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Yang Y, Hu Q, Yang C, Chen M, Han B. High- vs regular-dose recombinant human thrombopoietin plus cyclosporine A in patients with newly diagnosed non-severe aplastic anemia: a retrospective cohort study. Hematology 2024; 29:2298523. [PMID: 38156735 DOI: 10.1080/16078454.2023.2298523] [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: 08/14/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Cyclosporine A (CsA) and regular doses of recombinant human thrombopoietin (rhTPO) can accelerate platelet recovery in patients with non-severe aplastic anemia (NSAA). However, it is unclear whether CsA plus rhTPO at a higher dose can further increase the efficacy. METHODS Data from patients with newly diagnosed NSAA, who had been treated with CsA in combination with different doses of rhTPO between February 2021 and August 2021 at Peking Union Medical College Hospital, were reviewed. All the enrolled patients had been treated with CsA at 3-5 mg/(kg/d), and patients were further classified into high-dose (with rhTPO 30000U qd × 14 days for 2 months) group or regular-dose (with rhTPO 15000U qd × 7days for 3 months) group. The treatment response and therapy-related adverse events were compared. RESULTS 36 patients including 16 (44.4%) in the high-dose and 20 (55.6%) in the regular-dose group were enrolled. The baseline characteristics were compatible between the two groups. The platelet counts were significantly higher at 1/3/6 months in the high-dose group (p = 0.028, 0.0063 and p = 0.040, respectively). The high-dose group had a significantly shorter time to platelet transfusion independence ([1 (0.5-6) months vs 2.5 (1-12) months, p = 0.040]). There was no significant difference in overall response and complete response rate between the two groups at 1/3/6/12 months (p > 0.05). Treatment-related morbidities were similar between the two groups (p > 0.05). CONCLUSIONS Adding a higher dose of rhTPO can further accelerate platelet recovery and platelet transfusion independence in patients with newly diagnosed NSAA.
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Affiliation(s)
- Yuan Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
- Department of Hematology, Lymphoma Research Center, Third Hospital, Peking University, Beijing, People's Republic of China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
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Eapen M, Antin JH, Tolar J, Arai S, Horwitz ME, Kou J, Leifer E, McCarty JM, Nakamura R, Pulsipher MA, Rowley SD, Horowitz MM, Deeg HJ. Long-term survival after unrelated donor marrow transplantation for aplastic anaemia after optimized conditioning regimen: a retrospective multicentre cohort study. EClinicalMedicine 2024; 76:102819. [PMID: 39290639 PMCID: PMC11405822 DOI: 10.1016/j.eclinm.2024.102819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 08/12/2024] [Accepted: 08/21/2024] [Indexed: 09/19/2024] Open
Abstract
Background Almost all acquired severe aplastic anaemia is immune mediated and characterised by hypocellular bone marrow and ≥2 affected haematopoietic lineages. The optimal preparartive regimen for unrelated donor transplantation remains to be established. We aimed to study long-term outcomes after unrelated donor transplantation for severe aplastic anaemia with de-escalation of cyclophosphamide (Cy) dose in steps of 50 mg/kg (150, 100, 50, 0 mg/kg) in combination with total body irradiation (TBI) 2 Gy, anti-thymocyte globulin (ATG) and fludarabine. Methods Ninety-six patients with severe aplastic anaemia aged ≤65 years with adequate organ function enrolled on a trial of human leukocyte antigen (HLA)-matched or 1 HLA-locus mismatched unrelated donor marrow transplantation conducted between 02/2006 and 12/2013 in the United States (NCT00326417). Exclusion criteria were Karnofsky performance status of less than 60, clonal cytogenetic abnormalities and inherited marrow failure syndormes. The primary outcome was day-100 engraftment (achievement of absolute neutrophil recovery to at least 0.5 × 109/L without subsequent decline) and day-100 survival. The trial determined the lowest effective Cy dose as 50 mg/kg (n = 38) for day-100 engraftment and survival. Cy dose 100 mg/kg (n = 41) was also acceptable. Accrual to Cy doses 150 mg/kg (n = 15) and 0 mg/kg (n = 3) was terminated early for toxicities. The current study is an extended follow up of patients enrolled on the trial (NCT00326477) and includes 76 of 96 patients alive ≥1 year after transplantation. There were 20 deaths in the first year after transplantation (Cy 0 mg/kg [n = 2], Cy 50 mg/kg [n = 1], Cy 100 mg/kg [n = 10], Cy 150 mg/kg [n = 7]). Patients were followed prospectively from transplantation and data reported using standardized data collection forms until death, loss to follow up or last contact through November 2023. The incidence of graft failure was calculated using the cumulative incidence estimator and the probability of survival using the Kaplan-Meier estimator. Findings The median follow up of the cohort is 8.02 (IQR) 5.16-10.12) years. With Cy 50 mg/kg, there was one graft failure and five deaths ≥1 year after transplantation. With Cy 100 mg/kg there was only one late death and no graft failure. The 8-year probabilities of survival were 85.0% (95% CI 67.3-93.5) and 75.6% (95% CI 59.4-86.1) after Cy 50 mg/kg and 100 mg/kg, respectively, P = 0.31. With Cy 0 mg/kg and 150 mg/kg, there were no graft failures or death ≥1 year after transplantation. Regardless of Cy dose 12 of 15 patients aged ≥50 years died. Interpretation Cy 50 mg/kg or 100 mg/kg with TBI 2 Gy, ATG and fludarabine are effective conditioning regimens for unrelated donor marrow transplants for aplastic anaemia. Identification of an optimized transplantation approach for patients aged ≥50 years is needed. Funding US National Institutes of Health.
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Affiliation(s)
- Mary Eapen
- Division of Haematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Jakub Tolar
- Pediatric Blood and Marrow Transplant Program, University of Minnesota, MN, USA
| | - Sally Arai
- Stanford Hospital and Clinics, Stanford, CA, USA
| | | | - Jianqun Kou
- National Marrow Donor Program, Minneapolis, MN, USA
| | - Eric Leifer
- Intramural Research, National Heart Lung and Blood Institute, Bethesda, MD, USA
| | | | | | | | - Scott D Rowley
- Hackensack University Medical Centre, Hackensack, NJ, USA
| | - Mary M Horowitz
- Centre for International Blood and Marrow Transplant Program, Medical College of Wisconsin, WI, USA
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Zhao R, Ji D, Zhou Y, Qi L, Li F. Porcine Anti-Lymphocyte Globulin, Cyclosporine A Plus Thrombopoietin Receptor Agonists Achieved Similar Efficacy and Survival Compared to Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Aplastic Anemia. Int J Gen Med 2024; 17:4025-4036. [PMID: 39290233 PMCID: PMC11407318 DOI: 10.2147/ijgm.s465184] [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: 05/17/2024] [Accepted: 08/02/2024] [Indexed: 09/19/2024] Open
Abstract
Background Immunosuppressive therapy (IST) with horse or rabbit anti-human thymocyte immunoglobulin (h-/r-ATG) and hematopoietic stem cell transplantation (HSCT) are two baseline treatments for severe aplastic anemia (SAA) and transfusion-dependent non-severe aplastic anemia (TD-NSAA) patients. Addition of thrombopoietin receptor agonists (TPO-RAs) to standard IST therapy (h-/r-ATG) has greatly improved the survival of SAA, whereas porcine anti-lymphocyte globulin (p-ALG) combined with TPO-RAs still had a matter of debate. Methods We retrospectively compared the data of 48 AA patients in our center between 2020 and 2022, 23 AA patients received with p-ALG ± TPO-RAs, 25 AA patients underwent matched sibling donor (MSD-) or haploidentical (haplo-) HSCT. Results For patients in the HSCT group, the ORR was 90.9% which was significantly higher than that in the IST±TPO-RAs group (45.5%, P = 0.001) at 3 months; moreover, patients who underwent HSCT achieved faster transfusion independence, better CR rate, shorter time of recovery normal blood routine, and the percentage of normal blood routine (all P < 0.05) compared with IST±TPO-RAs group. However, the ORR were similary at 6 months in the two groups (95.5% vs 81.8% P = 0.342), with a median follow up of 19.8 months (range, 0.3-38.2 months), the 2-year FFS and OS in the two cohorts has no different. Subgroup analysis further indicated that the 2-year FFS and OS were similar between IST+TPO-RAs and haplo-HSCT subgroups, as well as in IST+TPO-RAs and MSD-HSCT cohorts. Moreover, the first-time hospitalizations were much more expensive in the HSCT group than in the IST±TPO-RAs group (402 756 vs. 292 902 yuan, P = 0.002). Conclusion P-ALG-based-IST±TPO-RAs is a good treatment option with similar FFS and OS compared to allo- HSCT for AA patients without the opportunity of HSCT.
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Affiliation(s)
- Ran Zhao
- Jiangxi Provincial Key Laboratory of Hematological Diseases, Department of Hematology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Dexiang Ji
- Jiangxi Provincial Key Laboratory of Hematological Diseases, Department of Hematology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Yulan Zhou
- Jiangxi Provincial Key Laboratory of Hematological Diseases, Department of Hematology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, Jiangxi, People's Republic of China
| | - Ling Qi
- Jiangxi Provincial Key Laboratory of Hematological Diseases, Department of Hematology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, Jiangxi, People's Republic of China
| | - Fei Li
- Jiangxi Provincial Key Laboratory of Hematological Diseases, Department of Hematology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, 330006, People's Republic of China
- Jiangxi Clinical Research Center for Hematologic Disease, Nanchang, Jiangxi, People's Republic of China
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4
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Chen WT, Wang SW, Huang Y, Tang RM, Liu D, Wang GY. The effect of hetrombopag combined with conventional treatment on immune function and quality of life in patients with severe aplastic anemia. Ann Hematol 2024:10.1007/s00277-024-05964-w. [PMID: 39235490 DOI: 10.1007/s00277-024-05964-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 08/20/2024] [Indexed: 09/06/2024]
Abstract
This study aimed to investigate the effect of hetrombopag combined with conventional treatment on immune function in patients with severe aplastic anemia (SAA). Patients were categorized into the control group (n = 50, receiving conventional treatment only) and experimental group (n = 50, receiving hetrombopag combined with conventional treatment). Before treatment and at weeks 18, 24, and 52 after treatment, the two groups were compared in routine blood test indicators, natural killer (NK) cell activity, and peripheral blood inflammatory factor levels. The overall remission rate and incidence of adverse events were also compared between the two groups. Outpatient or telephone follow-up was performed before treatment and at weeks 18, 24, and 52 after treatment to observe patients' immune function, treatment outcome, quality of life, and adverse events. Hemoglobin (Hb), and platelet count (PLT) (P < 0.05), and a rise in NK cell activity (P < 0.05). Interleukin (IL-10) levels were significantly higher, while IL-6 levels were significantly lower in the experimental group compared to the control group (P < 0.05). After receiving the treatment, all scores of SF-36 domains in both groups were higher than before treatment, particularly with higher scores in the experimental group (P < 0.05). Hetrombopag combined with conventional treatment improved the immune function and hematopoiesis of patients with SAA.
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Affiliation(s)
- Wen-Ting Chen
- Department of Hematology, Hainan General Hospital, Haikou, Hainan, 570311, China.
| | - Shu-Wen Wang
- Department of Clinical Laboratory, Hainan General Hospital, Haikou, Hainan, 570311, China
| | - Ying Huang
- Department of Hematology, Hainan General Hospital, Haikou, Hainan, 570311, China
| | - Rui-Mei Tang
- Department of Hematology, Hainan General Hospital, Haikou, Hainan, 570311, China
| | - Dan Liu
- Department of Hematology, Hainan General Hospital, Haikou, Hainan, 570311, China
| | - Gu-Yun Wang
- Department of Hematology, Hainan General Hospital, Haikou, Hainan, 570311, China
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Guarina A, Farruggia P, Mariani E, Saracco P, Barone A, Onofrillo D, Cesaro S, Angarano R, Barberi W, Bonanomi S, Corti P, Crescenzi B, Dell'Orso G, De Matteo A, Giagnuolo G, Iori AP, Ladogana S, Lucarelli A, Lupia M, Martire B, Mastrodicasa E, Massaccesi E, Arcuri L, Giarratana MC, Menna G, Miano M, Notarangelo LD, Palazzi G, Palmisani E, Pestarino S, Pierri F, Pillon M, Ramenghi U, Russo G, Saettini F, Timeus F, Verzegnassi F, Zecca M, Fioredda F, Dufour C. Diagnosis and management of acquired aplastic anemia in childhood. Guidelines from the Marrow Failure Study Group of the Pediatric Haemato-Oncology Italian Association (AIEOP). Blood Cells Mol Dis 2024; 108:102860. [PMID: 38889660 DOI: 10.1016/j.bcmd.2024.102860] [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: 02/15/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 06/20/2024]
Abstract
Acquired aplastic anemia (AA) is a rare heterogeneous disorder characterized by pancytopenia and hypoplastic bone marrow. The incidence is 2-3 per million population per year in the Western world, but 3 times higher in East Asia. Survival in severe aplastic anemia (SAA) has improved significantly due to advances in hematopoietic stem cell transplantation (HSCT), immunosuppressive therapy, biologic agents, and supportive care. In SAA, HSCT from a matched sibling donor (MSD) is the first-line treatment. If a MSD is not available, options include immunosuppressive therapy (IST), matched unrelated donor, or haploidentical HSCT. The purpose of this guideline is to provide health care professionals with clear guidance on the diagnosis and management of pediatric patients with AA. A preliminary evidence-based document prepared by a group of pediatric hematologists of the Bone Marrow Failure Study Group of the Italian Association of Pediatric Hemato-Oncology (AIEOP) was discussed, modified and approved during a series of consensus conferences that started online during COVID 19 and continued in the following years, according to procedures previously validated by the AIEOP Board of Directors.
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Affiliation(s)
- A Guarina
- Pediatric Onco-Hematology Unit, A.R.N.A.S. Civico Hospital, Palermo, Italy
| | - P Farruggia
- Pediatric Onco-Hematology Unit, A.R.N.A.S. Civico Hospital, Palermo, Italy
| | - E Mariani
- Scuola di Specializzazione in Pediatria, University of Milano-Bicocca, Milan, Italy; Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - P Saracco
- Hematology Unit, "Regina Margherita" Children's Hospital, Turin, Italy
| | - A Barone
- Pediatric Onco-Hematology Unit, University Hospital, Parma, Italy
| | - D Onofrillo
- Hematology Unit, Hospital of Pescara, Pescara, Italy
| | - S Cesaro
- Pediatric Hematology Oncology Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - R Angarano
- Pediatric Oncology-Hematology Unit, AOU Policlinico, Bari, Italy
| | - W Barberi
- Hematology, Department of Hematology, Oncology and Dermatology, AOU Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - S Bonanomi
- Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - P Corti
- Pediatric Hematology and Bone Marrow Transplant Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - B Crescenzi
- Hematology and Bone Marrow Transplantation Unit, Hospital of Perugia, Perugia, Italy
| | - G Dell'Orso
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - A De Matteo
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - G Giagnuolo
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - A P Iori
- Hematology and HSCT Unit, University La Sapienza, Rome, Italy
| | - S Ladogana
- Pediatric Onco-Hematology Unit, Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, Italy
| | - A Lucarelli
- Pediatric Emergency Department, Giovanni XXIII Pediatric Hospital, University of Bari, Bari, Italy
| | - M Lupia
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - B Martire
- Pediatrics and Neonatology Unit, Maternal-Infant Department, "Monsignor A.R. Dimiccoli" Hospital, Barletta, Italy
| | - E Mastrodicasa
- Hematology and Bone Marrow Transplantation Unit, Hospital of Perugia, Perugia, Italy
| | - E Massaccesi
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - L Arcuri
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - M C Giarratana
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - G Menna
- Oncology Hematology and Cell Therapies Department, AORN Santobono-Pausilipon, Naples, Italy
| | - M Miano
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - L D Notarangelo
- Medical Direction, Children's Hospital, ASST-Spedali Civili, Brescia, Italy
| | - G Palazzi
- Department of Mother and Child, University Hospital of Modena, Modena, Italy
| | - E Palmisani
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - S Pestarino
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - F Pierri
- HSCT Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - M Pillon
- Maternal and Child Health Department Pediatric Hematology, Oncology and Stem Cell Transplant Center, University of Padua, Padua, Italy
| | - U Ramenghi
- Hematology Unit, "Regina Margherita" Children's Hospital, Turin, Italy
| | - G Russo
- Division of Pediatric Hematology/Oncology, University of Catania, Catania, Italy
| | - F Saettini
- Centro Tettamanti, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - F Timeus
- Pediatrics Department, Chivasso Hospital, Turin, Italy
| | - F Verzegnassi
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - M Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - F Fioredda
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy
| | - C Dufour
- Hematology Unit, IRCCS Giannina Gaslini Children Hospital, Genoa, Italy.
