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Baig MFA, Chaliki K. Inpatient outcomes of NSTEMI among patients with immune thrombocytopenia: a propensity matched national study. Ann Hematol 2024:10.1007/s00277-024-05913-7. [PMID: 39096370 DOI: 10.1007/s00277-024-05913-7] [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: 04/20/2024] [Accepted: 07/25/2024] [Indexed: 08/05/2024]
Abstract
Patients with immune thrombocytopenia (ITP) admitted for non-ST elevation myocardial infarction (NSTEMI) present a unique therapeutic challenge due to the increased risk of bleeding with antiplatelet and anticoagulation therapies. There is limited evidence studying hospital mortality and complications in this population. The study included a patient cohort from the 2018-2021 National Inpatient Sample database. Propensity score matched NSTEMI patients with and without ITP using a 1:1 matching ratio. Outcomes analyzed were in-hospital mortality, rates of diagnostic angiogram, percutaneous coronary intervention (PCI), acute kidney injury (AKI), congestive heart failure (CHF), cardiogenic shock, cardiac arrest, mechanical ventilation, tracheal intubation, ventricular tachycardia (VT), ventricular fibrillation (VF), major bleeding, need for blood and platelet transfusion, length of stay (LOS), and total hospitalization charges. A total of 1,699,020 patients met inclusion criteria (660,490 females [39%], predominantly Caucasian 1,198,415 (70.5%); mean [SD] age 67, [3.1], including 2,615 (0.1%) patients with ITP. Following the propensity matching, 1,020 NSTEMI patients with and without ITP were matched. ITP patients had higher rates of inpatient mortality (aOR 1.98, 95% CI 1.11-3.50, p 0.02), cardiogenic shock, AKI, mechanical ventilation, tracheal intubation, red blood cells and platelet transfusions, longer LOS, and higher total hospitalization charges. The rates of diagnostic angiogram, PCI, CHF, VT, VF, and major bleeding were not different between the two groups. Patients with ITP demonstrated higher odds of in-hospital mortality for NSTEMI and need for platelet transfusion with no difference in rates of diagnostic angiogram or PCI.
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Affiliation(s)
- Mirza Faris Ali Baig
- Department of Internal Medicine, Asante Three Rivers Medical Center, Grants Pass, OR, USA.
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2
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González-López TJ, Alperovich G, Burillo E, Espejo-Saavedra Soler M, Rebollo-Gómez E, Hernández I, Justicia JL, Lozano ML. Epidemiology, Treatment Patterns, and Cost Analysis of Immune Thrombocytopenia in Spain between 2014 and 2020: A Population-based Study. TH OPEN 2024; 8:e252-e265. [PMID: 38983689 PMCID: PMC11230702 DOI: 10.1055/a-2336-1062] [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: 09/28/2023] [Accepted: 05/06/2024] [Indexed: 07/11/2024] Open
Abstract
Background Immune thrombocytopenia (ITP) is characterised by low platelet counts and often leads to bleeding, fatigue, and reduced health-related quality of life. Methods This observational, retrospective, population-based study using BIG-PAC® database included Spanish paediatric and adult patients with primary ITP diagnosed in primary care and hospitals between 2014 and 2020 (median follow-up: 4 years). Epidemiology, baseline/clinical characteristics, treatment trends, healthcare resources and costs were analysed. Results The BIG-PAC® database contains records of 1,818,588 patients; 170 adults and 27 children with ITP were included in our analysis. ITP prevalence and annual incidence per 100,000 were estimated in 10.8 (2.8 in chronic ITP [cITP] patients) and 1.5 (0.3 in cITP patients), respectively. Epistaxis was the most common bleeding event, followed by genitourinary and gastrointestinal bleeding; >50%/> 75% of ITP/cITP patients reported fatigue. Chronic patients had lower platelet counts at baseline and required more transfusions. Corticosteroids, immunosuppressants, and thrombopoietin receptor agonists were the most used agents in first-, second- and third-line treatment, respectively. Thirty-five patients, all of them in chronic phase, underwent splenectomy. Patients had on average 13.9, 6.6, and 1.2 visits/year to primary care, haematology/internal medicine, and emergency departments, respectively. More than one-fourth of adult patients took on average 16.3 days of sick leave annually. Mean annual total health care costs were €10,741 (ITP patients) and €19,809 (cITP patients). Conclusion This is the first study to provide an overall perspective on the situation of the Spanish ITP population in terms of epidemiology, treatment trends, health care resources and costs, highlighting unmet patient needs, and direct and indirect costs/resource use between 2014 and 2020.
