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Agarwal N, Mangla A. Thrombopoietin receptor agonist for treatment of immune thrombocytopenia in pregnancy: a narrative review. Ther Adv Hematol 2021; 12:20406207211001139. [PMID: 33796239 PMCID: PMC7983475 DOI: 10.1177/20406207211001139] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/09/2021] [Indexed: 12/26/2022] Open
Abstract
The treatment of immune thrombocytopenia (ITP) in adults has evolved rapidly over the past decade. The second-generation thrombopoietin receptor agonists (TPO-RAs), romiplostim, eltrombopag, and avatrombopag are approved for the treatment of chronic ITP in adults. However, their use in pregnancy is labeled as category C by the United States Food and Drug Administration (FDA) due to the lack of clinical data on human subjects. ITP is a common cause of thrombocytopenia in the first and second trimester of pregnancy, which not only affects the mother but can also lead to thrombocytopenia in the neonatal thrombocytopenia secondary to maternal immune thrombocytopenia (NMITP). Corticosteroids, intravenous immunoglobulins (IVIGs) are commonly used for treating acute ITP in pregnant patients. Drugs such as rituximab, anti-D, and azathioprine that are used to treat ITP in adults, are labeled category C and seldom used in pregnant patients. Cytotoxic chemotherapy (vincristine, cyclophosphamide), danazol, and mycophenolate are contraindicated in pregnant women. In such a scenario, TPO-RAs present an attractive option to treat ITP in pregnant patients. Current evidence on the use of TPO-RAs in pregnant women with ITP is limited. In this narrative review, we will examine the preclinical and the clinical literature regarding the use of TPO-RAs in the management of ITP in pregnancy and their effect on neonates with NMITP.
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Affiliation(s)
- Nikki Agarwal
- Division of Pediatric Hematology and Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ankit Mangla
- Division of Hematology and Oncology, Seidman Cancer Center, University Hospitals, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Erythropoietin and thrombopoietin mimetics: Natural alternatives to erythrocyte and platelet disorders. Crit Rev Oncol Hematol 2016; 108:175-186. [DOI: 10.1016/j.critrevonc.2016.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 10/27/2016] [Accepted: 11/02/2016] [Indexed: 12/21/2022] Open
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Undi RB, Gutti U, Gutti RK. Role of let-7b/Fzd4 axis in mitochondrial biogenesis through wnt signaling: In neonatal and adult megakaryocytes. Int J Biochem Cell Biol 2016; 79:61-68. [DOI: 10.1016/j.biocel.2016.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/29/2016] [Accepted: 08/05/2016] [Indexed: 12/11/2022]
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Cremer M, Sallmon H, Kling PJ, Bührer C, Dame C. Thrombocytopenia and platelet transfusion in the neonate. Semin Fetal Neonatal Med 2016; 21:10-8. [PMID: 26712568 DOI: 10.1016/j.siny.2015.11.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Neonatal thrombocytopenia is widespread in preterm and term neonates admitted to neonatal intensive care units, with up to one-third of infants demonstrating platelet counts <150 × 10(9)/L. Thrombocytopenia may arise from maternal, placental or fetal/neonatal origins featuring decreased platelet production, increased consumption, or both mechanisms. Over the past years, innovations in managing neonatal thrombocytopenia were achieved from prospectively obtained clinical data on thrombocytopenia and bleeding events, animal studies on platelet life span and production rate and clinical use of fully automated measurement of reticulated platelets (immature platelet fraction). This review summarizes the pathophysiology of neonatal thrombocytopenia, current management including platelet transfusion thresholds and recent developments in megakaryopoietic agents. Furthermore, we propose a novel index score for bleeding risk in thrombocytopenic neonates to facilitate clinician's decision-making when to transfuse platelets.
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Affiliation(s)
- Malte Cremer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Germany.