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Li X, Shangguan X, Wang H, Wang Q, Zhang Y, Han B, Liu R, Zhang F, Fu R, Lin Z, Miao M, Ma X, Lei M, Wu D, Liu L. Comparison of efficacy of eltrombopag combined with immunosuppression in the treatment of severe aplastic anemia and very severe aplastic anemia: real-world data and evidence. Ann Hematol 2024; 103:3483-3491. [PMID: 39088061 DOI: 10.1007/s00277-024-05910-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 07/23/2024] [Indexed: 08/02/2024]
Abstract
Eltrombopag combined with immunosuppressive therapy (IST) was superior to IST alone for severe aplastic anemia (SAA) in the previous studies. But in China, horse antithymocyte globulin (hATG) is not available, instead, we use rabbit ATG (rATG). Here, we compared the efficacy and safety of IST (rATG combined with cyclosporine) combined with or without eltrombopag for the first-line treatment of SAA and very severe aplastic anemia (VSAA). A total of 371 patients in ten institutions in China from April 1, 2017 to December 1, 2022 were enrolled. The overall response (OR) rate at 3 months (54.2% vs. 41%; P = 0.046), the complete response (CR) (31.3% vs. 19.4%; P = 0.041) and OR (78.3% vs. 51.1%; P < 0.0001) rates at 6 months were significantly higher with IST combined with eltrombopag than with IST alone in SAA patients. While in VSAA patients, the addition of eltrombopag to IST only increased the CR rate at 6 months (29.8% vs. 9.43%; P = 0.010). Liver injury increased significantly in groups treated with IST combined with eltrombopag (P < 0.05). Serious treatment-related toxicities were similar (P > 0.05). In patients with SAA, 3-year failure-free survival (FFS) of eltrombopag combined with IST group was significantly higher than that of IST group (70.7 ± 5.3% vs. 50.3 ± 3.9%; P = 0.007). In patients with VSAA, the addition of eltrombopag significantly improved 3-year overall survival (OS) (82.2 ± 5.7% vs. 57.3 ± 7.2%; P = 0.020). Our findings suggested that IST combined with eltrombopag could improve the hematological recovery of newly diagnosed SAA without increasing severe toxicities. But in VSAA, the addition of eltrombopag seemed to show no other improvement to efficacy except the CR rate at 6 months.
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Affiliation(s)
- Xiaoli Li
- Soochow Hopes Hematonosis Hospital, Suzhou, Jiangsu, China
| | - Xiaohui Shangguan
- Department of Hematology, Longyan First Hospital, Affiliated to Fujian Medical University, Longyan, Fujian, China
| | - Hong Wang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, Jiangsu, China
| | - Qingyuan Wang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, Jiangsu, China
| | - Yanming Zhang
- Department of Hematology, The Affiliated Huai'an Hospital of Xuzhou Medical University and The Second People's Hospital of Huai'an, Huai'an, Jiangsu, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rongrong Liu
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Fengkui Zhang
- State Key Laboratory of Experimental Hematology, Anemia Therapeutic Center, Institute of Hematology & Blood Diseases Hospital, National Clinical Research Center for Blood Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Rong Fu
- Department of Hematology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Zenghua Lin
- Department of Hematology, The Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
| | - Miao Miao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, Jiangsu, China
| | - Xiao Ma
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, Jiangsu, China
| | - Meiqing Lei
- Department of Hematology in Haikou Municipal People's Hospital, Affiliated Haikou Hospital Xiangya School of Medicine Central South University, Haikou, Hainan, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, Jiangsu, China.
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Collaborative Innovation Center of Hematology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu, 215006, P.R. China.
| | - Limin Liu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, Jiangsu, China.
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Collaborative Innovation Center of Hematology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, Jiangsu, 215006, P.R. China.
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7
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Mingot-Castellano ME, Reguera-Ortega JL, Zafra Torres D, Hernani R, Lopez-Godino O, Guerreiro M, Herrero B, López-Corral L, Luna A, Gonzalez-Pinedo L, Chinea-Rodriguez A, Africa-Martín A, Bailen R, Martinez-Cibrian N, Balsalobre P, Filaferro S, Alonso-Saladrigues A, Barba P, Perez-Martinez A, Calbacho M, Perez-Simón JA, Sánchez-Pina JM, On Behalf Of The Spanish Group Of Hematopoietic Transplant And Cell Therapy Geth-Tc. Use of Eltrombopag to Improve Thrombocytopenia and Tranfusion Requirement in Anti-CD19 CAR-T Cell-Treated Patients. J Clin Med 2024; 13:5117. [PMID: 39274330 PMCID: PMC11396136 DOI: 10.3390/jcm13175117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 08/23/2024] [Accepted: 08/27/2024] [Indexed: 09/16/2024] Open
Abstract
Background/Objectives: Immune effector cell-associated hematotoxicity (ICAHT) is a frequent adverse event after chimeric antigen receptor (CAR)-T cell therapy. Grade ≥ 3 thrombocytopenia occurs in around one-third of patients, and many of them become platelet transfusion-dependent. Eltrombopag is a thrombopoietin receptor agonist (TPO-RA) able to accelerate megakaryopoiesis, which has been used successfully in patients with bone marrow failure and immune thrombocytopenia (ITP). Its role in managing thrombocytopenia and other cytopenias in CAR-T cell-treated patients has been scarcely addressed. Our aim was to report the safety and efficacy of this approach in patients included in the Spanish Group for Hematopoietic Transplantation and Cellular Therapy (GETH-TC) registry. Methods: This is a retrospective, multicenter, observational study. Patients who developed platelet transfusion dependence subsequently to CAR-T cells and received eltrombopag to improve platelet counts were recruited in 10 Spanish hospitals. Results: Thirty-eight patients were enrolled and followed up for a median (interquartile range [IQR]) of 175 (99, 489) days since CAR-T cell infusion. At the moment eltrombopag was indicated, 18 patients had thrombocytopenia and another severe cytopenia, while 8 patients had severe pancytopenia. After 32 (14, 38) days on eltrombopag, 29 (76.3%) patients recovered platelet transfusion independence. The number of platelet units transfused correlated with the time needed to restore platelet counts higher than 20 × 109/L (Rho = 0.639, p < 0.001). Non-responders to eltrombopag required more platelet units (58 [29, 69] vs. 12 [6, 26] in responders, p = 0.002). Nineteen out of twenty-three (82.6%) patients recovered from severe neutropenia after 22 (11, 31) days on eltrombopag. Twenty-nine out of thirty-five (82.9%) patients recovered red blood cell (RBC) transfusion independence after 29 (17, 44) days. Seven patients recovered all cell lineages while on treatment. No thromboembolic events were reported. Only two transient toxicities (cholestasis, hyperbilirubinemia) were reported during eltrombopag treatment, none of which compelled permanent drug withdrawal. Conclusions: Eltrombopag could be safely used to manage thrombocytopenia and accelerate transfusion independence in CAR-T cell-treated patients.
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Affiliation(s)
- Maria-Eva Mingot-Castellano
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, IBiS/CSIC, Universidad de Sevilla, 41004 Sevilla, Spain
| | - Juan Luis Reguera-Ortega
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, IBiS/CSIC, Universidad de Sevilla, 41004 Sevilla, Spain
| | | | - Rafael Hernani
- INCLIVA Health Research Institute, Hospital Clínico Universitario, 46010 Valencia, Spain
| | - Oriana Lopez-Godino
- Hematology Department, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, Hospital Universitario Morales-Meseguer, 30008 Murcia, Spain
| | - Manuel Guerreiro
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain
| | - Blanca Herrero
- Hospital Infantil Universitario del Niño Jesús, 28009 Madrid, Spain
| | - Lucia López-Corral
- IBSAL, CIBERONC, Centro de Investigación del Cáncer-IBMCC (USAL-CSIC), Hospital Universitario de Salamanca (Spain), 37007 Salamanca, Spain
| | - Alejandro Luna
- Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Lesli Gonzalez-Pinedo
- Hospital Universitario de Gran Canaria Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain
| | | | - Ana Africa-Martín
- IBSAL, CIBERONC, Centro de Investigación del Cáncer-IBMCC (USAL-CSIC), Hospital Universitario de Salamanca (Spain), 37007 Salamanca, Spain
| | - Rebeca Bailen
- Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, 28009 Madrid, Spain
| | - Nuria Martinez-Cibrian
- Hospital Clinic Barcelona, Institut de Recerca Sant Joan de Déu, Barcelona Hospital Sant Joan de Déu, 08950 Barcelona, Spain
| | | | | | | | - Pere Barba
- Grupo Español de Trasplante Hematopoyético y Terapia Celular, 28040 Madrid, Spain
| | - Antonio Perez-Martinez
- Pediatric Hematology-Oncology Department, La Paz University Hospital, 28034 Madrid, Spain
- Pediatric Department, Autonomous University of Madrid, 28034 Madrid, Spain
- CIBERER-ISCIII, IdiPAZ-CNIO Pediatric OncoHematology Clinical Research Unit, 28034 Madrid, Spain
| | - María Calbacho
- Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | - Jose Antonio Perez-Simón
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, IBiS/CSIC, Universidad de Sevilla, 41004 Sevilla, Spain
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8
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Seiders LL. Family reflections: George Elliott: a first-person commentary on pediatric aplastic anemia research. Pediatr Res 2024:10.1038/s41390-024-03500-0. [PMID: 39198587 DOI: 10.1038/s41390-024-03500-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 06/25/2024] [Indexed: 09/01/2024]
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9
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Zhang L, Li J, Liang W, Zhang X, Chen S, Shi Y, Hao M, Zhao X, Gong M, Wei J, He Y, Jiang E, Han M, Zhang F, Feng S. Comparison of hematopoietic stem cell transplantation and repeated intensified immunosuppressive therapy as second-line treatment for relapsed/refractory severe aplastic anemia. Front Immunol 2024; 15:1425076. [PMID: 39221245 PMCID: PMC11361938 DOI: 10.3389/fimmu.2024.1425076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
The optimal treatment for patients with severe aplastic anemia (SAA) who fail an initial course of antithymocyte globulin (ATG) plus cyclosporine has not yet been established. We compared the effectiveness of allogeneic hematopoietic stem cell transplantation (allo-HSCT) (n = 36) with repeated immunosuppressive therapy (IST) (n = 33) for relapsed/refractory SAA between 2007 and 2022. In the IST group, patients were retreated with ATG (n = 16) or high-dose cyclophosphamide (n = 17). The overall response rate was 57.6% at 6 months and 60.6% at 12 months. In the allo-HSCT group, patients received a transplant from a matched sibling donor (n = 6), matched unrelated donor (n = 7), or haploidentical donor (n = 23). All patients achieved neutrophil engraftment, and there were no cases of primary graft failure. The cumulative incidences (CIs) of grades II-IV and III-IV acute graft-versus-host disease (GVHD) were 36.1% ± 0.7% and 13.9% ± 0.3% at day +100, respectively. The 4-year CI of chronic GVHD (cGVHD) was 36.2% ± 0.7%, with moderate to severe cGVHD at 14.9% ± 0.4%. Compared with IST, HSCT recipients showed much higher hematologic recovery rate at 3, 6, and 12 months (63.9%, 83.3%, and 86.1%, respectively, p < 0.001). The estimated 4-year overall survival (OS) (79.8% ± 6.8% vs. 80.0% ± 7.3%, p = 0.957) was similar; however, the failure-free survival (FFS) was significantly better in the HSCT group (79.8% ± 6.8% vs. 56.6% ± 8.8%, p = 0.049). Of note, children in the HSCT cohort were all alive without treatment failures, exhibiting superior OS (100% vs. 50.0% ± 17.7%, p = 0.004) and FFS (100% vs. 50.0% ± 17.7%, p = 0.004) than children in the IST cohort. Subgroup analysis revealed that younger patients (age ≤ 35 years), especially children, and those with refractory SAA benefited more from HSCT. Therefore, for these patients, salvage HSCT may be more preferable than a second course of IST.
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Affiliation(s)
- Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Jianping Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Weiru Liang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaoyu Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Shulian Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yuanyuan Shi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Mengze Hao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaoli Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ming Gong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yi He
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Fengkui Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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10
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Babushok DV, DeZern AE, de Castro CM, Rogers ZR, Beenhouwer D, Broder MS, Fanning SR, Gibbs SN, Hanna R, Maciejewski JP, Scott BL, Tantravahi SK, Wlodarski MW, Yermilov I, Patel BJ. Modified Delphi panel consensus recommendations for management of severe aplastic anemia. Blood Adv 2024; 8:3946-3960. [PMID: 38669341 PMCID: PMC11331724 DOI: 10.1182/bloodadvances.2023011642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 03/28/2024] [Accepted: 04/21/2024] [Indexed: 04/28/2024] Open
Abstract
ABSTRACT Severe aplastic anemia (SAA) is a rare hematologic condition for which there is no clear management algorithm. A panel of 11 experts on adult and pediatric aplastic anemia was assembled and, using the RAND/University of California, Los Angeles modified Delphi panel method, evaluated >600 varying patient care scenarios to develop clinical recommendations for the initial and subsequent management of patients of all ages with SAA. Here, we present the panel's recommendations to rule out inherited bone marrow failure syndromes, on supportive care before and during first-line therapy, and on first-line (initial management) and second-line (subsequent management) therapy of acquired SAA, focusing on when transplant vs medical therapy is most appropriate. These recommendations represent the consensus of 11 experts informed by published literature and experience. They are intended only as general guidance for experienced clinicians who treat patients with SAA and are in no way intended to supersede individual physician and patient decision making. Current and future research should validate this consensus using clinical data. Once validated, we hope these expert panel recommendations will improve outcomes for patients with SAA.
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Affiliation(s)
- Daria V. Babushok
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Amy E. DeZern
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Carlos M. de Castro
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Durham, NC
| | - Zora R. Rogers
- Division of Pediatric Hematology-Oncology, University of Texas, Southwestern Medical Center, Dallas, TX
| | | | | | - Suzanne R. Fanning
- Prisma Health Cancer Institute, University of South Carolina, Greenville, SC
| | - Sarah N. Gibbs
- Partnership for Health Analytic Research, Beverly Hills, CA
| | - Rabi Hanna
- Department of Pediatric Hematology Oncology and Bone Marrow Transplantation, Cleveland Clinic, Cleveland, OH
| | | | - Bart L. Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Srinivas K. Tantravahi
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Marcin W. Wlodarski
- Department of Hematology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Irina Yermilov
- Partnership for Health Analytic Research, Beverly Hills, CA
| | - Bhumika J. Patel
- Prisma Health Cancer Institute, University of South Carolina, Greenville, SC
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11
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Zhang W, Chang LX, Zhao BB, Zheng Y, Shan DD, Tang BH, Yang F, Zhou Y, Hao GX, Zhang YH, van den Anker J, Zhu XF, Zhang L, Zhao W. Efficacy, Safety, and Population Pharmacokinetics of Eltrombopag in Children with Different Severities of Aplastic Anemia. J Clin Pharmacol 2024; 64:932-943. [PMID: 38497347 DOI: 10.1002/jcph.2430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/18/2024] [Indexed: 03/19/2024]
Abstract
Eltrombopag was approved as a first-line treatment for patients older than 2 years old with severe aplastic anemia (SAA). However, data on eltrombopag in children with different types of aplastic anemia (AA), especially non-severe AA (NSAA), are limited. We performed a prospective, single-arm, and observational study to investigate eltrombopag's efficacy, safety, and pharmacokinetics in children with NSAA, SAA, and very severe AA (VSAA). The efficacy and safety were assessed every 3 months. The population pharmacokinetic (PPK) model was used to depict the pharmacokinetic profile of eltrombopag. Twenty-three AA children with an average age of 7.9 (range of 3.0-14.0) years were enrolled. The response (complete and partial response) rate was 12.5%, 50.0%, and 100.0% after 3, 6, and 12 months in patients with NSAA. For patients with SAA and VSAA, these response rates were 46.7%, 61.5%, and 87.5%. Hepatotoxicity occurred in one patient. Fifty-three blood samples were used to build the PPK model. Body weight was the only covariate for apparent clearance (CL/F) and volume of distribution. The allele-T carrier of adenosine triphosphate-binding cassette transporter G2 was found to increase eltrombopag's clearance. However, when normalized by weight, the clearance between the wild-type and variant showed no statistical difference. In patients with response, children with NSAA exhibited lower area under the curve from time zero to infinity, higher CL/F, and higher weight-adjusted CL/F than those with SAA or VSAA. However, the differences were not statistically significant. The results may support further individualized treatment of eltrombopag in children with AA.