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Affiliation(s)
| | | | | | | | | | | | | | - María L Lozano
- Department of Haematology, Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-ISCIII, Murcia, Spain
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Xiao Z, He Z, Nguyen HLL, Thakur RK, Hammami MB, Narvel H, Vegivinti CTR, Townsend N, Billett H, Murakhovskaya I. Obesity is associated with adverse outcomes in primary immune thrombocytopenia - a retrospective single-center study. Ann Hematol 2024:10.1007/s00277-024-05836-3. [PMID: 38864906 DOI: 10.1007/s00277-024-05836-3] [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: 03/20/2024] [Accepted: 06/05/2024] [Indexed: 06/13/2024]
Abstract
The pathophysiology of immune thrombocytopenia (ITP) involves immune-mediated platelet destruction. The presence of adipose tissue in obese individuals creates an inflammatory environment that could potentially impact the clinical course and outcomes of ITP. However the relationship between obesity and ITP outcomes has not been well described. We evaluated ITP outcomes in 275 patients diagnosed with primary ITP from 2012 to 2022. Patients were categorized into four groups based on their body mass index (BMI) at diagnosis. Female gender was associated with a lower platelet count at the time of diagnosis at any BMI. Patients with high BMI had lower platelet counts at diagnosis and at platelet nadir (p < 0.001), an increased likelihood of requiring therapy (p < 0.001) and requiring multiple lines of therapy (p = 0.032). Non-obese patients who required corticosteroid treatment experienced a longer remission duration compared to obese patients (p = 0.009) and were less likely to be steroid-dependent (p = 0.048). Our findings suggest that obesity may be a significant risk factor for developing ITP and for ITP prognosis. Future studies are needed to evaluate the role of weight loss intervention in improving ITP outcomes.
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Affiliation(s)
- Zhengrui Xiao
- Division of Hematology, Department of Hematology-Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | - Zhiqiang He
- School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Hieu Liem Le Nguyen
- Division of Hematology, Department of Hematology-Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | - Rahul Kumar Thakur
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - M Bakri Hammami
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Hiba Narvel
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Charan Thej Reddy Vegivinti
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Noelle Townsend
- Division of Hematology, Department of Hematology-Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | - Henny Billett
- Division of Hematology, Department of Hematology-Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | - Irina Murakhovskaya
- Division of Hematology, Department of Hematology-Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10467, USA.
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Wang W, Xu X, Xu Y, Zhan Y, Wu C, Xiao X, Cheng C, Gao C. Quercetin, a key active ingredient of Jianpi Zishen Xiehuo Formula, suppresses M1 macrophage polarization and platelet phagocytosis by inhibiting STAT3 activation based on network pharmacology. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:4219-4233. [PMID: 38055068 DOI: 10.1007/s00210-023-02870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune hemorrhagic disease, and abnormal M1 macrophage polarization participates in the pathogenesis of ITP. Jianpi Zishen Xiehuo (JZX) Formula has a good therapeutic effect on ITP. However, its key active ingredients and molecular mechanisms remain unclear. In this study, we explored the key active ingredients and potential targets of JZX in treating ITP using network pharmacology combined with in vitro experimental verification. A total of 157 active ingredients of JZX were identified from public databases, and quercetin was the most important one. One hundred sixty-five intersection targets of active ingredients in JZX, ITP, and macrophage polarization were obtained by Venn diagram. The top three potential targets were signal transducer and activator of transcription 3 (STAT3), protein kinase B (PKB/AKT) 1, and c-JUN through protein-protein interaction analysis. Molecular docking showed that quercetin had strong binding affinities with them all. In vitro experiment, CD16+ monocytes increased in ITP patients compared with healthy controls, which indicated a M1/M2 polarization imbalance in ITP. The expression levels of M1 polarization markers, CD86, CD80, and inducible nitric oxide synthase (iNOS), M1 polarization-associated cytokines, tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6), and antibody-opsonized platelet phagocytosis significantly increased in THP-1 macrophages stimulated with lipopolysaccharide (LPS). Quercetin markedly inhibited the expressions of M1 markers, decreased the levels of TNF-α and IL-6, and down-regulated the phosphorylated STAT3 (p-STAT3) protein, which confirmed the prediction by network pharmacology and molecular docking. Importantly, quercetin significantly reduced the phagocytosis of antibody opsonised platelet. In conclusion, quercetin suppressed platelet phagocytosis in M1 macrophages via its anti-inflammatory effects and may serve as a potential drug for the treatment of ITP. Quercetin could be a key ingredient for JZX against ITP.
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Affiliation(s)
- Wei Wang
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Xuewen Xu
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Yang Xu
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Yueping Zhan
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Chuanyong Wu
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Xiao Xiao
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Cheng Cheng
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Chunfang Gao
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China.
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Liang Y, Rascati K, Barner JC, Lawson KA, Nair R. Treatment patterns and outcomes among adults with immune thrombocytopenia receiving pharmaceutical second-line therapies: a retrospective cohort study using administrative claims data. Curr Med Res Opin 2024; 40:781-788. [PMID: 38465414 DOI: 10.1080/03007995.2024.2328653] [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: 11/06/2023] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVES To describe and compare real-world treatment patterns and clinical outcomes among individuals with immune thrombocytopenia (ITP) receiving second-line therapies (rituximab, romiplostim, or eltrombopag). METHODS A retrospective cohort study was conducted using a large administrative claims database (January 2013-May 2020) among continuously enrolled patients ≥18 years prescribed second-line ITP therapies. The index date was the date of the first claim of the study medications. Treatment patterns and outcomes were measured during the 12-month follow-up period. Inverse probability of treatment weighting (IPTW) was used to balance covariates across treatment groups. Multivariable logistic regression was used to compare treatment patterns and bleeding risk outcomes. RESULTS A total of 695 patients were included (rituximab, N = 285; romiplostim, N = 212; eltrombopag, N = 198). After IPTW, all baseline covariates were balanced. Compared to eltrombopag, patients in the rituximab cohort were 57% more likely to receive other ITP therapies (systematic corticosteroids or third-line therapies) during the follow-up period (odds ratio [OR] = 1.571, p = .030). There was no significant difference in the odds of receiving a different second-line therapy or experiencing a bleeding-related episode among three groups (p > .050). Patients in the romiplostim cohort were 69% more likely to receive rescue therapy compared to those in the rituximab cohort (OR = 1.688, p = .025). CONCLUSION Patients with ITP receiving rituximab were more likely to need other ITP therapies but did not experience higher risk of bleeding compared to those receiving eltrombopag or romiplostim. Benefits, risks, cost-effectiveness, and patient preference should all be considered in optimizing second-line therapy for ITP.