| | - Hannes Sallmon
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Germany
| | - Pamela J Kling
- Department of Pediatrics, University of Wisconsin - Madison, Madison, WI, USA
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Germany
| | - Christof Dame
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Germany
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Christensen RD, Baer VL, Henry E, Snow GL, Butler A, Sola-Visner MC. Thrombocytopenia in Small-for-Gestational-Age Infants. Pediatrics 2015; 136. [PMID: 26216323 PMCID: PMC4906543 DOI: 10.1542/peds.2014-4182] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Thrombocytopenia is common among small-for-gestational-age (SGA) neonates (birth weight <10th percentile reference range), but several aspects of this thrombocytopenia are unclear, including the incidence, typical nadir, duration, association with preeclampsia, mechanism, and risk of death. METHODS Using 9 years of multihospital records, we studied SGA neonates with ≥2 platelet counts <150,000/μL in their first week. RESULTS We found first-week thrombocytopenia in 31% (905 of 2891) of SGA neonates versus 10% of non-SGA matched controls (P < .0001). Of the 905, 102 had a recognized cause of thrombocytopenia (disseminated intravascular coagulation, early-onset sepsis, or extracorporeal membrane oxygenation). This group had a 65% mortality rate. The remaining 803 did not have an obvious cause for their thrombocytopenia, and we called this "thrombocytopenia of SGA." They had a mortality rate of 2% (P < .0001) and a mean nadir count on day 4 of 93,000/μL (SD 51,580/μL, 10th percentile 50,000/μL, 90th percentile 175,000/μL). By day 14, platelet counts were ≥150,000/μL in more than half of the patients. Severely SGA neonates (<1st percentile) had lower counts and longer thrombocytopenia duration (P < .001). High nucleated red cell counts at birth correlated with low platelets (P < .0001). Platelet transfusions were given to 23%, and counts typically more than tripled. Thrombocytopenia was more associated with SGA status than with the diagnosis of maternal preeclampsia. CONCLUSIONS SGA neonates with clearly recognized varieties of thrombocytopenia have a high mortality rate. In contrast, thrombocytopenia of SGA is a hyporegenerative condition of moderate severity and 2 weeks' duration and is associated with evidence of intrauterine hypoxia and a low mortality rate.
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Affiliation(s)
- Robert D. Christensen
- Divisions of Hematology/Oncology, and,Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah;,Primary Children’s Hospital, Salt Lake City, Utah;,Address correspondence to Robert D. Christensen, MD, University of Utah Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT 84108. E-mail:
| | - Vickie L. Baer
- Women and Newborn’s Clinical Program, Intermountain Healthcare, Salt Lake City, Utah
| | - Erick Henry
- Primary Children’s Hospital, Salt Lake City, Utah
| | - Gregory L. Snow
- Statistical Data Center, LDS Hospital, Salt Lake City, Utah; and
| | - Allison Butler
- Statistical Data Center, LDS Hospital, Salt Lake City, Utah; and
| | - Martha C. Sola-Visner
- Division of Neonatal Medicine, Children’s Hospital and Harvard Medical School, Boston, Massachusetts
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Understanding thrombocytopenia: physiological role of microRNA in survival of neonatal megakaryocytes. J Thromb Thrombolysis 2015; 40:310-6. [DOI: 10.1007/s11239-015-1238-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Carr R, Kelly AM, Williamson LM. Neonatal thrombocytopenia and platelet transfusion - a UK perspective. Neonatology 2015; 107:1-7. [PMID: 25301082 DOI: 10.1159/000365163] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Five percent of newborn infants admitted to UK neonatal units during a recent study developed a platelet count <60 × 10(9)/l, and 60% of these were transfused platelets. This review summarises the common causes and mechanisms of thrombocytopenia in the newborn. Relevant evidence relating the platelet count to the risk of haemorrhage is reviewed, and current UK guidance on transfusion thresholds outlined. The UK policy for the provision of platelets for transfusion to neonates is described, including the particular requirements for neonatal allo-immune thrombocytopenia. Finally, we look towards the future and prospects for reducing the need to expose newborns to donor-derived platelets.
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Affiliation(s)
- Robert Carr
- Department of Haematology, Guy's and St Thomas' Hospital, King's College London, London, UK
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Kulshrestha M, Sola-Visner M, Widness JA, Veng-Pedersen P, Mager DE. Mathematical model of platelet turnover in thrombocytopenic and nonthrombocytopenic preterm neonates. Am J Physiol Heart Circ Physiol 2014; 308:H68-73. [PMID: 25362135 DOI: 10.1152/ajpheart.00528.2013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Neonatal thrombocytopenia affects 22-35% of all neonates admitted to neonatal intensive care units. The purpose of this study was to develop a mathematical model for characterizing platelet (PLT) kinetics in thrombocytopenic preterm neonates. Immature PLT fraction (IPF) and PLT counts were measured for up to 35 days after birth in 27 very low birth weight preterm neonates. PLT transfusions were administered to 8 of the 27 (24%) subjects. The final model included a series of four transit compartments to mimic the production and survival of IPF and PLT. Model parameters were estimated using nonlinear mixed effects modeling with the maximum likelihood expectation maximization algorithm. The model adequately captured the diverse phenotypes expressed by individual subject profiles. Typical population survival values for IPF and PLT life spans in nonthrombocytopenic patients were estimated at 0.912 and 10.7 days, respectively. These values were significantly shorter in thrombocytopenic subjects, 0.429 and 2.56 days, respectively. The model was also used to evaluate the influence of growth and laboratory phlebotomy loss on the time course of IPF and PLT counts. Whereas incorporating body weight was essential to correct for expanding blood volume due to growth, phlebotomy loss, a possible covariate, did not significantly influence PLT kinetics. This study provides a platform for identifying potential covariates that influence the interindividual variability in model parameters regulating IPF and PLT kinetics and for evaluating future pharmacological therapies for treating thrombocytopenic neonates.