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Affiliation(s)
- Wei Zhang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Li-Xian Chang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Bei-Bei Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yi Zheng
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dan-Dan Shan
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bo-Hao Tang
- Department of Pharmacy, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Fan Yang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yue Zhou
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ya-Hui Zhang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Departments of Pediatrics, Pharmacology & Physiology, Genomics & Precision Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Xiao-Fan Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Li Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
- NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, Qilu Hospital of Shandong University, Shandong University, Jinan, China
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12
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Shimano KA, Rothman JA, Allen SW, Castillo P, de Jong JLO, Dror Y, Geddis AE, Lau BW, McGuinn C, Narla A, Overholt K, Pereda MA, Sharathkumar A, Sasa G, Nakano TA, Myers K, Gloude NJ, Broglie L, Boklan J. Treatment of newly diagnosed severe aplastic anemia in children: Evidence-based recommendations. Pediatr Blood Cancer 2024; 71:e31070. [PMID: 38757488 DOI: 10.1002/pbc.31070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/27/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
Severe aplastic anemia (SAA) is a rare potentially fatal hematologic disorder. Although overall outcomes with treatment are excellent, there are variations in management approach, including differences in treatment between adult and pediatric patients. Certain aspects of treatment are under active investigation in clinical trials. Because of the rarity of the disease, some pediatric hematologists may have relatively limited experience with the complex management of SAA. The following recommendations reflect an up-to-date evidence-based approach to the treatment of children with newly diagnosed SAA.
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Affiliation(s)
- Kristin A Shimano
- Department of Pediatrics, Division of Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Jennifer A Rothman
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Steven W Allen
- Department of Pediatrics, Pediatric Hematology/Oncology, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paul Castillo
- Department of Pediatrics, Division of Pediatric Hematology Oncology, UF Health Shands Children's Hospital, Gainesville, Florida, USA
| | - Jill L O de Jong
- Department of Pediatrics, Section of Hematology/Oncology/Stem Cell Transplantation, University of Chicago, Chicago, Illinois, USA
| | - Yigal Dror
- Department of Pediatrics, Marrow Failure and Myelodysplasia Program, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Amy E Geddis
- Department of Pediatrics, Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, Washington, USA
| | - Bonnie W Lau
- Department of Pediatrics, Pediatric Hematology-Oncology, Dartmouth-Hitchcock, Lebanon, New Hampshire, USA
| | - Catherine McGuinn
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Anupama Narla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kathleen Overholt
- Department of Pediatrics, Pediatric Hematology/Oncology, Riley Hospital for Children at Indiana University, Indianapolis, Indiana, USA
| | - Maria A Pereda
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Anjali Sharathkumar
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Ghadir Sasa
- Sarah Cannon Transplant and Cellular Therapy Network, San Antonio, Texas, USA
| | - Taizo A Nakano
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kasiani Myers
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas J Gloude
- Department of Pediatrics, University of California San Diego, Rady Children's Hospital, San Diego, California, USA
| | - Larisa Broglie
- Department of Pediatric Hematology/Oncology/Blood and Marrow Transplantation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jessica Boklan
- Department of Pediatrics, Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, Arizona, USA
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13
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Chen H, Ma J, Ouyang J, Fu L, Ma J, Yao J, Wu R, Chen Z. The Differences of Serum Thrombopoietin Levels Between Acquired Aplastic Anemia and Immune Thrombocytopenia in Pediatric Patients. J Pediatr Hematol Oncol 2024; 46:281-286. [PMID: 38857156 DOI: 10.1097/mph.0000000000002873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 04/02/2024] [Indexed: 06/12/2024]
Abstract
Thrombopoietin (TPO) is the critical regulator of platelet production. However, the role of TPO in pediatric patients with thrombocytopenic disorders has not been fully elucidated. In the present study, we attempted to investigate serum TPO levels in patients with acquired aplastic anemia (aAA) and immune thrombocytopenia (ITP). We analyzed the endogenous plasma concentration of TPO and platelet count at the time of TPO measurement in 166 patients with aAA and 280 patients with ITP retrospectively. We further observed a correlation between platelet counts and TPO. Serum TPO levels were significantly higher in aAA compared with ITP (1142 vs. 77.99 pg/mL, P <0.001). In patients with aAA, an elevation for TPO levels in very severe AA (VSAA) was seen when compared with non-severe AA (NSAA) (1360 vs. 984.4 pg/mL, P <0.05). In contrast, the circulating TPO levels with chronic ITP (CITP) showed a decrease than newly diagnosed ITP (NITP) and persistent ITP (PITP) (62.28 vs. 81.56 pg/mL, P <0.01, 62.28 vs. 87.82 pg/mL, P <0.05, respectively). There was a negative correlation between platelet counts and TPO levels in aAA (r s =-0.3325, P <0.001) as well as ITP (r s =-0.2570, P <0.001). Especially, TPO levels were inversely correlated with platelet counts in NSAA (r s =-0.3672, P <0.001) and NITP (r s =-0.3316, P <0.001). After grouping by age or sex, there were no statistical differences in aAA or ITP. Serum TPO levels were markedly elevated in pediatric patients with aAA compared with ITP. It was higher in VSAA and lower in CITP, suggesting that serum TPO level could play a role in classifying disease severity or clinical course in aAA and ITP.
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Affiliation(s)
- Hui Chen
- Hematologic Disease Laboratory, Hematology Center
| | - Jie Ma
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | | | - Lingling Fu
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Jingyao Ma
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Jiafeng Yao
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Runhui Wu
- Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University); Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
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14
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Yokota H, Miyao K, Sawa M, Terakura S, Kurahashi S, Ikoma Y, Imahashi N, Morishita T, Okamoto A, Kajiguchi T, Ono T, Narita T, Kanemura N, Ozeki K, Kojima Y, Naito K, Uchino K, Tomita A, Iida H, Imoto N, Kasahara S, Inagaki Y, Nishida T, Murata M. Long-Term Outcome of Eltrombopag With First-Line Immunosuppressive Therapy for Newly Diagnosed Severe Aplastic Anemia. J Hematol 2024; 13:142-149. [PMID: 39247063 PMCID: PMC11379047 DOI: 10.14740/jh1289] [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: 05/26/2024] [Accepted: 07/23/2024] [Indexed: 09/10/2024] Open
Abstract
Background To investigate whether the addition of eltrombopag (EPAG) to rabbit anti-thymocyte globulin (ATG)-based immunosuppressive therapy (IST) for newly diagnosed severe aplastic anemia (SAA) improves outcomes and affects the cumulative incidence of clonal evolution (CE), we conducted a multicenter retrospective analysis. Methods Data were collected from 101 patients, aged 15 - 65 years, undergoing initial IST. Results No significant imbalance in age, sex, or severity was observed between the EPAG (n = 20) and non-EPAG (n = 81) groups. The median duration of EPAG administration in EPAG group was 16.1 months (range: 0.6 - 41.1 months). Six months after the initiation of IST, the complete response (CR) rate significantly improved in the EPAG group (P < 0.01). The cumulative incidence of allogeneic stem cell transplantation (allo-SCT) at 2 years and the 2-year overall survival (OS) were not significantly different between the two groups (allo-SCT, P = 0.31; OS, P = 0.64). Grade 3-4 adverse events in the EPAG group and the cumulative incidence of CE (P = 0.96) showed no increase. Conclusion In summary, IST showed significantly better initial efficacy in the EPAG group. Although the addition of EPAG did not reduce the need for allo-SCT, no increase was observed in the incidence of CE with long-term EPAG use.
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Affiliation(s)
- Hirofumi Yokota
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kotaro Miyao
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Masashi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Seitaro Terakura
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shingo Kurahashi
- Division of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Yoshikazu Ikoma
- Department of Hematology, Gifu Municipal Hospital, Gifu, Japan
- Department of Hematology and Infectious Disease, Gifu University Hospital, Gifu, Japan
| | | | - Takanobu Morishita
- Department of Hematology, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Akinao Okamoto
- Department of Hematology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Tomohiro Kajiguchi
- Department of Hematology and Oncology, Tosei General Hospital, Seto, Japan
| | - Takaaki Ono
- Department of Internal Medicine, School of Medicine, Hamamatsu University, Hamamatsu, Japan
| | - Tomoko Narita
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nobuhiro Kanemura
- Department of Hematology and Infectious Disease, Gifu University Hospital, Gifu, Japan
| | - Kazutaka Ozeki
- Department of Hematology and Oncology, Konan Kosei Hospital, Konan, Japan
| | - Yumi Kojima
- Department of Hematology, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Kensuke Naito
- Department of Hematology, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Kaori Uchino
- Department of Internal Medicine, Division of Hematology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Akihiro Tomita
- Department of Hematology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hiroatsu Iida
- Department of Hematology, NHO Nagoya Medical Center, Nagoya, Japan
| | - Naoto Imoto
- Division of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Senji Kasahara
- Department of Hematology, Gifu Municipal Hospital, Gifu, Japan
| | - Yuichiro Inagaki
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Tetsuya Nishida
- Department of Hematology, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | - Makoto Murata
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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15
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Nakamura Y, Zaimoku Y, Yamaguchi H, Yamazaki H, Kanaya M, Uchida N, Doki N, Sakurai M, Hiramoto N, Kako S, Onizuka M, Onodera K, Maruyama Y, Ohigashi H, Nishida T, Yoshihara S, Matsuoka KI, Eto T, Kanda Y, Fukuda T, Atsuta Y, Onishi Y. Significance of absolute neutrophil count before allogeneic hematopoietic stem cell transplantation in adult patients with aplastic anemia. Ann Hematol 2024; 103:3121-3133. [PMID: 38750374 DOI: 10.1007/s00277-024-05800-1] [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: 01/27/2024] [Accepted: 05/10/2024] [Indexed: 07/28/2024]
Abstract
The impact of absolute neutrophil count (ANC) before allogenic hematopoietic stem cell transplantation (HSCT) on the outcomes for patients with aplastic anemia (AA) remains unclear. We retrospectively evaluated the relationship between ANC before transplantation and patient outcomes, involving 883 adult Japanese patients with AA who underwent allogeneic HSCT as their first transplantation between 2008 and 2020. Patients were divided into three groups based on ANC: 0/µL (n = 116); 1-199 (n = 210); and ≥ 200 (n = 557). In the low ANC groups (ANC < 200), patient age was higher, previous anti-thymocyte globulin (ATG) treatments were infrequent, duration from diagnosis to transplantation was shorter, hematopoietic cell transplantation-comorbidity index (HCT-CI) was higher, ATG-based conditioning was used infrequently, and peripheral blood stem cell from related donor and cord blood were used frequently. In multivariate analysis, patient age, previous ATG treatment, HCT-CI, stem cell source, and ANC before transplantation were significantly associated with 5-year overall survival (OS) ("ANC ≥ 200": 80.3% vs. "ANC 1-199": 71.7% vs. "ANC 0": 64.4%). The cumulative incidence of bacterial infection, invasive fungal disease, and early death before engraftment were significantly higher in the low ANC groups. Among patients with ANC of zero before transplantation, younger patient age, shorter duration from diagnosis to transplantation, HCT-CI of 0, and bone marrow from related donor as stem cell source were significantly associated with better OS. Consequently, ANC before allogeneic HSCT was found to be a significant prognostic factor in adult patients with AA. Physicians should pay attention to ANC before transplantation.
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Affiliation(s)
- Yukinori Nakamura
- Third Department of Internal Medicine, Yamaguchi University Hospital, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8505, Japan.
| | - Yoshitaka Zaimoku
- Department of Infection Control and Prevention, Kanazawa University Hospital, Ishikawa, Japan
| | | | - Hirohito Yamazaki
- Division of Transfusion Medicine, Kanazawa University Hospital, Ishikawa, Japan
| | - Minoru Kanaya
- Blood Disorders Center, Aiiku Hospital, Hokkaido, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Masatoshi Sakurai
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Nobuhiro Hiramoto
- Department of Hematology, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Koichi Onodera
- Department of Hematology, Tohoku University Hospital, Miyagi, Japan
| | - Yumiko Maruyama
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
| | - Hiroyuki Ohigashi
- Department of Hematology, Hokkaido University Hospital, Hokkaido, Japan
| | - Tetsuya Nishida
- Department of Hematology, Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Aichi, Japan
| | - Satoshi Yoshihara
- Department of Hematology, Hyogo Medical University Hospital, Hyogo, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Tetsuya Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
- Division of Hematology, Jichi Medical University, Tochigi, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Aichi, Japan
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Aichi, Japan
| | - Yasushi Onishi
- Department of Hematology, Tohoku University Hospital, Miyagi, Japan
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16
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Illango J, Seffah KD, Naveen N, Paudel Y, Patel A, Pachchipulusu VK, Desai HN, Najam B, Hamid P. A Systematic Review and Meta-Analysis of Eltrombopag Efficacy Combined With Immunosuppressive Drugs in Treatment of Severe Aplastic Anemia. Cureus 2024; 16:e65970. [PMID: 39221321 PMCID: PMC11365712 DOI: 10.7759/cureus.65970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 08/01/2024] [Indexed: 09/04/2024] Open
Abstract
Severe aplastic anemia (SAA) is a life-threatening disorder with high mortality. The only curative treatment is hematopoietic stem cell transplantation (HSCT), but it is mainly for young patients with suitable donors. The alternative is immunosuppressive therapy (IST), which can improve blood counts in about 58% of patients, but many relapse after discontinuation. Recently, eltrombopag, a thrombopoietic receptor agonist, was tested. As a single drug, it improved blood counts in 40-50% of patients. However, combining eltrombopag and IST proved more effective and safer. A review of 20 randomized controlled trials with 2,469 patients showed that the group receiving eltrombopag and IST had a significantly higher overall response rate (86% vs. 74%) after six months. After two years, 54% of the experimental group had relapsed compared to 39% in the control group. Despite this, eltrombopag tends to increase relapse rates over time. In conclusion, combining eltrombopag with IST is a superior treatment for SAA.