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Affiliation(s)
- Yi Liang
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Karen Rascati
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- TxCORE - Texas Center for Health Outcomes Research and Education, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Jamie C Barner
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- TxCORE - Texas Center for Health Outcomes Research and Education, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Kenneth A Lawson
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- TxCORE - Texas Center for Health Outcomes Research and Education, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
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Urdaneta V, Esposito DB, Dharia P, Moraga MS, Anteyi K, Oduyebo-Omotosho T, Rossi M, Burton P, Vega JM, Dawson R, Straus W. Global Safety Assessment of Adverse Events of Special Interest Following 2 Years of Use and 772 Million Administered Doses of mRNA-1273. Open Forum Infect Dis 2024; 11:ofae067. [PMID: 38500575 PMCID: PMC10946654 DOI: 10.1093/ofid/ofae067] [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: 01/31/2024] [Indexed: 03/20/2024] Open
Abstract
Background Large-scale use of mRNA COVID-19 vaccines during the pandemic was associated with enhanced safety monitoring to ensure accurate and timely review of safety. We reviewed the mRNA-1273 (original strain) safety profile following 2 years of use (>772 million administered doses), primarily focusing on predefined safety topics (ie, adverse events of special interest [AESIs]) proposed in advance of COVID-19 vaccine use. Methods Cumulative mRNA-1273 safety data were included from spontaneous adverse event (AE) cases reported to Moderna's global safety database between 18 December 2020 and 17 December 2022. Reporting rates of AESIs were calculated per 1 million doses of mRNA-1273 administered. Observed-to-expected (OE) ratios were computed by comparing observed rates of AESIs with the background/expected rate for these events to evaluate potential associations with mRNA-1273. Results There were 658 759 identified case reports associated with 2 517 669 AEs. Most AEs were nonserious (83.4%; 2 098 954/2 517 669). Overall 0.7% (17 751/2 517 669) were fatal. AESIs represented 13.7% of all AEs (344 921/2 517 669), with reporting rates for most AESIs below the expected background incidence. Exceptions included anaphylaxis (OE ratio 3 days after vaccination, 2.09; 95% CI, 1.93-2.25) and, among individuals aged 12 to 40 years, myocarditis (OE ratio 7 days after any dose, 3.89 [3.50-4.32]; among men after dose 2, 8.57 [6.88-10.68]) and pericarditis (OE ratio 7 days after vaccination, 3.47; 2.89-4.16). Conclusions This safety analysis of mRNA-1273 identified evidence of increased risk for anaphylaxis, myocarditis, and pericarditis but not for other AESIs identified for enhanced monitoring ahead of COVID-19 vaccine use.