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Affiliation(s)
- Mudit Kulshrestha
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Martha Sola-Visner
- Division of Newborn Medicine, Children's Hospital Boston, Boston, Massachusetts
| | - John A Widness
- Department of Pediatrics, College of Medicine, University of Iowa, Iowa City, Iowa; and
| | | | - Donald E Mager
- Department of Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, New York;
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Kühne T. Treatment of pediatric primary immune thrombocytopenia with thrombopoietin receptor agonists. Semin Hematol 2014; 52:25-30. [PMID: 25578416 DOI: 10.1053/j.seminhematol.2014.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Chronic immune thrombocytopenia (ITP) occurs in approximately one fifth of children with primary ITP and is characterized by a significant lack of clinical data. A minority of these children exhibit bleeding and need treatment. Often standard therapy used for patients with newly diagnosed ITP is administered to stop bleeding and to increase the platelet count. These drugs are associated with adverse effects, which is particularly evident when used during long time. In adult patients with chronic ITP, thrombopoietin receptor agonists (TPO-RAs) demonstrated efficacy in approximately 80% of patients. These drugs have been studied intensely for registration purposes; however, for children and adolescents they are not yet approved and studies are ongoing. First experiences with these drugs show similar effects and safety as in adults, though based on very small numbers of children. These drugs have the potential to be used during long time, in order to increase platelets, to stop or prevent bleeding and to augment quality of life, making long-term safety an important issue.
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Affiliation(s)
- Thomas Kühne
- Division of Oncology/Hematology, University Children's Hospital, Basel, Switzerland.
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Abstract
Thrombocytopenia is a very frequent problem among sick neonates, affecting up to 35% of all infants admitted to the neonatal intensive care unit (NICU), and serves as an important indicator of multiple clinical conditions. The cause of the thrombocytopenia is unclear in up to 60% of affected neonates. A clinical classification of thrombocytopenia is based on the time of presentation, early (≤72 hours of life) vs. late (>72 hours of life). Early thrombocytopenia is commonly associated with feto-maternal conditions, is most commonly caused by disorders associated with placental insufficiency, and is generally mild to moderate and resolves spontaneously within 7-10 days without any intervention. In contrast, neonates who develop late-onset thrombocytopenia frequently have bacterial sepsis or necrotizing enterocolitis. It is often severe (platelets <50,000/μL), prolonged and frequently requires multiple platelet transfusions. Platelet transfusions represent the only specific therapy currently available for most thrombocytopenic neonates, even though much evidence suggests that platelet transfusions are not benign. Many of the prophylactic platelet transfusions currently given to NICU patients are unnecessary, convey no benefits, and carry known and unknown risks. For this reason, pharmacological alternatives have been investigated as potential therapies for thrombocytopenia, but they still have limited use treating the common varieties of neonatal thrombocytopenia.
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Affiliation(s)
- Antonio Del Vecchio
- Department of Maternal and Child Health, Division of Neonatology, Neonatal Intensive Care Unit, Di Venere Hospital, Bari, Italy.