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Affiliation(s)
- Janan Illango
- Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Kofi D Seffah
- Internal Medicine, Phoebe Putney Memorial Hospital, Albany, USA
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, Piedmont Athens Regional Medical, Athens, USA
| | - Namballa Naveen
- Internal Medicine, Steel Authority of India Limited (SAIL) Hospital, Dhanbad, IND
| | - Yubraj Paudel
- Internal Medicine, Pushpanjali Hospital Pvt. Ltd., Bharatpur, NPL
| | - Anandkumar Patel
- Neurology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Neurology, Shalby Hospital Naroda, Ahmedabad, IND
- Medicine, Maharshi Hospital Private Limited, Surendranagar, IND
| | | | - Heet N Desai
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Beenish Najam
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Pousette Hamid
- Neurology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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17
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Zhang T, Yu Q, Chen X, Yang H, Gong Y, Zhang Y, Liu X, Yang Z, Fang Y, Yan X, Zhou X, Shi J, He G. Avatrombopag as alternative therapy for severe aplastic anemia patients who are intolerant or unresponsive to eltrombopag. Front Immunol 2024; 15:1393829. [PMID: 39114665 PMCID: PMC11303196 DOI: 10.3389/fimmu.2024.1393829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 07/09/2024] [Indexed: 08/10/2024] Open
Abstract
Introduction Eltrombopag (EPAG), a thrombopoietin receptor agonist, was approved for the treatment of severe aplastic anemia (SAA) combined with immunosuppressive therapy (IST). However, EPAG contains a typical biphenyl structure, which causes liver function damage. Methods Twenty patients with SAA who were intolerant or refractory to EPAG were enrolled in a multicenter prospective registry of the Chinese Eastern Collaboration Group of Anemia (ChiCTR2100045895) from October 2020 to June 2023. Results Eight patients who were ineffective to EPAG, six with kidney impairment, and nine with abnormal liver function (two with concomitant liver and kidney impairment) were converted to avatrombopag (AVA) therapy with the median duration of AVA treatment was 6 (3-24) months. 17 cases (85%) achieved trilineage hematological response (HR): complete remission (CR) in 3 cases (15%), good partial remission (GPR) in 4 cases (20%), partial remission (PR) in 10 cases (50%), and no response (NR) in 3 cases (15%). The median time to response was 1.7 (0.5-6.9) months, with 16 cases (94%) achieving response within six months and 17 cases (100%) within 12 months. 9 cases (50%) achieved transfusion independence. AVA converted treatment was associated with higher neutrophil counts (0.8×109/L vs 2.2×109/L, p=0.0003), platelet counts (11×109/L vs 39×109/L, p=0.0008), hemoglobin count (59g/L vs 98g/L, p=0.0002), red cell count (1.06×1012/L vs 2.97×1012/L, p=0.001), and absolute reticulocyte count (31.99 ×109/L vs 67.05×109/L p=0.0004) were all significantly elevated compared with the pre-treatment level. After the conversion to AVA therapy, liver and kidney function indexes were maintained within the normal range, no AVA related grade 2 or higher adverse events occurred, and no thrombotic events occurred. Conclusion The conversion to AVA was an optimal choice for patients with SAA who were EPAG intolerant or refractory. Clinical trial registration http://www.chictr.org.cn/showproj.html?proj=125480, identifier ChiCTR2100045895.
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Affiliation(s)
- Ting Zhang
- Department of Hematology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Qingling Yu
- Department of Hematology, Affiliated Jianhu Hospital of Nantong University Xinglin College, Yancheng, China
| | - Xiaoyu Chen
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Hui Yang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Yuemin Gong
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Yawen Zhang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Xiaoqing Liu
- Department of Hematology, Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing Second Hospital, Nanjing, China
| | - Zhinan Yang
- Department of Hematology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Yu Fang
- Department of Hematology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Xue Yan
- Department of Hematology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Xuan Zhou
- Department of Hematology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Jinning Shi
- Department of Hematology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Guangsheng He
- Department of Hematology, Affiliated Jianhu Hospital of Nantong University Xinglin College, Yancheng, China
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18
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Prabahran A, Durrani J, Coelho-Da Silva J, Shalhoub R, Lotter J, Rios O, Ritchie DS, Wu CO, Patel BA, Young NS, Groarke EM. Safety and efficacy of immunosuppressive therapy for elderly patients with severe aplastic anaemia. Br J Haematol 2024. [PMID: 39021060 DOI: 10.1111/bjh.19648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 07/06/2024] [Indexed: 07/20/2024]
Abstract
Uncertainty remains regarding the safety and tolerability of immunosuppressive therapy (IST) with anti-thymocyte globulin (ATG) and cyclosporine (CSA) in older patients. We retrospectively analysed two prospective clinical trials of IST in treatment-naïve severe aplastic anaemia (SAA) to assess safety in older compared to younger patients. Patients ≥18 years of age who had received IST with ATG and CSA +/- eltrombopag (EPAG) were included. Pre-treatment baseline characteristics and co-morbidities were assessed as predictors of therapy-related complications in younger (<60 years) versus older (≥60 years) patients. Out of 245 eligible patients, 54 were older and 191 were younger. Older patients had a similar frequency of SAEs, ICU admissions and hospital length of stay compared to younger patients. Older patients had a higher frequency of cardiac events related to IST, but none resulted in death. Older patients had worse long-term overall survival, and more relapse and clonal evolution post-IST. However, older patients who responded to IST had a similar survival at a median follow-up to younger patients. Disease-related factors and limited therapeutic options in refractory disease likely contribute to poorer outcomes in older patients, not complications of upfront IST. Therefore, IST should be considered first-line therapy for most older SAA patients.
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Affiliation(s)
- Ashvind Prabahran
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre/The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- ACRF Laboratory, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Jibran Durrani
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Juan Coelho-Da Silva
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Ruba Shalhoub
- Office of Biostatistics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer Lotter
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Olga Rios
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - David S Ritchie
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre/The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- ACRF Laboratory, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Colin O Wu
- Office of Biostatistics, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Bhavisha A Patel
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Neal S Young
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Emma M Groarke
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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19
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Sharathkumar A, Carr J, Claassen D, Syrbu S, Bhagavathi S, Al-Huniti A, Modi A, Bates M, Mott SL. Romiplostim for Treatment of Children and Young Adults With Severe Aplastic Anemia and Myelodysplastic Syndrome. J Pediatr Hematol Oncol 2024; 46:252-261. [PMID: 38787686 DOI: 10.1097/mph.0000000000002891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024]
Abstract
Thrombopoietin receptor agonists (TPO-RAs) induce trilineage hematopoiesis under conditions with acquired hematopoietic failure. We evaluated safety, tolerability, and preliminary efficacy of a TPO-RA, romiplostim (Nplate), with or without standard-of-care immunosuppressive therapy (±IST) for children (ages < 21 y) with newly diagnosed and relapsed/refractory severe aplastic anemia (SAA) and myelodysplastic syndrome (MDS). Data were collected from an observational study and a single arm interventional pilot study. The safety outcome was treatment-related adverse events (AEs). Efficacy was evaluated by complete hematopoietic response (CHR) at week 24. Romiplostim was commenced at 5 µg/kg/week, with dose escalation of 2.5 µg/kg/week (maximum, 20 µg/kg/dose) based on platelet response. Romiplostim was continued until CHR was observed. Ten subjects (SAA, 9 [IST, 4; without IST, 5]; MDS, 1) completed the study (median age: 9.2 y). Median romiplostim dose was 10 µg/kg/week (range: 5 to 17.5 µg/kg/week). The cumulative incidence of CHR was 70.4% (95% CI, 20.2%-92.6%). Among 21 AEs (Grade 1 to 3), 3 were attributed to romiplostim. At a median posttherapy follow-up of 10.9 months (range: 0.7 to 77.5), no clonal evolution, bone marrow fibrosis or mortality was reported. This proof-of-concept study provides data about short-term safety, tolerability, and preliminary efficacy of romiplostim (±IST) for treatment of pediatric SAA/MDS.
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Affiliation(s)
- Anjali Sharathkumar
- Stead Family Department of Pediatrics, Carver College of Medicine
- Holden Comprehensive Cancer Center
| | - Jamie Carr
- Institute for Clinical and Translational Science
| | - David Claassen
- Stead Family Department of Pediatrics, Carver College of Medicine
| | - Sergei Syrbu
- Department of Pathology, University of Iowa, Iowa City, IA
| | | | - Ahmad Al-Huniti
- Department of Pediatrics, Mayo Clinic, Hematology, Rochester, MN
| | - Arunkumar Modi
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Melissa Bates
- Holden Comprehensive Cancer Center
- Department of Health and Human Physiology
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
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20
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Kashif R, Horn B, Milner J, Joyce M, Dalal M, Lee JJ, McNerney K, Cline J, Fort J, Castillo P, Galvez J, Alperstein W, Ligon J, Ziga E, Crawford D, Chellapandian D. The role of donor type and pre-transplant immunosuppression on outcomes of hematopoietic stem cell transplantation in children and young adults with severe aplastic anemia. Pediatr Transplant 2024; 28:e14784. [PMID: 38766976 DOI: 10.1111/petr.14784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/08/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The goal of this study was to assess the effect of donor type and pre-transplant immunotherapy (IST) on outcomes of hematopoietic stem cell transplantation (HSCT) for children and young adults with severe aplastic anemia (SAA). METHODS This retrospective, multi-center study included 52 SAA patients, treated in 5 pediatric transplant programs in Florida, who received HSCT between 2010 and 2020 as the first- or second-line treatment. RESULTS The median age at HSCT for all 52 patients was 15 years (range 1-25). The 3-year overall survival (OS) by donor type were as follows: 95% [95% CI 85.4-99] for matched related donors (MRD) (N = 24), 84% [95% CI 63.5-99] for haploidentical (N = 13), and 71% [95% CI 36-99] for matched unrelated donors (MUD) (N = 7). The 3-year OS was 81% [95% CI 69.7-99] for all patients, 90.5% [95% CI 79.5-99] for non-IST patients (N = 27), and 70% [95% CI 51-99] for IST patients (N = 24) (log-rank p = .04). Survival of haploidentical HSCT (haplo-HSCT) recipients with post-transplant cyclophosphamide (PTCy) (N = 13) was excellent for both groups: 100% for non-IST patients (N = 3) and 80% for IST patients (N = 10). The 3-year OS for patients with previous IST by donor type in groups where >5 patients were available was 78.8% [95% CI 52.3-99] for haplo-HSCT (N = 10) and 66.7% [95% CI 28.7-99] for MUD (N = 6). Although it appears that patients receiving HSCT ≥6 months after the start of IST had worse survival, the number of patients in each category was small and log-rank was not significant(p = .65). CONCLUSIONS Patients receiving MUD and haplo-HSCT with PTCy had similar outcomes, suggesting that haplo-HSCT with PTCy could be included in randomized trials of upfront IST versus alternative donor HSCT.
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Affiliation(s)
- Reema Kashif
- Department of Pediatrics, Division of Pediatric Hematology-Oncology & BMT, University of Florida, Gainesville, Florida, USA
| | - Biljana Horn
- Department of Pediatrics, Division of Pediatric Hematology-Oncology & BMT, University of Florida, Gainesville, Florida, USA
| | - Jordan Milner
- Department of Pediatrics, Division of Pediatric Hematology-Oncology & BMT, University of Florida, Gainesville, Florida, USA
| | - Michael Joyce
- Nemours Children's Health & Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Mansi Dalal
- Department of Pediatrics, Division of Pediatric Hematology-Oncology & BMT, University of Florida, Gainesville, Florida, USA
| | - Jin-Ju Lee
- Department of Pediatrics, Division of Pediatric Hematology-Oncology & BMT, University of Florida, Gainesville, Florida, USA
| | - Kevin McNerney
- Center for Cell & Gene Therapy for Non-Malignant Conditions, John Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Jessica Cline
- Department of Pediatrics, Division of Pediatric Hematology-Oncology & BMT, University of Florida, Gainesville, Florida, USA
| | - John Fort
- Department of Pediatrics, Division of Pediatric Hematology-Oncology & BMT, University of Florida, Gainesville, Florida, USA
| | - Paul Castillo
- Department of Pediatrics, Division of Pediatric Hematology-Oncology & BMT, University of Florida, Gainesville, Florida, USA
| | - Jorge Galvez
- Pediatric Blood & Marrow Transplantation Program, Nicklaus Children's Hospital, Miami, Florida, USA
| | | | - John Ligon
- Department of Pediatrics, Division of Pediatric Hematology-Oncology & BMT, University of Florida, Gainesville, Florida, USA
| | - Edward Ziga
- School of Medicine, University of Miami, Miami, Florida, USA
| | - David Crawford
- School of Medicine, University of Miami, Miami, Florida, USA
| | - Deepak Chellapandian
- Center for Cell & Gene Therapy for Non-Malignant Conditions, John Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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21
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Wirk B. Acquired Aplastic Anemia Therapies: Immunosuppressive Therapy Versus Alternative Donor Hematopoietic Cell Transplantation. J Hematol 2024; 13:61-70. [PMID: 38993743 PMCID: PMC11236356 DOI: 10.14740/jh1264] [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] [Received: 03/18/2024] [Accepted: 05/24/2024] [Indexed: 07/13/2024] Open
Abstract
Immunosuppressive therapy for acquired severe aplastic anemia improves pancytopenia but has a significant risk of relapse (40%) and clonal evolution to myeloid neoplasms (15%), especially in patients older than 40. Yet, current guidelines for newly diagnosed severe aplastic anemia patients over the age of 40 recommend immunosuppressive therapy instead of curative allogeneic stem cell transplantation. Upfront allogeneic stem cell transplants are restricted to the rare patient who is not only young but also has a matched sibling donor. This article will discuss practice-changing data on the recent advances in upfront alternative donor hematopoietic cell transplants that could rewrite current treatment algorithms.
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Affiliation(s)
- Baldeep Wirk
- Cellular Immunotherapies and Transplant Program, Massey Comprehensive Cancer Center, Virginia Commonwealth University, Richmond, VA 23219, USA.
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22
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Yang B, Fu L, Li H, Chen H, Zhang R, Yao J, Zhang L, Wu R, Ma J. Eltrombopag combined with immunosuppressive therapy for pediatric severe aplastic anemia. Pediatr Res 2024:10.1038/s41390-024-03253-w. [PMID: 38822136 DOI: 10.1038/s41390-024-03253-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 03/04/2024] [Accepted: 03/28/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Severe aplastic anemia (SAA) is caused by immune-mediated destruction. Standard immunosuppressive therapy (IST) is effective but needs to be improved. METHODS The data of patients with SAA and received IST were analyzed retrospectively to conducted this historical control study. RESULTS A total of 115 SAA patients (60 males; median age of 5.77 years and median follow-up time of 45 months) were enrolled in this study. The complete response rates (CRR) of the eltrombopag group at 3 and 6 months were higher than the control group (30.3% vs.8.2% at 3 months; 50.0% vs. 10.2% at 6 months). The overall response rates (ORR) showed no differences. There were significant differences in the times from G-CSF, Red blood cell transfusion, and Platelet transfusion between the two groups. No difference in overall survival (OS), event-free survival (EFS), and relapse rate between two groups. There is no variable were associated with prognosis in both groups. CONCLUSION Addition of eltrombopag to IST confers faster hematological response and higher early hematological response in pediatric SAA patients. IMPACT Addition of eltrombopag to standard immunosuppressive therapy confers faster hematological response and higher early hematological response in pediatric severe aplastic anemia patients. Eltrombopag showed reliable safety but had no impact on long-term response and prognosis. This article is a historical controlled study consisting of 115 pediatric severe aplastic anemia patients and makes up for the lack of clinical data deficient on pediatric severe aplastic anemia with TPO-RA combined with IST.
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Affiliation(s)
- Bixi Yang
- Department of Hematology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lingling Fu
- Department of Hematology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hongmin Li
- Department of Hematology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Hui Chen
- Hematologic Disease Laboratory, Hematology Center, Beijing, China
| | - Rui Zhang
- Department of Hematology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jiafeng Yao
- Department of Hematology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Liqiang Zhang
- Department of Hematology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Runhui Wu
- Department of Hematology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jie Ma
- Department of Hematology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
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23
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Fu A, Peng Y, Cheng P, Wu J, Zhu X, Yang Y, Huang L, Wang N, Wang J, Xu J, Wan Y, Cao Y, Wei J, Xiao Y, Meng F, Cheng H, Zhang Y, Zhang D. Recombinant Human Thrombopoietin Promotes Platelet Engraftment in Severe Aplastic Anemia Patients Following Treatment With Haploid Hematopoietic Stem Cell Transplantation using Modified Post-Transplantation Cyclophosphamide. Transplant Cell Ther 2024; 30:500-509. [PMID: 38447750 DOI: 10.1016/j.jtct.2024.02.023] [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: 09/22/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Recombinant human TPO (rhTPO) promotes platelet engraftment in patients after allogeneic HSCT (allo-HSCT). However, the effects of rhTPO on platelet recovery after Haplo-HSCT in patients with severe aplastic anemia (SAA) have not been intensively studied. OBJECTIVE We aimed to evaluate the efficacy of rhTPO on platelet engraftment in patients with SAA who were treated with Haplo-HSCT using post-transplantation cyclophosphamide (PTCy). STUDY DESIGN SAA patients who received Haplo-HSCT plus PTCy regimen were divided into the rhTPO group (with subcutaneous injection of rhTPO, n = 28) and Control group (no rhTPO administration, n = 27). The engraftment of platelet/neutrophil, platelet infusion amount, and transplant-related complications between the 2 groups were compared. RESULTS All 55 patients showed successful hematopoietic reconstitution. The median time of platelet engraftment was 11 (9 to 29) days in the rhTPO group and 14 (9 to 28) days in the Control group (P = .003). The rhTPO group had a significantly reduced amount of infused platelets compared to the Control group (2 (1 to 11.5) versus 3 (1 to 14) therapeutic doses; P = .004). There was no significant difference between the 2 groups regarding median time of neutrophil engraftment, incidence of acute graft-versus-host disease (aGVHD) and chronic GVHD (cGVHD), incidence of cytomegalovirus or Epstein-Barr virus reactivation, 3-yr overall survival rate, and failure-free-survival rate. No obvious adverse reactions were observed in the rhTPO group. CONCLUSION rhTPO promoted platelet engraftment, reduced the amount of transfused platelets, and demonstrated good safety profiles without evidence of adverse reactions in patients with SAA who received Haplo-HSCT using PTCy regimen.