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Affiliation(s)
- Veronica Urdaneta
- Clinical Safety and Risk Management, Moderna, Inc, Cambridge, Massachusetts, USA
| | | | | | - Margot Stam Moraga
- Clinical Safety and Risk Management, Moderna, Inc, Cambridge, Massachusetts, USA
| | - Kate Anteyi
- Clinical Safety and Risk Management, Moderna, Inc, Cambridge, Massachusetts, USA
| | | | - Melissa Rossi
- Clinical Safety and Risk Management, Moderna, Inc, Cambridge, Massachusetts, USA
| | - Paul Burton
- Medical Affairs, Moderna, Inc, Cambridge, Massachusetts, USA
- Clinical Safety and Pharmacovigilance, Moderna, Inc, Cambridge, Massachusetts, USA
| | - José M Vega
- Clinical Safety and Pharmacovigilance, Moderna, Inc, Cambridge, Massachusetts, USA
| | - Rachel Dawson
- Medical Affairs, Moderna, Inc, Cambridge, Massachusetts, USA
| | - Walter Straus
- Clinical Safety and Pharmacovigilance, Moderna, Inc, Cambridge, Massachusetts, USA
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Hu W, Thornton M, Livingston RA. Real-World Use of Ruxolitinib Cream: Safety Analysis at 1 Year. Am J Clin Dermatol 2024; 25:327-332. [PMID: 38243107 PMCID: PMC10866801 DOI: 10.1007/s40257-023-00840-1] [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] [Accepted: 12/18/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Ruxolitinib cream is the first topical Janus kinase (JAK) inhibitor approved in the United States (US) for the treatment of mild to moderate atopic dermatitis and nonsegmental vitiligo. A postmarketing study with oral tofacitinib, approved for rheumatoid arthritis, triggered class warnings for JAK inhibitors, including risk of serious infections, mortality, malignancy, major adverse cardiovascular events, and thrombosis. Because ruxolitinib cream is indicated for inflammatory conditions, it is subject to the same warnings as oral JAK inhibitors in the US. Here, nearly 14,000 patient-years of postmarketing safety data from the first year following market approval of ruxolitinib cream were reviewed. METHODS The Incyte global safety database (21 September 2021-20 September 2022) and US FDA Adverse Event Reporting System (as of 30 September 2022) were queried for adverse event (AE) reports received for ruxolitinib cream. RESULTS The search identified 294 postmarketing individual case safety reports containing 589 events, including four serious AEs and no fatal AEs. AEs (i.e., any unfavorable sign, symptom, or disease) representing >2% of all events included application site pain (n = 16), atopic dermatitis (n = 15), skin irritation (n = 15), scratch (n = 14), and condition aggravated (n = 13). The four serious AEs were skin cancer (n = 2), pericarditis, and thrombocytopenia (both n = 1), none of which had sufficient information to assess possible relatedness to ruxolitinib cream. Serious AEs associated with the class warnings for JAK inhibitors were not reported. CONCLUSIONS Postmarketing safety data from the year following approval suggest ruxolitinib cream is generally well tolerated, without significant systemic AEs, and with a low incidence of application site reactions.
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Affiliation(s)
- Wilson Hu
- Incyte Corporation, 1801 Augustine Cut-Off, Wilmington, DE, 19803, USA.
| | - Michele Thornton
- Incyte Corporation, 1801 Augustine Cut-Off, Wilmington, DE, 19803, USA
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Guntu R, Patel A, Movahed MR, Hashemzadeh M, Hashemzadeh M. Association Between Idiopathic Thrombocytopenic Purpura and Hemorrhagic and Nonhemorrhagic Stroke. Crit Pathw Cardiol 2024; 23:26-29. [PMID: 37625190 DOI: 10.1097/hpc.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
BACKGROUND Idiopathic thrombocytopenic purpura (ITP) is characterized by a low platelet count. This may lead to an increased risk of hemorrhagic stroke but a lower rate of nonhemorrhagic stroke. The goal of this study was to evaluate the association between ITP and both hemorrhagic and nonhemorrhagic strokes using a large database. METHODS We used the Nationwide Inpatient Sample (NIS) database to analyze the occurrence of hemorrhagic and nonhemorrhagic stroke in patients with and without a diagnosis of ITP from 2005 to 2014. RESULTS Univariate analysis revealed a higher incidence of hemorrhagic stroke in patients with ITP in the year studied. (for example, in 2005: OR, 1.75; 95% CI, 1.57-1.94; P < 0.001; 2014: OR, 2.19; 95% CI, 2.03-2.36; P < 0.001). After adjusting for age, gender, race, and hypertension, hemorrhagic stroke remained significantly associated with ITP (in 2005: OR, 1.85; 95% CI, 1.49-1.89; P < 0.001; 2014: OR, 2.01; 95% CI, 1.86-2.18; P < 0.001) for all the years studied. Nonhemorrhagic stroke occurred at a lower rate in patients with ITP in most years (2006: OR, 0.91; 95% CI, 0.85-0.97; P = 0.004; 2014: OR, 0.88; 95% CI, 0.83-0.93; P < 0.001). Multivariate analysis confirmed a higher rate of nonhemorrhagic stroke in ITP patients. CONCLUSION Our analysis showed that there was a higher rate of hemorrhagic stroke but a lower rate of ischemic stroke in ITP patients, suggesting an important role of platelets in the occurrence of stroke.