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Christensen RD, Baer VL, Yaish HM. Thrombocytopenia in late preterm and term neonates after perinatal asphyxia. Transfusion 2014; 55:187-96. [DOI: 10.1111/trf.12777] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/28/2014] [Accepted: 05/30/2014] [Indexed: 12/12/2022]
Affiliation(s)
| | - Vickie L. Baer
- Women and Newborn's Clinical Program; Intermountain Healthcare; Salt Lake City Utah
| | - Hassan M. Yaish
- Department of Pediatrics, Division of Hematology/Oncology; University of Utah School of Medicine; Salt Lake City Utah
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Venkatesh V, Curley AE, Clarke P, Watts T, Stanworth SJ. Do we know when to treat neonatal thrombocytopaenia? Arch Dis Child Fetal Neonatal Ed 2013; 98:F380-2. [PMID: 23531628 DOI: 10.1136/archdischild-2012-302535] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Vidheya Venkatesh
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, UK
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Ferrer-Marin F, Stanworth S, Josephson C, Sola-Visner M. Distinct differences in platelet production and function between neonates and adults: implications for platelet transfusion practice. Transfusion 2013; 53:2814-21; quiz 2813. [PMID: 23889476 DOI: 10.1111/trf.12343] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 01/19/2023]
Abstract
Thrombocytopenia is a common problem among sick neonates admitted to the neonatal intensive care unit. Among neonates, preterm infants are the subgroup at highest risk for thrombocytopenia and hemorrhage, which is frequently intracranial. Although there is no evidence of a relationship between platelet (PLT) count and occurrence of major hemorrhage, preterm infants are commonly transfused prophylactically when PLT counts fall below an arbitrary limit, and this threshold is usually higher than for older infants or adults. This liberal practice has been influenced by the observation that, in vitro, neonatal PLTs are hyporeactive in response to multiple agonists. However, full-term infants exhibit normal to increased primary hemostasis due to factors in neonatal blood that enhance the PLT-vessel wall interaction. Additionally, cardiorespiratory problems are considered the main etiologic factors in the development of neonatal intraventricular hemorrhage. In this review, we will discuss the developmental differences that exist in regard to PLT production and function, as well as in primary hemostasis in preterm and term neonates, and the implications of these developmental differences to transfusion medicine. PLT transfusions are not exempt of risk, and a better understanding of the PLT function and the hemostatic profile of premature infants and their changes over time and in response to illness is the starting point to design randomized controlled trials to define optimal use of PLT transfusions in premature neonates. Without these future trials, the marked disparities in PLT transfusion practice in neonates between hospitals and countries will remain over time.
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Affiliation(s)
- Francisca Ferrer-Marin
- Unidad de Hematología y Oncología Médica, Hospital Universitario Morales-Meseguer, Centro de Hemodonacion, Murcia, Spain; Department of Haematology/Transfusion Medicine, NHS Blood & Transplant/Oxford University Hospitals NHS Trust, Oxford, UK; Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Georgia; Division of Newborn Medicine, Children's Hospital Boston, Boston, Massachusetts
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Abstract
Abstract
Survival rates for infants born prematurely have improved significantly, in part due to better supportive care such as RBC transfusion. The role of platelet transfusions in neonates is more controversial. Neonatal thrombocytopenia is common in premature infants. The primary causal factors are intrauterine growth restriction/maternal hypertension, in which the infant presents with thrombocytopenia soon after birth, and sepsis/necrotizing enterocolitis, which are the common morbidities associated with thrombocytopenia in neonates > 72 hours of age. There is no evidence of a relationship between platelet count and occurrence of major hemorrhage, and cardiorespiratory problems are considered the main etiological factors in the development of intraventricular and periventricular hemorrhage in the neonatal period. Platelet transfusions are used commonly as prophylaxis in premature neonates with thrombocytopenia. However, there is widespread variation in the pretransfusion thresholds for platelet count and evidence of marked disparities in platelet transfusion practice between hospitals and countries. Platelet transfusions are biological agents and as such are associated with risks. Unlike other patient groups, specifically patients with hematological malignancies, there have been no recent clinical trials undertaken comparing different thresholds for platelet transfusion in premature neonates. Therefore, there is no evidence base with which to inform safe and effective practice for prophylactic platelet transfusions. There is a need for randomized controlled trials to define the optimal use of platelet transfusions in premature neonates, who at present are transfused heavily with platelets.
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Christensen RD. Platelet transfusion in the neonatal intensive care unit: benefits, risks, alternatives. Neonatology 2011; 100:311-8. [PMID: 21986337 DOI: 10.1159/000329925] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Platelet transfusions were introduced into clinical medicine about 60 years ago when they were shown to reduce the mortality rate of patients with leukemia who were bleeding secondary to hyporegenerative thrombocytopenia. In modern neonatology units, platelet transfusions are integral and indeed lifesaving for some neonates. However, the great majority of platelet transfusions currently administered in neonatal intensive care units (NICUs) are not given in the original paradigm to treat thrombocytopenic hemorrhage, but instead are administered prophylactically with the hope that they will reduce the risk of spontaneous bleeding. Weighing the risks and benefits of platelet transfusion, although imprecise, should be attempted each time a platelet transfusion is ordered. Adopting guidelines specific for platelet transfusion will improve consistency of care and will also generally reduce transfusion usage, thereby reducing costs and conserving valuable blood bank resources. Initiating specific programs to improve compliance with transfusion guidelines can further improve NICU transfusion practice.
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