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Affiliation(s)
- Andie Fu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yizhou Peng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Cheng
- Department of Hematology, Wuhan First People's Hospital, Wuhan, China
| | - Jiaying Wu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojian Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Yang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lifang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Na Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jue Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinhuan Xu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuling Wan
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Cao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wei
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Xiao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fankai Meng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Hui Cheng
- Department of Hematology, Wuhan First People's Hospital, Wuhan, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Donghua Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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24
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Duncan BB, Lotter JL, Superata J, Barranta ME, Machado T, Darden I, Venugopal S, Wu CO, Abkowitz JL, Dunbar CE, Young DJ. Treatment of refractory/relapsed Diamond-Blackfan anaemia with eltrombopag. Br J Haematol 2024; 204:2077-2085. [PMID: 38462764 PMCID: PMC11212774 DOI: 10.1111/bjh.19357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/13/2024] [Indexed: 03/12/2024]
Abstract
Diamond-Blackfan anaemia (DBA) is a rare, inherited bone marrow failure syndrome with a ribosomal defect causing slowed globin chain production with normal haem synthesis, causing an overabundance of reactive iron/haem and erythroid-specific cellular toxicity. Eltrombopag, a non-peptide thrombopoietin receptor agonist, is a potent intracellular iron chelator and induced a robust durable response in an RPS19-mutated DBA patient on another trial. We hypothesized eltrombopag would improve RBC production in DBA patients. We conducted a single-centre, single-arm pilot study (NCT04269889) assessing safety and erythroid response of 6 months of daily, fixed-dose eltrombopag for DBA patients. Fifteen transfusion-dependent (every 3-5 weeks) patients (median age 18 [range 2-56]) were treated. One responder had sustained haemoglobin improvement and >50% reduction in RBC transfusion frequency. Of note, 7/15 (41%) patients required dose reductions or sustained discontinuation of eltrombopag due to asymptomatic thrombocytosis. Despite the low response rate, eltrombopag has now improved erythropoiesis in several patients with DBA with a favourable safety profile. Dosing restrictions due to thrombocytosis may cause insufficient iron chelation to decrease haem production and improve anaemia in most patients. Future work will focus on erythropoiesis dynamics in patients and use of haem synthesis inhibitors without an impact on other haematopoietic lineages.
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Affiliation(s)
- Brynn B Duncan
- Translational Stem Cell Biology Branch, NHLBI, Bethesda, Maryland, USA
| | | | | | | | - Tania Machado
- Office of the Clinical Director, NHLBI, Bethesda, Maryland, USA
| | - Ivana Darden
- Office of the Clinical Director, NHLBI, Bethesda, Maryland, USA
| | | | - Colin O Wu
- Office of Biostatistics Research, NHLBI, Bethesda, Maryland, USA
| | - Janis L Abkowitz
- Division of Hematology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Cynthia E Dunbar
- Translational Stem Cell Biology Branch, NHLBI, Bethesda, Maryland, USA
| | - David J Young
- Translational Stem Cell Biology Branch, NHLBI, Bethesda, Maryland, USA
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25
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Kilic Gunes E, Yigit Kaya S, Yaman F, Yeniay MK, Vural K, Comert M, Sevindik OG, Andic N, Dagdas S, Nizam Ozen I, Kaynar L, Yavasoglu F, Ozet G, Karakus V, Ayli M. Eltrombopag treatment in thrombocytopenia following hematopoietic stem cell transplantation: A multicenter real-world experience. Leuk Res 2024; 140:107484. [PMID: 38520796 DOI: 10.1016/j.leukres.2024.107484] [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: 01/05/2024] [Revised: 02/16/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
INTRODUCTION Thrombocytopenia is among the most common complications following hematopoietic stem cell transplantation and is associated with increased mortality and morbidity with no standard treatment yet. In this multicenter and retrospective study, we aim to present our multi-center experience of Eltrombopag treatment in patients with isolated thrombocytopenia following HSCT. MATERIAL-METHOD A total of 73 patients from 5 centers who underwent autologous or allogeneic stem cell transplantation, had no primary disease relapse, all of whom had neutrophil engraftment, complete chimerism, and who were diagnosed with Prolonged Isolated Thrombocytopenia (PIT) or Secondary Failure Of Platelet Recovery (SFPR) were included in the study. The patients were initiated on Eltrombopag at a dose of 50-150 mg. Complete response was defined as a platelet count >50×109/L for 7 consecutive days with no transfusion support. RESULTS A total of 50.3% of the patients underwent Autologous and 49.7% Allogeneic Stem Cell Transplantation, 54.8% were diagnosed with PIT, and 45.2% were diagnosed with SFPR, and the treatment with 50-150 mg/day Eltrombopag was initiated on the median day +42. Complete response was achieved in 71.2% of these patients on the median day 23 of the treatment. No significant effects of the initial dose (50-150 mg/day) were detected in the Complete Response in the multivariate analysis on response. An insufficient number of Megakaryocytes in the bone marrow before Eltrombopag treatment was determined as an independent risk factor in determining the response (OR 3.57, 95% CI 1.21-10.55). The overall survival of the patients who did not respond to Eltrombopag was found to be significantly worse than that of patients who responded (p=0.022, HR:2.74, 95% CI 1.12-6.54). CONCLUSION As a result of the present study, Eltrombopag treatment was found to be effective and safe in thrombocytopenia that develops following hematopoietic stem cell transplantation. It was concluded that its use may be more effective in patients with sufficient bone marrow megakaryocytes before the treatment and an initial dose of 50 mg/day may be appropriate in terms of cost, effectiveness, and toxicity. Large-scale randomized and controlled prospective studies are needed to determine the roles of Eltrombopag treatment in patients with post-transplant PIT and SFPR.
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Affiliation(s)
- Ebru Kilic Gunes
- University of Health and Sciences, Gulhane Training and Research Hospital, Department of Hematology, Ankara, Turkiye.
| | - Sureyya Yigit Kaya
- Istanbul Medipol University, Faculty of Medicine, Department of Hematology, Istanbul, Turkiye
| | - Fatih Yaman
- Eskisehir Osmangazi University, Faculty of Medicine, Department of Hematology, Eskisehir, Turkiye
| | - Mustafa Kemal Yeniay
- University of Health and Sciences, Ankara Bilkent City Hospital, Department of Hematology, Ankara, Turkiye
| | - Kurtulus Vural
- University of Health and Sciences, Antalya Training and Research Hospital, Department of Hematology, Antalya, Turkiye
| | - Melda Comert
- University of Health and Sciences, Gulhane Training and Research Hospital, Department of Hematology, Ankara, Turkiye
| | - Omur Gokmen Sevindik
- Istanbul Medipol University, Faculty of Medicine, Department of Hematology, Istanbul, Turkiye
| | - Neslihan Andic
- Eskisehir Osmangazi University, Faculty of Medicine, Department of Hematology, Eskisehir, Turkiye
| | - Simten Dagdas
- University of Health and Sciences, Ankara Bilkent City Hospital, Department of Hematology, Ankara, Turkiye
| | - Ilknur Nizam Ozen
- University of Health and Sciences, Antalya Training and Research Hospital, Department of Hematology, Antalya, Turkiye
| | - Leylagul Kaynar
- Istanbul Medipol University, Faculty of Medicine, Department of Hematology, Istanbul, Turkiye
| | - Filiz Yavasoglu
- Eskisehir Osmangazi University, Faculty of Medicine, Department of Hematology, Eskisehir, Turkiye
| | - Gulsum Ozet
- University of Health and Sciences, Ankara Bilkent City Hospital, Department of Hematology, Ankara, Turkiye; Ankara Yildirim Beyazit University, Faculty of Medicine, Department of Hematology, Ankara Bilkent City Hospital, Ankara, Turkiye
| | - Volkan Karakus
- University of Health and Sciences, Antalya Training and Research Hospital, Department of Hematology, Antalya, Turkiye
| | - Meltem Ayli
- University of Health and Sciences, Gulhane Training and Research Hospital, Department of Hematology, Ankara, Turkiye
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26
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Kaushansky K. Thrombopoietin, the Primary Regulator of Platelet Production: From Mythos to Logos, a Thirty-Year Journey. Biomolecules 2024; 14:489. [PMID: 38672505 PMCID: PMC11047867 DOI: 10.3390/biom14040489] [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: 02/29/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Thrombopoietin, the primary regulator of blood platelet production, was postulated to exist in 1958, but was only proven to exist when the cDNA for the hormone was cloned in 1994. Since its initial cloning and characterization, the hormone has revealed many surprises. For example, instead of acting as the postulated differentiation factor for platelet precursors, megakaryocytes, it is the most potent stimulator of megakaryocyte progenitor expansion known. Moreover, it also stimulates the survival, and in combination with stem cell factor leads to the expansion of hematopoietic stem cells. All of these growth-promoting activities have resulted in its clinical use in patients with thrombocytopenia and aplastic anemia, although the clinical development of the native molecule illustrated that "it's not wise to mess with mother nature", as a highly engineered version of the native hormone led to autoantibody formation and severe thrombocytopenia. Finally, another unexpected finding was the role of the thrombopoietin receptor in stem cell biology, including the development of myeloproliferative neoplasms, an important disorder of hematopoietic stem cells. Overall, the past 30 years of clinical and basic research has yielded many important insights, which are reviewed in this paper.
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Affiliation(s)
- Kenneth Kaushansky
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
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27
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Piekarska A, Pawelec K, Szmigielska-Kapłon A, Ussowicz M. The state of the art in the treatment of severe aplastic anemia: immunotherapy and hematopoietic cell transplantation in children and adults. Front Immunol 2024; 15:1378432. [PMID: 38646536 PMCID: PMC11026616 DOI: 10.3389/fimmu.2024.1378432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Acquired aplastic anemia (AA) is an immune-mediated bone marrow (BM) failure where marrow disruption is driven by a cytotoxic T-cell-mediated autoimmune attack against hematopoietic stem cells. The key diagnostic challenge in children, but also in adults, is to exclude the possible underlying congenital condition and myelodysplasia. The choice of treatment options, either allogeneic hematopoietic cell transplantation (alloHCT) or immunosuppressive therapy (IST), depends on the patient's age, comorbidities, and access to a suitable donor and effective therapeutic agents. Since 2022, horse antithymocyte globulin (hATG) has been available again in Europe and is recommended for IST as a more effective option than rabbit ATG. Therefore, an update on immunosuppressive strategies is warranted. Despite an improved response to the new immunosuppression protocols with hATG and eltrombopag, some patients are not cured or remain at risk of aplasia relapse or clonal evolution and require postponed alloHCT. The transplantation field has evolved, becoming safer and more accessible. Upfront alloHCT from unrelated donors is becoming a tempting option. With the use of posttransplant cyclophosphamide, haploidentical HCT offers promising outcomes also in AA. In this paper, we present the state of the art in the management of severe AA for pediatric and adult patients based on the available guidelines and recently published studies.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Pawelec
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
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28
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Zhang Y, Li J, Li X, Geng Q, Xie Y, Zhang G, Wei M, Ma Y. Efficacy and safety of immunosuppressive therapy combined with eltrombopag for severe aplastic anemia: a systematic review and meta-analysis. Syst Rev 2024; 13:101. [PMID: 38576005 PMCID: PMC10993616 DOI: 10.1186/s13643-024-02515-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/17/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Immunosuppressive therapy (IST) is the first choice for severe aplastic anemia (SAA) patients with hematopoietic stem cell transplantation (HSCT) limitation, and the main factor limiting its efficacy is too few residual hematopoietic stem/progenitor cells (HSPC). Eltrombopag (EPAG), as a small molecule thrombopoietin receptor agonist, can stimulate the proliferation of residual HSPC and restore the bone marrow hematopoietic function of patients. In recent years, many studies have observed the efficacy and safety of IST combined with EPAG in the treatment of SAA, but the results are still controversial. The aim of this study is to systematically evaluate the efficacy and safety of IST combined with or without EPGA in the treatment of SAA. METHODS We conducted a systematic review of all relevant literature published up to January 19, 2024. Pooled odds ratio (OR) was calculated to compare the rates, along with 95% confidence intervals (CI) and p value to assess whether the results were statistically significant by Review Manager 5.4.1. The p values for the interactions between each subgroup were calculated by Stata 15.1. The Newcastle-Ottawa Scale and the Cochrane bias risk assessment tools were respectively used to evaluate the quality of the literature with cohort studies and randomized controlled trials. The Review Manager 5.4.1 and Stata 15.1 were used to assess bias risk and perform the meta-analysis. RESULTS A total of 16 studies involving 2148 patients were included. The IST combined with the EPAG group had higher overall response rate (ORR) than the IST group at 3 months (pooled OR = 2.10, 95% CI 1.58-2.79, p < 0.00001) and 6 months (pooled OR = 2.13, 95% CI 1.60-2.83, p < 0.00001), but the difference between the two groups became statistically insignificant at 12 months (pooled OR = 1.13, 95% CI 0.75-1.72, p = 0.55). The results of complete response rate (CRR) (pooled OR at 3 months = 2.73, 95% CI 1.83-4.09, p < 0.00001, 6 months = 2.76, 95% CI 2.08-3.67, p < 0.00001 and 12 months = 1.38, 95% CI 0.85-2.23, p = 0.19) were similar to ORR. Compared with the IST group, the IST combined with the EPAG group had better overall survival rate (OSR) (pooled OR = 1.70, 95% CI 1.15-2.51, p = 0.008), but there were no statistically significant differences in event-free survival rate (EFSR) (pooled OR = 1.40, 95% CI 0.93-2.13, p = 0.11), clonal evolution rate (pooled OR = 0.68, 95% CI 0.46-1.00, p = 0.05) and other adverse events between the two groups. The results of subgroup analysis showed that different ages were a source of heterogeneity, but different study types and different follow-up times were not. Moreover, all p-values for the interactions were greater than 0.05, suggesting that the treatment effect was not influenced by subgroup characteristics. CONCLUSION EPAG added to IST enables patients to achieve earlier and faster hematologic responses with a higher rate of complete response. Although it had no effect on overall EFSR, it improved OSR and did not increase the incidence of clonal evolution and other adverse events.
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Affiliation(s)
- Yan Zhang
- Department of Hematology, Heji Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Jie Li
- Department of Oncology and Hematology, Liuyang Hospital of Traditional Chinese Medicine, Hunan University of Chinese Medicine, Changsha, 410300, Hunan, China
| | - Xi Li
- Department of Nephrology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Qianshuang Geng
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Yuqin Xie
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Guoxiang Zhang
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China
| | - Mingxia Wei
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China.
| | - Yanmei Ma
- Department of Hematology, Heji Hospital Affiliated to Changzhi Medical College, Changzhi, 046000, Shanxi, China.