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Affiliation(s)
- Rachna Guntu
- From the University of Arizona, College of Medicine Phoenix, AZ
| | - Aamir Patel
- From the University of Arizona, College of Medicine Phoenix, AZ
| | - Mohammad Reza Movahed
- From the University of Arizona, College of Medicine Phoenix, AZ
- University of Arizona, Sarver Heart Center
| | | | - Mehrnoosh Hashemzadeh
- From the University of Arizona, College of Medicine Phoenix, AZ
- Pima Community College, Tucson, AZ
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Chaudhry M, Stadler JK, Fitzgerald K, Modi J, Jones G, Magana K, Ward S, Magee T, Hughes G, Ford AI, Vassar M. Assessing uptake of the core outcome set in clinical trials for immune thrombocytopenia: A cross-sectional analysis. Thromb Res 2024; 234:113-119. [PMID: 38211379 DOI: 10.1016/j.thromres.2023.12.017] [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: 08/02/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Clinical trials (CTs) guide clinical practice, but inconsistent outcome reporting presents challenges. To increase comparability, a core outcome set (COS) was created for primary Immune thrombocytopenia (ITP) in 2009 to standardize outcome measurements. We aimed to evaluate uptake of the primary ITP COS in CT registries. MATERIALS & METHODS Our cross-sectional analysis employed a search string on ClinicalTrials.gov and ICTRP for phase III/IV CTs in June 2023. Inclusion criteria consisted of subjects with primary ITP, study was registered five years before COS publication to June 26, 2023, and assessed effectiveness of interventions. Two investigators extracted data in a masked, duplicate manner. Interrupted time series analysis, ANOVAs, and correlation analyses were conducted to assess the main outcome of COS uptake pre/post COS publication. RESULTS The search identified 131 eligible trials for data extraction. Altogether, 38.2 % (50/131) followed IWG platelet response guidelines. An alternative platelet count measurement was 50,000 × 109 L, with 46.56 % (61/131) of trials reporting it. The most measured outcome was adverse events (106/131, 80.9 %). Remaining secondary outcomes were measured in <50 % of studies. After COS publication, there was a statistically non-significant 0.03 % (p = 0.50, CI 95 % = [-0.06, 0.13]) 0.03 % (p = 0.50, CI 95 % = [-0.06, 0.13]) increase in the monthly trend of COS-defined outcomes. CONCLUSION We found a non-significant increase in uptake of the ITP COS since its publication and highlighted the lack of standardization among endpoints within ITP clinical trials. Our analysis highlights the need for heightened awareness and a COS update that acknowledges the variability in clinical trials.
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Affiliation(s)
- Mahad Chaudhry
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States.
| | - John K Stadler
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Kyle Fitzgerald
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Jay Modi
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Garrett Jones
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Kimberly Magana
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Shaelyn Ward
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Trevor Magee
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Griffin Hughes
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Alicia Ito Ford
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
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10
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Kubrusly BS, Kubrusly ES, Rocha HAL, Júnior ABV, Kubrusly MS, Ribeiro LLPA, Ribeiro RDA, Duarte FB. Epidemiology of immune thrombocytopenia: study of adult patients at a referral hematology service in Northeastern Brazil. Hematol Transfus Cell Ther 2023:S2531-1379(23)02585-3. [PMID: 38177057 DOI: 10.1016/j.htct.2023.09.2363] [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: 12/05/2022] [Revised: 06/04/2023] [Accepted: 09/05/2023] [Indexed: 01/06/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an acquired bleeding disorder observed in the clinical practice. Little is known about its epidemiology in Brazil. The present study was conducted at a hematology referral center which covers a population of over 8 million in 184 municipalities in the state of Ceará. The purpose of this study was to draw a demographic profile of adult ITP patients with regard to sex, age, geographical origin and distribution across the state, and the proportion of secondary ITP. Following ethics committee approval, information was collected with an ad hoc instrument. The sample consisted of 187 adult ITP patients attending the Walter Cantídio University Hospital in 2015. The median follow-up time was 67 months (range: 1 month to 29 years). Female sex (n = 154; 82.35 %) was strongly prevalent in all age brackets, with an overall female/male ratio of 4.7:1. The median age was 41 ± 16.1 with an interquartile range of 29-55.5 years; there was no difference between the genders. Secondary ITP (18/187; 9.6 %) displayed a bimodal distribution and a linear increase between 38 and >68 years of age. The results of this survey on the epidemiology of ITP in Brazil suggest that ethnic and geographical factors may have a great impact on age and sex distribution and on the distribution of secondary ITP.
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Affiliation(s)
| | - Elsie Sobreira Kubrusly
- Hospital Universitário Walter Cantídio of the Universidade Federal do Ceará, (HUWC-UFC), Fortaleza, CE, Brazil; Medicine School of the Centro Universitário Christus (UNICHRISTUS), Fortaleza, CE, Brazil
| | - Hermano Alexandre Lima Rocha
- Medicine School of the Universidade Federal do Ceará (FAMED-UFC), Fortaleza, CE, Brazil; Medicine School of the Centro Universitário Christus (UNICHRISTUS), Fortaleza, CE, Brazil
| | - Antonio Brazil Viana Júnior
- Hospital Universitário Walter Cantídio of the Universidade Federal do Ceará, (HUWC-UFC), Fortaleza, CE, Brazil; Maternidade-Escola Assis Chateaubriand, Universidade Federal do Ceará (MEAC UFC), Fortaleza, CE, Brazil
| | | | | | | | - Fernando Barroso Duarte
- Medicine School of the Universidade Federal do Ceará (FAMED-UFC), Fortaleza, CE, Brazil; Hospital Universitário Walter Cantídio of the Universidade Federal do Ceará, (HUWC-UFC), Fortaleza, CE, Brazil; Medicine School of the Centro Universitário Christus (UNICHRISTUS), Fortaleza, CE, Brazil
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11
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Arnold DM, Clerici B, Ilicheva E, Ghanima W. Refractory immune thrombocytopenia in adults: Towards a new definition. Br J Haematol 2023; 203:23-27. [PMID: 37642211 DOI: 10.1111/bjh.19075] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune haematological disorder characterized by immune-mediated thrombocytopenia and a variable risk of bleeding. Despite the availability of multiple treatment options, some patients are considered refractory since they do not achieve a platelet count response to multiple treatments and are at risk of bleeding. The term 'refractory' has been used to identify this patient group; however, with the advent of multiple lines of treatment, its meaning has become ambiguous. To address this issue, we reviewed previous definitions of refractory ITP, solicited the views of ITP experts and collected data from registries to inform a definition. Twenty ITP experts who attended the 7th Expert Meeting of the Intercontinental Cooperative ITP Study Group in September 2022 answered a web-based survey: 95% felt that there was a need for a new definition of refractory ITP for clinical and research purposes. The use of the term refractory, accompanied by a clear indication of the type and timing of failed treatments, was supported by 85% of respondents. Preliminary data on the frequency of refractory patients from the McMaster and Norwegian ITP Registries demonstrated that the proportion of adult ITP patients who had failed first-line therapy, rituximab, thrombopoietin receptor agonists, any immune suppressant medication and splenectomy ranged from 0.4% to 3.8%. We propose a definition of refractory ITP that could be evaluated in future studies.
