 intron 8 was performed by polymerase chain reaction and subsequent analysis with polyacrylamide gel electrophoresis. We did not find direct association between CD72 genotypes and susceptibility to ITP. The haplotype that contained one repeat of 13 nucleotides in intron 8 (designated as *1, and haplotype containing two repeat of 13 nucleotides in intron 8 is designated as *2) was significantly associated with early first onset age (< or = 14) in ITP patients (P = 0.03). ITP patients with CD72*1\*1 and *1\*2 genotype had a 3.09-fold [95% confidence interval (CI), 1.32-7.25] and 1.98-fold (95% CI, 0.92-4.25) increased risk of appearing ITP manifestation at their childhood respectively. The haplotype CD72*1 is apparently a risk allele, whereas CD72*2 a protective allele for child-onset of ITP disease.
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Age of Onset
- Antigens, CD/genetics
- Antigens, Differentiation, B-Lymphocyte/genetics
- Autoantibodies/biosynthesis
- Case-Control Studies
- Child
- Child, Preschool
- China/epidemiology
- Chronic Disease
- Cytokines/biosynthesis
- Female
- Genetic Predisposition to Disease
- Humans
- Infant
- Male
- Middle Aged
- Polymorphism, Genetic
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/epidemiology
- Purpura, Thrombocytopenic, Idiopathic/genetics
- Purpura, Thrombocytopenic, Idiopathic/immunology
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Affiliation(s)
- Jianhui Xu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 288 Nanjing Road, Tianjin 300020, China
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6
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Abstract
Treatment of immune thrombocytopenic purpura (ITP), the most common bleeding disorder of childhood, is a controversial subject for most practitioners. Diagnosis and management of ITP has historically been based primarily on expert opinion rather than on evidence. Due to a paucity of carefully conducted clinical trials in children, the management of ITP varies widely, ranging from observation only, to aggressive management with intravenous immunoglobulin (IVIG), intravenous anti-D rhesus (Rh)0 immunoglobulin (IV RhIG), corticosteroids, and splenectomy. To address the controversies, the American Society of Hematology (ASH) and the British Society for Hematology (BSH) have developed ITP practice guidelines. These guidelines, based on expert opinion, differ in their recommendations for treatment. The ASH guidelines favor therapy based on a low platelet count, and the more current BSH guidelines recommend a more conservative 'wait and watch' approach. In addition to treating children with severe bleeding symptoms, there is a tendency (not evidence based) to treat early in order to prevent a life-threatening bleeding episode, including intracerebral hemorrhage. Corticosteroids are a highly effective therapy, inexpensive, and can usually increase the platelet count within hours to days. However, chronic or prolonged use is associated with toxicity. In the US, based on the knowledge of known toxicities of corticosteroids, as well as the efficacy of alternative treatments (IV RhIG, IVIG), many pediatricians prefer to treat with IVIG and IV RhIG, reserving corticosteroid treatment for serious bleeding or refractory disease. However, in the UK, for the most part, corticosteroids are used as first-line therapy in children with ITP. Splenectomy is rarely indicated in children except for those with life-threatening bleeding and chronic, severe ITP with impairment of quality of life. For children who develop chronic or refractory ITP, immunosuppressive drugs and/or chemotherapy agents may offer some promise. However, the long-term effects of these drugs in children are unknown and they should not be considered unless there is unequivocal evidence that the patient is refractory to IV RhIG, IVIG, and corticosteroids. To date, virtually all of the randomized clinical trials conducted in children with ITP have focused on platelet counts as the sole outcome measure. Only carefully designed, multicenter, randomized clinical trials comparing the effects of different treatment modalities in terms of bleeding, quality of life, adverse effects, and treatment-related costs will be able to address the controversies surrounding childhood ITP treatment and allow management of this condition to be based on scientific data rather than treatment philosophy.
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Affiliation(s)
- Aziza T Shad
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Georgetown University Medical Center, Washington, DC 20007, USA.
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Park SJ, Han CW, Lee JH, Eom HS, Lee SH, Jeong DC, Lim JH. Cyclosporine A in the treatment of a patient with immune thrombocytopenia accompanied by myelodysplastic syndrome and nephrotic syndrome. Acta Haematol 2003; 110:36-40. [PMID: 12975556 DOI: 10.1159/000072413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2002] [Accepted: 06/10/2003] [Indexed: 11/19/2022]
Abstract
We describe a complete remission with cyclosporine A in a myelodysplastic syndrome (MDS) patient who had a 9-year history of nephrotic syndrome (NS) due to autoimmune nephritis. A 72-year-old woman with MDS and NS rapidly developed thrombocytopenia with multiple spontaneous bleeding episodes and profound proteinuria. She showed persistent platelet refractoriness to platelet transfusions. A flow cytometry examination strongly detected antiplatelet autoantibodies on the surface of her platelets. The treatment with high-dose corticosteroids and intravenous immunoglobulin did not lead to complete improvement in the platelet count, bleedings and proteinuria. However, a low dose of cyclosporine A resulted in a sustained normal range of blood platelet count and negative proteinuria. This finding suggests that, in selected cases, cyclosporine A can be an attractive alternative for MDS patients who also have immune-mediated diseases.
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Affiliation(s)
- Soo-Jeong Park
- Division of Hematology and Oncology, Department of Internal Medicine, Our Lady of Mercy Hospital, Catholic University, Inchon, Korea
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Abstract
PURPOSE To investigate combined immunosuppressive therapy with vincristine, methylprednisolone, and prolonged cyclosporine in adolescents with refractory idiopathic thrombocytopenic purpura (ITP). PATIENTS AND METHODS Ten adolescent patients with ITP refractory to previous medical management, including gluco-corticosteroid, intravenous immunoglobulin or anti-Rh (D) IgG, or splenectomy, were treated with combination immunosuppressive therapy at the University of Michigan between 1997 and 2001. Therapy consisted of weekly doses of vincristine 1.5 mg/m intravenous push (IVP) (maximum dose 2 mg), weekly methylprednisolone 100 mg/m IVP, and cyclosporine (CSA) 5 mg/kg orally twice daily (goal: CSA trough of 100-200 mg/mL). Vincristine and methylprednisolone were given weekly until the platelet count was greater than 50,000/mm for a minimum of 2 doses and a maximum of 4 doses. CSA was continued until the platelet count was normal for 3 to 6 months. RESULTS Seven patients had continuous complete responses (platelet count normal after cessation of CSA), a median of 13 months (9-37 months) since completion of therapy. One patient had a partial response (platelet count 80-120 x 10 /L off CSA for 3 months). Two patients were nonresponders (platelet count <40 x 10 /L), one of whom had all therapy discontinued after 2 weeks due to peripheral neuropathy. The median time to response was 7 days (range 7-67 days). CSA was administered for a median of 4 months (range 0.5-19 months). CONCLUSIONS A combination immunosuppressive approach that includes prolonged cyclosporine therapy may be promising for refractory ITP and is associated with sustained disease remissions in some patients.
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Affiliation(s)
- James A Williams
- University of Michigan Pediatric Hematology/Oncology Hospital, Ann Arbor, Michiga 48109-0238, USA.
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