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29
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Xu S, Xiao Y, Liang X, Lu Y, Deng M. The long-term outcomes and safety of severe aplastic anemia treated with porcine antilymphocyte globulin plus cyclosporine, with or without thrombopoietin receptor agonists: a double-center retrospective study. Expert Rev Hematol 2024; 17:181-188. [PMID: 38687471 DOI: 10.1080/17474086.2024.2350527] [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: 10/29/2023] [Accepted: 02/19/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Porcine antilymphocyte globulin (p-ALG) combined with cyclosporine (CsA) has been commonly used for severe aplastic anemia (SAA) patients, but few studies on the combination of p-ALG and thrombopoietin receptor agonist (TPO-RA). RESEARCH DESIGN AND METHODS We retrospectively analyzed the data of 85 people with diagnosed SAA who underwent p-ALG plus CsA, with or without TPO-RA from 2014 to 2023. RESULTS The overall response rates were 55.3% and 65.9% at 3 and 6 months, and the TPO-RA group were 66.7% and 72.3% at 3 and 6 months, without TPO-RA group were 27.8% and 55.6%. In multivariate analysis, baseline platelet count of > 10 × 109/L was a simple predictor of favorable response at 6 months (p = 0.015). The median follow-up time for all patients was 39 months (range 0.4 ~ 104), the 5-year overall survival (OS) rate was 90.6% [95% CI = 82.1-95.2%], and the failure-free survival (FFS) rate was 68.9% [95% CI = 56.6-78.4%]. Having hematologic responses in 6 months was an independent positive predictor for FFS (p = 0.000). Twelve patients (14.1%) suffered from serum sickness, and 9.5% of patients had mild hepatic impairment. CONCLUSIONS p-ALG along with CsA is an effective choice for patients with SAA. p-ALG combined with TPO-RA may contribute to the early restoration of hematopoiesis.
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Affiliation(s)
- Shan Xu
- The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yue Xiao
- The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xinquan Liang
- Chenzhou First People's Hospital, Nanhua University, Chenzhou, China
| | - Yan Lu
- The Second Xiangya Hospital, Central South University, Changsha, China
| | - Mingyang Deng
- The Second Xiangya Hospital, Central South University, Changsha, China
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30
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Zhao X, Lv W, Song K, Yao W, Li C, Tang B, Wan X, Geng L, Sun G, Qiang P, Liu H, Liu H, Sun Z. Upfront Umbilical Cord Blood Transplantation Versus Immunosuppressive Therapy for Pediatric Patients With Idiopathic Severe Aplastic Anemia. Transplant Cell Ther 2024; 30:442.e1-442.e13. [PMID: 38278182 DOI: 10.1016/j.jtct.2024.01.072] [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: 10/06/2023] [Revised: 12/14/2023] [Accepted: 01/17/2024] [Indexed: 01/28/2024]
Abstract
Umbilical cord blood transplantation (UCBT) has been rarely reported as a first-line treatment for idiopathic severe aplastic anemia (SAA) patients lacking HLA-matched sibling donors (MSD). Our study aimed to compare the clinical outcomes of pediatric SAA patients who received UCBT and immunosuppressive therapy (IST) upfront. A retrospective analysis was performed on 43 consecutive patients who received frontline IST (n = 17) or UCBT (n = 26) between July 2017 and April 2022. The 3-year overall survival (OS) was comparable between the UCBT and IST groups (96.2% versus 100%, P = .419), while the 3-year event-free survival (EFS) was significantly better in the former than in the latter (88.5% versus 58.8%, P = .048). In the UCBT group, 24 patients achieved successful engraftment, 2 patients developed severe acute graft-versus-host disease (aGVHD), no extensive chronic GVHD (cGVHD), and a high GVHD-free, failure-free survival (GFFS) of 84.6% at 3 years. After 1 year of treatment, 12 patients in the IST group responded, while 5 patients did not achieve remission and 2 patients had disease relapse. At both 3 and 6 months after treatment, the proportion of transfusion-independent patients was higher in the UCBT group than in the IST group. Faster immune recovery and earlier transfusion independence further reduced the risk of infection and bleeding, thereby improving health-related quality of life in the UCBT-treated group. Our results suggested that UCBT as upfront therapy may be an effective and safe option for pediatric SAA patients, with favorable outcomes in experienced centers.
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Affiliation(s)
- Xuxu Zhao
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China; Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wenxiu Lv
- Department of Hematology and Oncology, Anhui Provincial Children's Hospital (Anhui Hospital, Pediatric Hospital of Fudan University), Hefei, Anhui, China; Department of Pediatrics, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Kaidi Song
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wen Yao
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Chun Li
- Department of Pediatrics, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Baolin Tang
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Xiang Wan
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Liangquan Geng
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Guangyu Sun
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Ping Qiang
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Huilan Liu
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China; Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Hongjun Liu
- Department of Hematology and Oncology, Anhui Provincial Children's Hospital (Anhui Hospital, Pediatric Hospital of Fudan University), Hefei, Anhui, China; Department of Pediatrics, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Zimin Sun
- Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China; Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China.
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31
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Wu L, Liu L, Zhao X, Zhou M, Fu A, Zhang Y, Yang W, Chen X, Mo W, Wang C, Li Y, Xu S, Pan S, Zhou R, Meng F, Zhang F, Wu D, Wang S. Unrelated donor hematopoietic stem cell transplantation compared to immunosuppressive therapy plus eltrombopag as first-line treatment for adults with severe aplastic anemia. Blood Cancer J 2024; 14:37. [PMID: 38443356 PMCID: PMC10914753 DOI: 10.1038/s41408-024-01021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Grants
- the Innovative Clinical Technique of Guangzhou (2019GX04, 2023C-GX01), the 2019 Annual Research Project of The China Marrow Donor Program (No. CMDP201902)
- the Guangzhou Municipal Science and Technology Project (2024A03J1021, 202002030035), the Guangzhou General Science and Technology Project of Health and Family Planning (20241A011012)
- the National Key R&D Program of China (2016YFC0902800, 2017YFA0104502, and 2017ZX09304021), the Innovation Capability Development Project of Jiangsu Province (BM2015004), the Jiangsu Provincial Key Medical Center (YXZXA2016002), the Jiangsu Medical Outstanding Talents Project (JCRCA2016002), the Priority Academic Program Development of Jiangsu Higher Education Institutions (PAPD) and the Science Foundation of Suzhou (SKY2021040).
- the National Natural Science Foundation of China (81900127, 81890992)
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Affiliation(s)
- Liangliang Wu
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Limin Liu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, Jiangsu, China
| | - Xin Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Anemia Therapeutic Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Ming Zhou
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Andie Fu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuping Zhang
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Wenrui Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Anemia Therapeutic Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xiaowei Chen
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Wenjian Mo
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Caixia Wang
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Yumiao Li
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Shilin Xu
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Shiyi Pan
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Ruiqing Zhou
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China
| | - Fankai Meng
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Fengkui Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Anemia Therapeutic Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Institute of Blood and Marrow Transplantation of Soochow University, Suzhou, Jiangsu, China.
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, Guangdong, China.
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32
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Calado RT. Bone marrow failure on steroids: when to use androgens? Haematologica 2024; 109:695-697. [PMID: 37584294 PMCID: PMC10905100 DOI: 10.3324/haematol.2023.283564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 08/17/2023] Open
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33
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Groarke EM. Consideration of ATG-free therapy with eltrombopag and cyclosporine for severe aplastic anaemia. Lancet Haematol 2024; 11:e173-e174. [PMID: 38335977 DOI: 10.1016/s2352-3026(24)00003-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Emma M Groarke
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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34
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Kulasekararaj A, Cavenagh J, Dokal I, Foukaneli T, Gandhi S, Garg M, Griffin M, Hillmen P, Ireland R, Killick S, Mansour S, Mufti G, Potter V, Snowden J, Stanworth S, Zuha R, Marsh J. Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline. Br J Haematol 2024; 204:784-804. [PMID: 38247114 DOI: 10.1111/bjh.19236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024]
Abstract
Pancytopenia with hypocellular bone marrow is the hallmark of aplastic anaemia (AA) and the diagnosis is confirmed after careful evaluation, following exclusion of alternate diagnosis including hypoplastic myelodysplastic syndromes. Emerging use of molecular cyto-genomics is helpful in delineating immune mediated AA from inherited bone marrow failures (IBMF). Camitta criteria is used to assess disease severity, which along with age and availability of human leucocyte antigen compatible donor are determinants for therapeutic decisions. Supportive care with blood and platelet transfusion support, along with anti-microbial prophylaxis and prompt management of opportunistic infections remain key throughout the disease course. The standard first-line treatment for newly diagnosed acquired severe/very severe AA patients is horse anti-thymocyte globulin and ciclosporin-based immunosuppressive therapy (IST) with eltrombopag or allogeneic haemopoietic stem cell transplant (HSCT) from a matched sibling donor. Unrelated donor HSCT in adults should be considered after lack of response to IST, and up front for young adults with severe infections and a readily available matched unrelated donor. Management of IBMF, AA in pregnancy and in elderly require special attention. In view of the rarity of AA and complexity of management, appropriate discussion in multidisciplinary meetings and involvement of expert centres is strongly recommended to improve patient outcomes.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Jamie Cavenagh
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Inderjeet Dokal
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | - Theodora Foukaneli
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NHS Blood and Transplant, Bristol, UK
| | - Shreyans Gandhi
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
- British Society Haematology Task Force Representative, London, UK
| | | | | | - Robin Ireland
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Sally Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | - Sahar Mansour
- St George's Hospital/St George's University of London, London, UK
| | - Ghulam Mufti
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Victoria Potter
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Roslin Zuha
- James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, England
| | - Judith Marsh
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
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35
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Scheinberg P, Finelli C, Montaňo-Figueroa EH, Vallejo C, Norasetthada L, Calado RT, Turgut M, Peffault de Latour R, Kriemler-Krahn U, Haenig J, Clark J, Jang J. Activity and safety of eltrombopag in combination with cyclosporin A as first‑line treatment of adults with severe aplastic anaemia (SOAR): a phase 2, single-arm study. Lancet Haematol 2024; 11:e206-e215. [PMID: 38335978 DOI: 10.1016/s2352-3026(23)00395-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Antithymocyte globulin (ATG)-based immunosuppression is standard in front-line treatment for people with severe aplastic anaemia without a histocompatible donor or who are 40 years or older. However, ATG requires in-hospital administration, is associated with infusion-related toxicities and has limited availability worldwide. In this study, we investigated the activity and safety of an ATG-free regimen of eltrombopag with cyclosporin A as a potential treatment for patients with severe aplastic anaemia who might not have access to or cannot tolerate horse-ATG. METHODS SOAR was a multicentre, single-arm phase 2 trial investigating eltrombopag and cyclosporin in adult (≥18 years) patients with severe aplastic anaemia who were treatment-naive and had an Eastern Cooperative Oncology Group performance status of less than 2. Participants were recruited from 20 hospitals in ten countries. Eltrombopag was initiated at 150 mg (100 mg in patients of Asian ethnicity) and cyclosporin at 10 mg/kg per day (adjusted to a trough of 200-400 μg/L) orally from day 1 to 6 months. The primary outcome was an overall haematological response rate by 6 months in the intention-to-treat population. This is the final report of the primary analysis period. The trial was registered with ClinicalTrials.gov, NCT02998645, and has been completed. FINDINGS 54 patients were enrolled between May 11, 2017, and March 23, 2020. 34 (63%) patients were male and 20 (37%) were female. 22 (41%) were Asian, 22 (41%) were White, one (2%) was Native American or Alaska Native, one (2%) was Black or African American, and eight (15%) were other race or ethnicity. 35 patients (65%) completed 6 months of treatment with eltrombopag and cyclosporin and six (11%) completed the cyclosporin tapering period up to month 24. Overall haematological response rate by month 6 of treatment was 46% (25 of 54; 95% CI 33-60). The most reported adverse events were increased serum bilirubin (in 22 patients [41%]), nausea (16 [30%]), increased alanine aminotransferase concentration (12 [22%]), and diarrhoea (12 [22%]). Eight patients died on-treatment, but no deaths were considered related to the treatment. INTERPRETATION Eltrombopag and cyclosporin was active as front-line treatment of severe aplastic anaemia, with no unexpected safety concerns. This approach might be beneficial where horse-ATG is not available or not tolerated. FUNDING Novartis Pharmaceuticals.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, São Paulo, Brazil.
| | - Carlo Finelli
- Department of Oncology and Hematology, IRCCS Azienda Ospedaliero-Universitaria di Bologna Institute of Hematology Seràgnoli, Bologna, Italy
| | | | - Carlos Vallejo
- Department of Hematology, Donostia University Hospital, San Sebastián, Spain; Clinic University Hospital, Santiago de Compostela, Spain
| | - Lalita Norasetthada
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Rodrigo T Calado
- Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Mehmet Turgut
- Department of Internal Diseases, Division of Hematology, Ondokuz Mayıs University, Samsun, Turkey
| | - Régis Peffault de Latour
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint-Louis Hospital and Université de Paris Cité, Paris, France
| | | | | | | | - Junho Jang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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36
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Scheinberg P. Progress in medical therapy in aplastic anemia: why it took so long? Int J Hematol 2024; 119:248-254. [PMID: 38403842 DOI: 10.1007/s12185-024-03713-3] [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: 11/30/2023] [Revised: 12/27/2023] [Accepted: 01/15/2024] [Indexed: 02/27/2024]
Abstract
The treatment of aplastic anemia (AA) has significantly advanced in the last 50 years, evolving from a fatal condition to one where survival rates now exceed 80-85%. Hematopoietic stem cell transplantation (HSCT) and immunosuppressive therapy (IST) have become the primary treatments, with the latter widely adopted due to factors like the scarcity of compatible donors, patient age, comorbidities, and limited HSCT access. A therapy breakthrough was the introduction of antithymocyte globulin (ATG), with its effectiveness further boosted by cyclosporine. However, it took years to achieve another major milestone in management. Initially, treatments aimed to intensify immunosuppression following the success of the ATG-cyclosporine combination, but these methods fell short of expectations. A major turning point was combining immunosuppression with stem cell stimulation, surpassing the efficacy of IST alone. Earlier, growth factors had shown limited success in AA treatment, but thrombopoietin receptor agonists represented a significant advancement. Initially applied alone as salvage, these were later combined with IST, forming the most effective current regimen for medically managing SAA. Horse ATG is the preferred formulation combined with cyclosporine and eltrombopag. This progress in AA treatment offers improved outcomes for patients afflicted with this once-lethal disease.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Rua Martiniano de Carvalho, 951, São Paulo, SP, 01321-001, Brazil.
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37
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Foucar CE, Foley DH, Aldous J, Burke PW, Pettit KR, Benitez LL, Perissinotti AJ, Marini BL, Boonstra P, Bixby DL. Real-world outcomes with immunosuppressive therapy for aplastic anemia in patients treated at the University of Michigan. Eur J Haematol 2024; 112:424-432. [PMID: 37929654 DOI: 10.1111/ejh.14131] [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: 07/31/2023] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
Aplastic anemia (AA) is a rare bone marrow failure disorder that is treated with either allogeneic stem cell transplant or immunosuppressive therapy (IST) consisting of antithymocyte globulin (ATG), cyclosporine (CSA), and eltrombopag. While outcomes are favorable in younger patients, older patients (>60) have significantly worse long-term survival. The dose of ATG is often reduced in older patients and those with multiple comorbidities given concerns for tolerability. The efficacy and safety of dose-attenuated IST in this population is largely undescribed. We performed a retrospective review of patients with AA treated with IST. Our analysis was confounded by changes in practice patterns and the introduction of eltrombopag. We identified 53 patients >60 years old, of which, 20 received dose-attenuated IST, with no statistically significant difference in overall survival between full and attenuated dose cohorts. Overall response rates in both cohorts were similar at 6 months at 71% and 68%. There were more documented infectious complications in the full dose cohort (13 vs. 3). This supports the consideration of dose-attenuated IST in older patients with concerns about tolerance of IST. Lastly, our data confirmed favorable outcomes of younger patients receiving IST, especially in combination with eltrombopag.