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Affiliation(s)
- Donald M Arnold
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Bianca Clerici
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Dipartimento di Scienze della Salute, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Università degli Studi di Milano, Milan, Italy
| | | | - Waleed Ghanima
- Department of Research, Østfol Hospital, Sarpsborg, Norway
- Department of Hemato-Oncolology, Østfol Hospital, Sarpsborg, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
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12
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Wall E, Podstawka J, Patterson JM, Bolster L, Goodyear MD, Rydz N, Sun HL. Geographic disparities in the care and outcomes in adult chronic immune thrombocytopenia. Thromb Res 2023; 225:87-94. [PMID: 37031501 DOI: 10.1016/j.thromres.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Despite expert-based recommendations, real-world adherence to immune thrombocytopenia (ITP) guidelines is unclear. The impact of geographic and socioeconomic disparities on the quality of care and outcomes is unknown. We sought to determine the association between geographic remoteness and material deprivation on ITP care and outcomes. METHODS We conducted a multi-centre retrospective cohort study of adults with chronic ITP requiring a second-line therapy between 2012 and 2019 in the province of Alberta, Canada. Socioeconomic status was measured using the Pampalon material deprivation index quintiles. Geographic disparities were assessed by the driving distance to a major centre, with geographic remoteness defined as >200 km from major centre. We examined the impact of geographic and material deprivation on quality of care, resource utilization (hospitalizations, transfusions), and outcomes (major bleeding, all-cause mortality and ITP-related mortality). Cox proportional hazards models were used to examine the impact of geographic remoteness, rural residence and material deprivation on overall survival and ITP-related survival. RESULTS We included 326 ITP patients, median age of ITP diagnosis was 57 years, 182 (56 %) were female. Most patients (58 %) lived within 20 km of a major centre, whereas 49 (15 %) lived in a geographically remote area (>200 km). Geographic remoteness was significantly associated with material deprivation and lower likelihood of management by hematologists (84 % vs 99 %, P = 0.0001). It was also associated with lower rates of hepatitis C (71 % vs 89 %, P = 0.005) and hepatitis B testing (69 % vs 86 %, P = 0.03), and a non-significant trend towards lower rates of HIV testing (73 % vs 83 %, P = 0.051) compared with those <20 km from a major centre. Incomplete hyposplenic vaccinations among splenectomized patients (52 %), early splenectomy within 12 months of ITP diagnosis (35 %), inappropriate platelet transfusions (41 %), and inappropriate hospitalizations for asymptomatic thrombocytopenia (16 %) were common regardless of geographic distribution. There were 28 (9 %) ITP-related deaths (major bleeding or infections), most occurred within the first year of ITP diagnosis. Material deprivation, but not geographic remoteness, was an independent predictor of all-cause mortality (aHR 1.9, 95 % CI 1.1-3.3 in the most deprived quintile vs least deprived quintile). Rural residence trended towards increased hazard of ITP-related deaths (aHR 1.7, 95 % CI 0.9-3.2). CONCLUSION We demonstrated substantial deviations of ITP care from consensus guidelines, and geographic disparities in access to care and diagnostic workup. Future quality improvement initiatives are critical to improve the quality of care and reduce inequities.
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13
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Anat GG. Current approaches for the diagnosis and management of immune thrombocytopenia. Eur J Intern Med 2023; 108:18-24. [PMID: 36424271 DOI: 10.1016/j.ejim.2022.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/05/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
Abstract
Immune thrombocytopenia (ITP), is an acquired autoimmune disorder characterized by the destruction of platelets and megakaryocytes, resulting in thrombocytopenia (platelet count <100 × 10⁹/L). This review focuses on the diagnosis and current management of ITP. The diagnosis of ITP is based principally on the exclusion of other causes of isolated thrombocytopenia using patient history, physical examination, blood count, and evaluation of the peripheral blood film. The clinical treatment goals should be to resolve bleeding events and to prevent severe bleeding episodes. The platelet count should be improved to attain a minimum of > 20-30 × 10⁹/L. Therapy should be given as an inpatient in newly diagnosed ITP with a platelet count of > 20 × 10⁹/L or if there is active bleeding. Corticosteroids are considered the standard initial treatment for newly diagnosed patients. Subsequent medical therapies with robust evidence include thrombopoietin receptor agonists (TPO-RAs), rituximab and fostamatinib. Surgical therapy with splenectomy may be considered for patients failing medical therapy. The choice between therapy options is highly dependent upon patient values and preferences.