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Affiliation(s)
- Charles E Foucar
- Division of Hematology and Oncology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Daniel H Foley
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jessica Aldous
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Patrick W Burke
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kristen R Pettit
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Lydia L Benitez
- Department of Pharmacy Services and Clinical Sciences, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Sciences, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Bernard L Marini
- Department of Pharmacy Services and Clinical Sciences, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Philip Boonstra
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Dale L Bixby
- Division of Hematology and Medical Oncology, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
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38
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Vallejo C, Rosell A, Xicoy B, García C, Albo C, Polo M, Jarque I, Esteban B, Codesido ML. A multicentre ambispective observational study into the incidence and clinical management of aplastic anaemia in Spain (IMAS study). Ann Hematol 2024; 103:705-713. [PMID: 38175253 DOI: 10.1007/s00277-023-05602-x] [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: 06/22/2023] [Accepted: 12/21/2023] [Indexed: 01/05/2024]
Abstract
Aplastic anemia (AA) is a rare, life-threatening hematological disease, with a poorly defined incidence. As the data available on AA varies substantially worldwide, a multicenter, ambispective, observational study was carried out between 2010 and 2019 to assess the incidence, clinical management and survival of AA at seven Spanish hospitals. The incidence of AA was 2.83 per million inhabitants per year, consistent with that reported previously in Europe, with a median age at diagnosis of 61 years-old (range 12-86), and a similar number of males and females. The initial diagnosis was severe or very severe AA in 55.8% of cases and 93.7% required transfusion. The most frequent first line therapy was anti-thymocyte globulin (ATG) plus cyclosporin A (CsA, 44.2%), followed by other CsA-based regimes (46.3%), with hematopoietic stem cell transplantation an infrequent 1st line therapy. The 6-month response rate was 68.2%, which then increased over a median follow-up of 3.9 years. The 5-year overall survival (5OS) was 73.6%, similar in severe (78.6%) and very severe AA patients (74.6%) but lower in moderate AA (MAA) patients (68.4%). The 5OS was 100% in 0-25 year-old patients but dropping to 58.3% in patients ≥ 60 years-old. At the last contact, 75.8% of the patients were alive. In conclusion, the incidence, characteristics and management of AA in our study are consistent with that reported previously. In terms of survival, although the global long-term OS rate was good, there is room for improvement, particularly in older patients. Finally, what appears to be a worse long-term survival of MAA patients, as reported previously, reinforces the importance of not underestimating this condition when diagnosed as MAA.
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Affiliation(s)
- Carlos Vallejo
- Complejo Asistencial Universitario de Salamanca, Salamanca, Spain.
- Hospital Universitario Donostia, San Sebastián, Spain.
- PETHEMA Cooperative Group, Madrid, Spain.
- Instituto de Investigación Sanitaria Biodonostia, Donostia-San Sebastián, Spain.
| | - Ana Rosell
- Hospital Universitario Virgen de La Victoria, Málaga, Spain
| | - Blanca Xicoy
- Institut Català d'Oncologia, Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Carmen García
- Hospital General Universitario de Alicante, Alicante, Spain
| | - Carmen Albo
- Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | - Marta Polo
- Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | - Brígida Esteban
- Instituto de Investigación Sanitaria Biodonostia, Donostia-San Sebastián, Spain
| | - M Lorena Codesido
- Instituto de Investigación Sanitaria Biodonostia, Donostia-San Sebastián, Spain
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39
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Cao J, Lu S, Luo D, Pei R, Lu Y, Chen D, Du X, Li S. Successful treatment pure red cell aplasia after ABO major mismatched allogeneic hematopoietic stem cell transplantation with avatrombopag and low dose rituximab. Transfusion 2024; 64:510-516. [PMID: 38351735 DOI: 10.1111/trf.17743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 03/16/2024]
Abstract
BACKGROUND Pure red cell aplasia (PRCA) following allogeneic hematopoietic stem cell transplantation (allo-HSCT) with ABO major incompatibility is characterized by transfusion dependent anemia. No standard treatment existed for PRCA following allo-HSCT yet. STUDY DESIGN AND METHODS We conducted a retrospective study, and reported our experience with the use of avatrombopag and lower dose rituximab to treat five patients with PRCA subsequent to major ABO-incompatible allo-HSCT. RESULTS Five cases of PRCA were identified from 72 patients who underwent allo-HSCT with major or bidirectional ABO mismatch. Cumulative incidence at Day +60 was 6.9% (5/72) at our center. All donor and recipient blood groups were A+ and O+ , respectively. In the first three cases we reported, patients received erythropoietin, plasma exchange, and donor lymphocyte infusion, but none of them had any effect. After 4 weeks of treatment with low dose rituximab (100 mg/week) combined with avatrombopag (40 mg/day), favorable outcomes were obtained. According to the aforementioned experience, Cases 4 and 5 were administered low-dose rituximab and avatrombopag in 3 months after transplantation, and erythroid response was observed on 3 weeks after treatment. Our patients tolerated low-dose rituximab and avatrombopag well and experienced rapid efficacy, with a median duration of 3 weeks. Furthermore, no severe infection or thrombocytosis necessitated a dose adjustment. CONCLUSION Low-dose rituximab and avatrombopag may be an effective treatment for patients with PRCA after major ABO-incompatible allo-HSCT. The patients should be treated at least 90 days post transplantation if conventional erythropoietin therapy fails.
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Affiliation(s)
- Junjie Cao
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Shaoyan Lu
- Department of blood transfusion, The Affiliated People's Hospital of Ningbo University, Ningbo, China
| | - Danjie Luo
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
| | - Renzhi Pei
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Ying Lu
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Dong Chen
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Xiaohong Du
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Shuangyue Li
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
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Chattopadhyay S, Lionel S, Selvarajan S, Devasia AJ, Korula A, Kulkarni U, Aboobacker FN, Lakshmi KM, Srivastava A, Mathews V, Abraham A, George B. Relapse and transformation to myelodysplastic syndrome and acute myeloid leukemia following immunosuppressive therapy for aplastic anemia is more common as compared to allogeneic stem cell transplantation with a negative impact on survival. Ann Hematol 2024; 103:749-758. [PMID: 38242970 DOI: 10.1007/s00277-024-05621-2] [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: 08/29/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024]
Abstract
We studied the incidence of relapse, transformation to myelodysplastic syndrome/acute myeloid leukemia, and survival in patients with aplastic anemia (AA) surviving more than 1 year after ATG/ALG-based immunosuppressive therapy (IST) between 1985 and 2020. Four-hundred seventy patients (413 adults and 57 children) were studied, and data were compared with 223 patients who underwent matched sibling donor transplant (MSD HSCT). Median follow-up is 50 months (12-359). Relapse occurred in 21.9% at a median time of 33.5 months (5-228) post IST. Twenty-six (5.5%) patients progressed to PNH, while 20 (4.3%) evolved to MDS/AML. Ten-year estimated overall survival (OS) is 80.9 ± 3% and was significantly better in patients without an event (85.1 ± 4%) compared to relapse (74.6% ± 6.2%) or clonal evolution (12.8% ± 11.8%) (p = 0.024). While the severity of AA (p = 0.011) and type of ATG (p = 0.028) used predicted relapse, only age at IST administration influenced clonal evolution (p = 0.018). Among HSCT recipients, relapse rates were 4.9% with no clonal evolution, and the 10-year OS was 94.5 ± 2%. In patients who survived 1 year following IST, outcomes were good except with clonal evolution to MDS/AML. These outcomes, however, were still inferior compared to matched sibling donor HSCT.
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Affiliation(s)
| | - Sharon Lionel
- Department of Haematology, Christian Medical College, Vellore, India
| | - Sushil Selvarajan
- Department of Haematology, Christian Medical College, Vellore, India
| | - Anup J Devasia
- Department of Haematology, Christian Medical College, Vellore, India
| | - Anu Korula
- Department of Haematology, Christian Medical College, Vellore, India
| | - Uday Kulkarni
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Kavitha M Lakshmi
- Department of Haematology, Christian Medical College, Vellore, India
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, India
| | - Aby Abraham
- Department of Haematology, Christian Medical College, Vellore, India
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, India.
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Araki D, Hong S, Linde N, Fisk B, Redekar N, Salisbury-Ruf C, Krouse A, Engels T, Golomb J, Dagur P, Magnani DM, Wang Z, Larochelle A. cMPL-Based Purification and Depletion of Human Hematopoietic Stem Cells: Implications for Pre-Transplant Conditioning. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.24.581887. [PMID: 38464076 PMCID: PMC10925094 DOI: 10.1101/2024.02.24.581887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The transplantation of gene-modified autologous hematopoietic stem and progenitor cells (HSPCs) offers a promising therapeutic approach for hematological and immunological disorders. However, this strategy is often limited by the toxicities associated with traditional conditioning regimens. Antibody-based conditioning strategies targeting cKIT and CD45 antigens have shown potential in mitigating these toxicities, but their long-term safety and efficacy in clinical settings require further validation. In this study, we investigate the thrombopoietin (TPO) receptor, cMPL, as a novel target for conditioning protocols. We demonstrate that high surface expression of cMPL is a hallmark feature of long-term repopulating hematopoietic stem cells (LT-HSCs) within the adult human CD34+ HSPC subset. Targeting the cMPL receptor facilitates the separation of human LT-HSCs from mature progenitors, a delineation not achievable with cKIT. Leveraging this finding, we developed a cMPL-targeting immunotoxin, demonstrating its ability to selectively deplete host cMPLhigh LT-HSCs with a favorable safety profile and rapid clearance within 24 hours post-infusion in rhesus macaques. These findings present significant potential to advance our understanding of human hematopoiesis and enhance the therapeutic outcomes of ex vivo autologous HSPC gene therapies.
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Affiliation(s)
- Daisuke Araki
- Cellular and Molecular Therapeutics Branch, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Sogun Hong
- Translational Stem Cell Biology Branch, NHLBI, NIH, Bethesda, MD 20892, USA
| | - Nathaniel Linde
- Translational Stem Cell Biology Branch, NHLBI, NIH, Bethesda, MD 20892, USA
| | - Bryan Fisk
- Integrated Data Science Services, National Institutes of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892, USA
| | - Neelam Redekar
- Integrated Data Science Services, National Institutes of Allergy and Infectious Diseases, NIH, Bethesda, MD 20892, USA
| | - Christi Salisbury-Ruf
- Cellular and Molecular Therapeutics Branch, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD 20892, USA
| | - Allen Krouse
- Translational Stem Cell Biology Branch, NHLBI, NIH, Bethesda, MD 20892, USA
| | - Theresa Engels
- Translational Stem Cell Biology Branch, NHLBI, NIH, Bethesda, MD 20892, USA
- Priority One Services, Inc., Alexandria, VA 22310, USA
| | - Justin Golomb
- Translational Stem Cell Biology Branch, NHLBI, NIH, Bethesda, MD 20892, USA
- Priority One Services, Inc., Alexandria, VA 22310, USA
| | - Pradeep Dagur
- Flow Cytometry Core Facility, NHLBI, NIH, Bethesda, MD 20892, USA
| | - Diogo M. Magnani
- Nonhuman Primate Reagent Resource, University of Massachusetts Medical School, Worcester, MA 01605, USA
| | - Zhirui Wang
- Division of Plastic and Reconstructive Surgery, and Division of Transplant Surgery, Department of Surgery, School of Medicine, University of Colorado Denver, Aurora, CO 80045, USA
| | - Andre Larochelle
- Cellular and Molecular Therapeutics Branch, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD 20892, USA
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Jain A, Jandial A, Mani T, Kishore K, Singh C, Lad D, Prakash G, Khadwal A, Das R, Varma N, Varma S, Malhotra P. Comparable outcomes with low-dose and standard-dose horse anti-thymocyte globulin in the treatment of severe aplastic anemia. Blood Res 2024; 59:6. [PMID: 38485832 PMCID: PMC10903521 DOI: 10.1007/s44313-024-00003-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/10/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The standard dose (SD) of horse anti-thymocyte globulin (hATG) ATGAM (Pfizer, USA) or its biosimilar thymogam (Bharat Serum, India) for the treatment of Aplastic Anemia (AA) is 40 mg/kg/day for 4 days in combination with cyclosporine. Data on the impact of hATG dose on long-term outcomes are limited. Here, we describe our comparative experience using 25 mg/kg/day (low-dose [LD]) hATG for 4 days with SD for the treatment of AA. METHODS We retrospectively studied patients with AA (age > 12 years) who received two doses of hATG combined with cyclosporine. Among 93 AA patients who received hATG, 62 (66.7%) and 31 (33.3%) patients received LD and SD hATG with cyclosporine, respectively. Among these,seventeen(18.2%) patients also received eltrombopag with hATG and cyclosporine. Overall response rates [complete response (CR) and partial response (PR)] of LD and SD hATG groups at 3 months (50% vs. 48.4%; p = 0.88), 6 months (63.8% vs. 71.4%; p = 0.67), and 12 months (69.6% vs. 79.2%; p = 0.167) were comparable. The mean (Standard Deviation) 5-year Kaplan-Meier estimate of overall survival and event-free survival was 82.1 (4.6)% and 70.9 (5.5)% for the study population. The mean (standard deviation) 5-year Kaplan-Meier estimate of overall survival and event-free survival of those who received LD hATG versus SD hATG dose was 82.9 (5·3)% versus 74.8 (10·3)% (P = 0·439), and 75.2 (6.2)% versus 61.4(11.2)% (P = 0·441). CONCLUSION Our study revealed that the response rates of patients with AA and LD were similar to those of patients with SD to hATG combined with cyclosporine in a real-world setting.
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Affiliation(s)
- Arihant Jain
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Aditya Jandial
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Thenmozhi Mani
- Department of Biostatistics, CMC, Vellore, Hematology, India
| | - Kamal Kishore
- Department of Biostatistics, PGIMER, Chandigarh, India
| | - Charanpreet Singh
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Gaurav Prakash
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Alka Khadwal
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India
| | - Reena Das
- Department of Hematology, PGIMER, Chandigarh, India
| | - Neelam Varma
- Department of Hematology, PGIMER, Chandigarh, India
| | | | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, PGIMER, Chandigarh, 160012, India.
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McQuilten Z, Heritier S, Fox L, Fox V, Young L, Blombery P, Cunningham I, Curnow J, Higgins A, Hiwase DK, Filshie R, Firkin F, Lacaze P, Mason K, Mills AK, Pepperell D, Patil S, Stevenson W, Szer J, Waters N, Wilson K, Ting S, Wood E. Efficacy and safety of avatrombopag in combination with immunosuppressive therapy in treatment-naïve and relapsed/refractory severe aplastic anaemia: protocol for the DIAAMOND-Ava-FIRST and DIAAMOND-Ava-NEXT Bayesian Optimal Phase II trials. BMJ Open 2024; 14:e076246. [PMID: 38238183 PMCID: PMC10806710 DOI: 10.1136/bmjopen-2023-076246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/14/2023] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION Immunosuppressive therapy (IST) with antithymocyte globulin (ATG) and ciclosporin is standard of care for patients with severe aplastic anaemia (sAA) not eligible or suitable for allogeneic stem cell transplant. While patients respond to IST, few achieve complete responses and a significant proportion are refractory or relapse. The addition of eltrombopag, a thrombopoietin-receptor agonist (TPO-A), to IST has been shown to improve haematological responses in sAA. Avatrombopag is a second-generation TPO-A with potential advantages over eltrombopag. However, to date avatrombopag has not been studied in sAA. METHODS AND ANALYSIS Investigator-initiated, single-arm registry-based Bayesian Optimal Phase II trial of avatrombopag conducted in two cohorts, patients with untreated sAA (FIRST cohort) and in patients with sAA that has relapsed or is refractory to IST (NEXT cohort). In the FIRST cohort, participants receive IST (equine ATG and ciclosporin) plus avatrombopag from day 1 until day 180 at 60 mg oral daily, with dose adjusted according to platelet count. Participants in the NEXT cohort receive avatrombopag at 60 mg oral daily from day 1 until day 180, with or without additional IST at the discretion of the treating clinician.For each cohort, two primary endpoints (haematological response and acquired clonal evolution) are jointly monitored and the trial reviewed at each interim analysis where a 'go/no-go' decision is made by evaluating the posterior probability of the events of interests. ETHICS AND DISSEMINATION The trial has received ethics approval (Monash Health RES-18-0000707A). The trial conduct will comply with ICH-GCP and all applicable regulatory requirements. The results of the trial will be submitted to a peer-review journal for publication. TRIAL REGISTRATION NUMBER ACTRN12619001042134, ACTRN12619001043123.