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Affiliation(s)
- Gafter-Gvili Anat
- Department of Medicine A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
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14
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Liu XG, Hou Y, Hou M. How we treat primary immune thrombocytopenia in adults. J Hematol Oncol 2023; 16:4. [PMID: 36658588 PMCID: PMC9850343 DOI: 10.1186/s13045-023-01401-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an immune-mediated bleeding disorder characterized by decreased platelet counts and an increased risk of bleeding. Multiple humoral and cellular immune abnormalities result in accelerated platelet destruction and suppressed platelet production in ITP. The diagnosis remains a clinical exclusion of other causes of thrombocytopenia. Treatment is not required except for patients with active bleeding, severe thrombocytopenia, or cases in need of invasive procedures. Corticosteroids, intravenous immunoglobulin, and anti-RhD immunoglobulin are the classical initial treatments for newly diagnosed ITP in adults, but these agents generally cannot induce a long-term response in most patients. Subsequent treatments for patients who fail the initial therapy include thrombopoietic agents, rituximab, fostamatinib, splenectomy, and several older immunosuppressive agents. Other potential therapeutic agents, such as inhibitors of Bruton's tyrosine kinase and neonatal Fc receptor, are currently under clinical evaluation. An optimized treatment strategy should aim at elevating the platelet counts to a safety level with minimal toxicity and improving patient health-related quality of life, and always needs to be tailored to the patients and disease phases. In this review, we address the concepts of adult ITP diagnosis and management and provide a comprehensive overview of current therapeutic strategies under general and specific situations.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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15
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Santhosh S, Malik B, Kalantary A, Kunadi A. Immune Thrombocytopenic Purpura (ITP) Following Natural COVID-19 Infection. Cureus 2022; 14:e26582. [PMID: 35815306 PMCID: PMC9270081 DOI: 10.7759/cureus.26582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 11/17/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) has been linked to the COVID-19 vaccine series as a rare adverse event but has recently emerged in the literature as a sequela of natural COVID-19 infection. ITP is a diagnosis of exclusion where a diagnosis is made by having isolated thrombocytopenia (platelet count <100,000/μL) and no other identifiable etiology for the thrombocytopenia. We share the case of a young male without any history of hematological or immunological disorders presenting with severe, symptomatic thrombocytopenia following a natural COVID-19 infection. Patients should be made aware of the potential risk of adverse events with not only vaccination but also even mild cases of natural infection with COVID-19. An emphasis should be placed on the fact that the benefits of vaccination continue to outweigh the potential risks of adverse events, even in those with a pre-existing diagnosis of ITP.
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16
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Developing and validating a mortality prediction model for ICH in ITP: a nationwide representative multicenter study. Blood Adv 2022; 6:4320-4329. [PMID: 35679462 PMCID: PMC9327537 DOI: 10.1182/bloodadvances.2022007226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/24/2022] [Indexed: 02/05/2023] Open
Abstract
Intraparenchymal hemorrhage, platelet count, serious infections, severe bleeding events, and Glasgow coma scale predict poor prognosis. A prognostic model was developed and validated, and an application was established.
Intracranial hemorrhage (ICH) is a rare and life-threatening hemorrhagic event in patients with immune thrombocytopenia (ITP). However, its mortality and related risk factors remain unclear. Herein, we conducted a nationwide multicenter real-world study of ICH in adult ITP patients. According to data from 27 centers in China from 2005 to 2020, the mortality rate from ICH was 33.80% (48/142) in ITP adults. We identified risk factors by logistic univariate and multivariate logistic regression for 30-day mortality in a training cohort of 107 patients as follows: intraparenchymal hemorrhage (IPH), platelet count ≤10 × 109/L at ICH, a combination of serious infections, grade of preceding bleeding events, and Glasgow coma scale (GCS) level on admission. Accordingly, a prognostic model of 30-day mortality was developed based on the regression equation. Then, we evaluated the performance of the prognostic model through a bootstrap procedure for internal validation. Furthermore, an external validation with data from a test cohort with 35 patients from 11 other centers was conducted. The areas under the receiver operating characteristic (ROC) curves for the internal and external validation were 0.954 (95% confidence interval [CI], 0.910-0.998) and 0.942 (95% CI, 0.871-1.014), respectively. Both calibration plots illustrated a high degree of consistency in the estimated and observed risk. In addition, the decision curve analysis showed a considerable net benefit for patients. Thus, an application (47.94.162.105:8080/ich/) was established for users to predict 30-day mortality when ICH occurred in adult patients with ITP.