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Affiliation(s)
- Zoe McQuilten
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lucy Fox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Vanessa Fox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lauren Young
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Piers Blombery
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Ilona Cunningham
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Jennifer Curnow
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Alisa Higgins
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Devendra K Hiwase
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australian Health & Medical Research Institute, Adelaide, South Australia, Australia
| | - Robin Filshie
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Frank Firkin
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Paul Lacaze
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kylie Mason
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Anthony K Mills
- University of Queensland, Brisbane, Queensland, Australia
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Dominic Pepperell
- Department of Haematology, Fiona Stanley Hospital, Murdoch, Perth, Australia
| | - Sushrut Patil
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - William Stevenson
- Department of Haematology, Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - Jeff Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Neil Waters
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kate Wilson
- University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Ting
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Haematology, Eastern Health, Melbourne, Victoria, Australia
| | - Erica Wood
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Al-Samkari H. Optimal management of chemotherapy-induced thrombocytopenia with thrombopoietin receptor agonists. Blood Rev 2024; 63:101139. [PMID: 37914568 PMCID: PMC10872905 DOI: 10.1016/j.blre.2023.101139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 11/03/2023]
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of antineoplastic therapy, resulting in antineoplastic therapy dose reductions, treatment delays, treatment discontinuation, and morbid bleeding events. Despite several decades of research into thrombopoietic growth factors in CIT, there are presently no available U.S. FDA- or EMA-approved agents to treat CIT. However, a respectable body of evidence has been published evaluating the thrombopoietin receptor agonists (TPO-RAs) for the management and prevention of CIT in patients with solid tumors, and critical studies are ongoing with the TPO-RAs romiplostim and avatrombopag. When employed in the appropriate patient population and used properly, TPO-RAs can successfully and safely manage CIT for extended periods of time with minimal apparent risks. This comprehensive review discusses the evidence for TPO-RAs in CIT in patients with solid tumors, provides detailed guidance for their use in the clinic, and discusses ongoing essential clinical trials in management of CIT.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Serio B, Giudice V, Selleri C. All Roads Lead to Interferon-γ: From Known to Untraveled Pathways in Acquired Aplastic Anemia. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2170. [PMID: 38138273 PMCID: PMC10744863 DOI: 10.3390/medicina59122170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023]
Abstract
Bone marrow failure (BMF) syndromes are a heterogeneous group of benign hematological conditions with common clinical features including reduced bone marrow cellularity and peripheral blood cytopenias. Acquired aplastic anemia (AA) is caused by T helper(Th)1-mediated immune responses and cytotoxic CD8+ T cell-mediated autologous immune attacks against hematopoietic stem and progenitor cells (HSPCs). Interferon-γ (IFNγ), tumor necrosis factor-α, and Fas-ligand are historically linked to AA pathogenesis because they drive Th1 and cytotoxic T cell-mediated responses and can directly induce HSPC apoptosis and differentiation block. The use of omics technologies has amplified the amount of data at the single-cell level, and knowledge on AA, and new scenarios, have been opened on "old" point of view. In this review, we summarize the current state-of-art of the pathogenic role of IFNγ in AA from initial findings to novel evidence, such as the involvement of the HIF-1α pathway, and how this knowledge can be translated in clinical practice.
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Affiliation(s)
- Bianca Serio
- Department of Medicine, Surgery, and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (B.S.); (C.S.)
| | - Valentina Giudice
- Department of Medicine, Surgery, and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (B.S.); (C.S.)
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
| | - Carmine Selleri
- Department of Medicine, Surgery, and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (B.S.); (C.S.)
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84131 Salerno, Italy
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Nakamura R, Patel BA, Kim S, Wong FL, Armenian SH, Groarke EM, Keesler DA, Hebert KM, Heim M, Eapen M, Young NS. Conditional survival and standardized mortality ratios of patients with severe aplastic anemia surviving at least one year after hematopoietic cell transplantation or immunosuppressive therapy. Haematologica 2023; 108:3298-3307. [PMID: 37259612 PMCID: PMC10690917 DOI: 10.3324/haematol.2023.282781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 05/23/2023] [Indexed: 06/02/2023] Open
Abstract
Immunosuppressive treatment (IST) and hematopoietic cell transplant (HCT) are standard therapies for severe aplastic anemia (SAA). We report on conditional survival and standardized mortality ratios (SMR), which compare the mortality risk with the general population adjusted for age, gender, and race/ethnicity, in patients with SAA alive for at least 12 months after treatment with IST or HCT between 2000 and 2018. Given changes to treatment regimens and differences in length of follow-up, two treatment periods were defined a priori: 2000-2010 and 2011-2018. The SMR of patients treated during the period 2000-2010 and who survived one year were 3.50 (95% confidence interval [CI]: 2.62-4.58), 4.12 (95% CI: 3.20-5.21), and 8.62 (95% CI: 6.88-10.67) after IST, matched related donor HCT, and alternative donor HCT, respectively. For the period 2011-2018, the corresponding SMR were 2.89 (95% CI: 1.54-4.94), 3.12 (95% CI: 1.90-4.82), and 4.75 (95% CI: 3.45-6.38), respectively. For IST patients, their mortality risk decreased over time, and became comparable to the general population by five years. For patients who underwent HCT during 2000-2010 and 2011-2018, their mortality risk became comparable to the general population after ten years and after five years, respectively. Thus, 1-year survivors after IST or HCT can expect their longevity beyond five years to be comparable to that of the general US population.
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Affiliation(s)
- Ryotaro Nakamura
- Department of Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Bhavisha A Patel
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Soyoung Kim
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI; Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - F Lennie Wong
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA
| | - Saro H Armenian
- Department of Population Sciences, City of Hope National Medical Center, Duarte, CA
| | - Emma M Groarke
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Daniel A Keesler
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Kyle M Hebert
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Michael Heim
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mary Eapen
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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Shinn LT, Benitez LL, Perissinotti AJ, Reid JH, Buhlinger KM, van Deventer H, Barth D, Wagner CB, Zacholski K, Desai R, Soule A, Stump SE, Weis TM, Bixby D, Burke P, Pettit K, Marini BL. Multicenter evaluation of the addition of eltrombopag to immunosuppressive therapy for adults with severe aplastic anemia. Int J Hematol 2023; 118:682-689. [PMID: 37882977 DOI: 10.1007/s12185-023-03670-3] [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: 02/22/2023] [Revised: 09/26/2023] [Accepted: 10/02/2023] [Indexed: 10/27/2023]
Abstract
Eltrombopag has been shown to improve response rates when added to standard therapy in adults with severe aplastic anemia in controlled trial settings. However, outcomes in real-world populations have mostly been examined in small retrospective studies. This robust, multicenter, retrospective cohort study across six academic health systems compared outcomes in patients who received immunosuppressive therapy with or without eltrombopag. The study included 82 patients who received front-line therapy from January 2014 to August 2021. Overall response rates at 6 months did not differ significantly for patients receiving eltrombopag versus immunosuppressive therapy alone (58% v. 65%, p = 0.56). However, complete response rates at 6 and 12 months were over two times higher in the eltrombopag arm (29% v. 12%, p = 0.06 and 48% v. 18%, p = 0.005). Rates of hepatotoxicity were similar across both arms. Eltrombopag addition did not impact overall survival (median not reached in either arm at 2 years, p = 0.86) or disease-free survival (median not reached v. 13.3 months at 2 years, p = 0.20). Eltrombopag may not produce as large of a benefit in real-world settings compared to controlled trial settings but may offer patients deeper responses with similar rates of toxicity to immunosuppressive therapy alone.
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Affiliation(s)
- Lauren T Shinn
- Department of Clinical Pharmacy, Michigan Medicine and University of Michigan College of Pharmacy, 1540 E. Hospital Dr., Room 251-B, Ann Arbor, MI, USA
| | - Lydia L Benitez
- Department of Clinical Pharmacy, Michigan Medicine and University of Michigan College of Pharmacy, 1540 E. Hospital Dr., Room 251-B, Ann Arbor, MI, USA
| | - Anthony J Perissinotti
- Department of Clinical Pharmacy, Michigan Medicine and University of Michigan College of Pharmacy, 1540 E. Hospital Dr., Room 251-B, Ann Arbor, MI, USA
| | - Justin H Reid
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Kaitlyn M Buhlinger
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Hendrik van Deventer
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Dylan Barth
- Department of Pharmacy, University of Utah Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Charlotte B Wagner
- Department of Pharmacy, University of Utah Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Kyle Zacholski
- Department of Pharmacy, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Ruchi Desai
- Department of Pharmacy, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Ashley Soule
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY, USA
| | - Sarah E Stump
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Taylor M Weis
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dale Bixby
- Department of Clinical Pharmacy, Michigan Medicine and University of Michigan College of Pharmacy, 1540 E. Hospital Dr., Room 251-B, Ann Arbor, MI, USA
| | - Patrick Burke
- Department of Clinical Pharmacy, Michigan Medicine and University of Michigan College of Pharmacy, 1540 E. Hospital Dr., Room 251-B, Ann Arbor, MI, USA
| | - Kristen Pettit
- Department of Clinical Pharmacy, Michigan Medicine and University of Michigan College of Pharmacy, 1540 E. Hospital Dr., Room 251-B, Ann Arbor, MI, USA
| | - Bernard L Marini
- Department of Clinical Pharmacy, Michigan Medicine and University of Michigan College of Pharmacy, 1540 E. Hospital Dr., Room 251-B, Ann Arbor, MI, USA.
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Wan Z, Chen M, Han B. Avatrombopag, a promising novel thrombopoietin receptor agonist for refractory/relapsed/intolerant non-severe aplastic anemia: a phase 2 single-arm clinical trial. Ann Med 2023; 55:2224044. [PMID: 37318085 DOI: 10.1080/07853890.2023.2224044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 04/01/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION The therapeutic options for thrombocytopenia in non-severe aplastic anaemia (NSAA) are limited. Avatrombopag (AVA) is prescribed for thrombocytopenic diseases but not for NSAA. METHODS Herein, we conducted a phase 2, non-randomized, single-arm trial to explore the efficacy and safety of AVA in refractory/relapsed/intolerant NSAA. AVA dose was initiated at 20 mg/d and titrated to a maximum of 60 mg/d. The primary endpoint was the haematological response at 3 months. RESULTS Twenty-five patients were analyzed. The overall response rate (ORR) at 3 months was 56% (14/25), with 12% (3/25) achieving a complete response (CR). At a median follow-up of 7 (3-10) months, the OR and CR rates were 52% and 20%, respectively. Responders had a shorter duration of diagnosis of AVA administration than non-responders (10 (6-80) vs 37 (6-480) months, p = 0.027) and belonged to the relapsed/intolerant NSAA type (71% vs 27%, p = 0.047); 44% (8/18) patients previously treated with eltrombopag before enrollment responded at 3 months, with an average prior eltrombopag dose of median 72.5 (50-100) mg/d and an average AVA dose for a response of median 43.5 (20-60) mg/d. 3-month ORR had no significant correlation with eltrombopag exposure (p = 0.09), prior eltrombopag length (R2=0.11), or cumulative eltrombopag dose (R2=0.30). Only one patient relapsed after stopping AVA for 1 month. No serious AVA-related side effects or clone evolution were detected. CONCLUSION AVA is effective and well-tolerated in NSAA patients who are refractory, relapsed, or intolerant to CsA/tacrolimus ± eltrombopag. Earlier treatment and relapsed/intolerant AA may show a better short-term response rate. More studies are needed to define the optimal dose and the long-term efficacy (NCT04728789).
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Affiliation(s)
- Ziqi Wan
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, P.R. China
- Peking Union Medical College, Beijing, P.R. China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, P.R. China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, P.R. China
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Vissers LTW, van der Burg M, Lankester AC, Smiers FJW, Bartels M, Mohseny AB. Pediatric Bone Marrow Failure: A Broad Landscape in Need of Personalized Management. J Clin Med 2023; 12:7185. [PMID: 38002797 PMCID: PMC10672506 DOI: 10.3390/jcm12227185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023] Open
Abstract
Irreversible severe bone marrow failure (BMF) is a life-threatening condition in pediatric patients. Most important causes are inherited bone marrow failure syndromes (IBMFSs) and (pre)malignant diseases, such as myelodysplastic syndrome (MDS) and (idiopathic) aplastic anemia (AA). Timely treatment is essential to prevent infections and bleeding complications and increase overall survival (OS). Allogeneic hematopoietic stem cell transplantation (HSCT) provides a cure for most types of BMF but cannot restore non-hematological defects. When using a matched sibling donor (MSD) or a matched unrelated donor (MUD), the OS after HSCT ranges between 60 and 90%. Due to the introduction of post-transplantation cyclophosphamide (PT-Cy) to prevent graft versus host disease (GVHD), alternative donor HSCT can reach similar survival rates. Although HSCT can restore ineffective hematopoiesis, it is not always used as a first-line therapy due to the severe risks associated with HSCT. Therefore, depending on the underlying cause, other treatment options might be preferred. Finally, for IBMFSs with an identified genetic etiology, gene therapy might provide a novel treatment strategy as it could bypass certain limitations of HSCT. However, gene therapy for most IBMFSs is still in its infancy. This review summarizes current clinical practices for pediatric BMF, including HSCT as well as other disease-specific treatment options.
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Affiliation(s)
- Lotte T. W. Vissers
- Laboratory for Pediatric Immunology, Department of Pediatrics, Willem-Alexander Children’s Hospital, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.T.W.V.); (M.v.d.B.)
| | - Mirjam van der Burg
- Laboratory for Pediatric Immunology, Department of Pediatrics, Willem-Alexander Children’s Hospital, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.T.W.V.); (M.v.d.B.)
| | - Arjan C. Lankester
- Department of Pediatrics, Hematology and Stem Cell Transplantation, Willem-Alexander Children’s Hospital, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (A.C.L.); (F.J.W.S.)
| | - Frans J. W. Smiers
- Department of Pediatrics, Hematology and Stem Cell Transplantation, Willem-Alexander Children’s Hospital, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (A.C.L.); (F.J.W.S.)
| | - Marije Bartels
- Department of Pediatric Hematology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Alexander B. Mohseny
- Department of Pediatrics, Hematology and Stem Cell Transplantation, Willem-Alexander Children’s Hospital, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (A.C.L.); (F.J.W.S.)
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Hurley K, Clow R, Jadhav A, Azzam EI, Wang Y. Mitigation of acute radiation syndrome (ARS) with human umbilical cord blood. Int J Radiat Biol 2023; 100:317-334. [PMID: 37967239 DOI: 10.1080/09553002.2023.2277372] [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: 05/30/2023] [Accepted: 09/27/2023] [Indexed: 11/17/2023]
Abstract
PURPOSE The growing concern over potential unintended nuclear accidents or malicious activities involving nuclear/radiological devices cannot be overstated. Exposure to whole-body doses of radiation can result in acute radiation syndrome (ARS), colloquially known as "radiation sickness," which can severely damage various organ systems. Long-term health consequences, such as cancer and cardiovascular disease, can develop many years post-exposure. Identifying effective medical countermeasures and devising a strategic medical plan represents an urgent, unmet need. Various clinical studies have investigated the therapeutic use of umbilical cord blood (UCB) for a range of illnesses, including ARS. The objective of this review is to thoroughly discuss ARS and its sub-syndromes, and to highlight recent findings regarding the use of UCB for radiation injury. UCB, a rich source of stem cells, boasts numerous advantages over other stem cell sources, like bone marrow, owing to its ease of collection and relatively low risk of severe graft-versus-host disease. Preclinical studies suggest that treatment with UCB, and often UCB-derived mesenchymal stromal cells (MSCs), results in improved survival, accelerated hematopoietic recovery, reduced gastrointestinal tract damage, and mitigation of radiation-induced pneumonitis and pulmonary fibrosis. Interestingly, recent evidence suggests that UCB-derived exosomes and their microRNAs (miRNAs) might assist in treating radiation-induced damage, largely by inhibiting fibrotic pathways. CONCLUSION UCB holds substantial potential as a radiation countermeasure, and future research should focus on establishing treatment parameters for ARS victims.
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Affiliation(s)
- Kate Hurley
- Radiobiology and Health, Canadian Nuclear Laboratories, Chalk River, Canada
| | - Rachel Clow
- Radiobiology and Health, Canadian Nuclear Laboratories, Chalk River, Canada
| | - Ashok Jadhav
- Radiobiology and Health, Canadian Nuclear Laboratories, Chalk River, Canada
| | - Edouard I Azzam
- Radiobiology and Health, Canadian Nuclear Laboratories, Chalk River, Canada
| | - Yi Wang
- Radiobiology and Health, Canadian Nuclear Laboratories, Chalk River, Canada
- Department of Biochemistry, Microbiology, and Immunology, University of Ottawa, Ottawa, Canada
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