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17
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Ding B, Liu L, Dai Y, Li M, Xia A, Song X, Liu J, Wang X, Song Y, Zhou H. Identification and verification of differentially expressed key genes in peripheral blood-derived T cells between chronic immune thrombocytopenia patients and healthy controls. Bioengineered 2022; 13:13587-13595. [PMID: 35796625 PMCID: PMC9450975 DOI: 10.1080/21655979.2022.2080422] [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] [Indexed: 11/23/2022] Open
Abstract
Immune thrombocytopenia (ITP), characterized by decreased platelet counts, is a complex immune-mediated disorder with unelucidated pathogenesis. Accumulating evidence shows that T cell-mediated platelet destruction is one crucial process during the progression of ITP. Here, we attempted to identify core genes in peripheral blood-derived T-cells of chronic ITP through the analysis of microarray data (GSE43179) and clinical verification, with the aim to further understand the pathogenesis and progression of ITP. Compared with healthy controls, 97 differentially expressed genes (DEGs), including 63 up-regulated and 34 down-regulated were identified in ITP patients. Functional enrichment analysis showed that the DEGs were mainly enriched in innate immune response, inflammatory response, and IL-17 signaling pathway. Among the DEGs, top 15 hub genes ranked by degree score were identified via protein-protein interaction (PPI) network and were further confirmed by quantitative reverse transcription PCR (qRT-PCR). Among top 15 hub genes, the expression levels of 14 DEGs like TLR4, S100A8, S100A9, and S100A12 were significantly up-regulated, while one DEG IFNG was down-regulated in ITP patients. Noticeably, TLR4 exhibited the highest degree score, and S100A8 had the largest fold change in qRT-PCR analysis. Altogether, our results suggested that the pathogenesis and progression of ITP are related with multiple immune-related pathways, and that TLR4 and S100A8 are likely to play crucial roles.
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Affiliation(s)
- Bingjie Ding
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Liu Liu
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yingtong Dai
- Department of Blood Component Preparation, Henan Province Red Cross Blood Center, Zhengzhou, Henan, China
| | - Mengjuan Li
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Ao Xia
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Xuewen Song
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Jianping Liu
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Xiaoran Wang
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Yongping Song
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Hu Zhou
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
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18
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Janssens A, Selleslag D, Depaus J, Beguin Y, Lambert C. Primary immune thrombocytopenia in adults: Belgian recommendations for diagnosis and treatment anno 2021 made by the Belgian Hematology Society. Acta Clin Belg 2022; 77:470-483. [PMID: 33635747 DOI: 10.1080/17843286.2021.1876310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The Belgian Hematology Society (BHS) updated the 2013 guidelines for diagnosis and treatment of primary immune thrombocytopenia (ITP) [1]. As knowledge about ITP pathophysiology is increasing, the mode of action of old therapies is better understood and novel drugs are introduced to target more specific pathways.Corticosteroids with or without intravenous immunoglobulins (IgIV) remain the first-line treatment. According to the updated international guidelines a short course of corticosteroids rather than a prolonged treatment has to be recommended. The same guidelines stress that consequent therapies as thrombopoietic agents (TPO-RAs) and rituximab should be available independent of duration of ITP.Although the majority of recommendations is based on very low-quality evidence, it is strongly advised to individualize the ITP management taking patient values. and preferences in account. The main treatment goal in all ITP patients must be to maintain a safe platelet count to prevent or stop bleeding with a minimum of toxicity and not to normalize the platelet count.
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Affiliation(s)
- A. Janssens
- Department of Hematology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - D. Selleslag
- Department of Hematology, AZ Sint-Jan Brugge, Brugge, Belgium
| | - J. Depaus
- Department of Hematology, CHU UCL Namur, Yvoir, Belgium
| | - Y. Beguin
- Department of Hematology, Centre Hospitalier Universitaire Liège, Liège, Belgium
| | - C. Lambert
- Department of Hematology, Cliniques Universitaire St Luc, Bruxelles, Belgium
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19
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Pogna EA, Middleton S, Nazir J, Ralph L, Wilson K, Jurczak W. Characterization and treatment of immune thrombocytopenia in Europe: a qualitative observational study. ACTA ACUST UNITED AC 2021; 26:860-869. [PMID: 34719349 DOI: 10.1080/16078454.2021.1992945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a rare disease, characterized by increased platelet destruction/suboptimal platelet production, leading to thrombocytopenia and risk of severe bleeding events. METHODS Interviews with 23 physicians and 12 payors, a survey with 113 physicians and validation using published data were used to define the current treatment paradigm and healthcare resource utilization and to determine the costs associated with managing acute bleeds in six European countries (Germany, Spain, France, Italy, Netherlands, UK). The study estimated a prevalence of 9 to 10 per 100,000 adults in 2020 across all six countries (disease severity split: 34% mild, 32% moderate, 33% severe (due to rounding up some values might not sum up to 100%). RESULTS Physician feedback showed that most patients with ITP (60%) received first-line treatment or were monitored by their physician; ∼75% of patients relapsed within 3-4 months. Thrombopoietin-receptor agonists (TPO-RAs) and rituximab were used to achieve disease stabilization in patients who relapse; patients could switch to an alternative TPO-RA to control symptoms, manage side-effects or improve adherence. The costs of rescue therapies and hospital services (e.g. surgery and admissions) accounted for the majority of healthcare resources to manage bleeding events. CONCLUSION Physicians would welcome earlier use of TPO-RAs to help maintain long-term control of ITP bleeds and potentially reduce both hospitalization and therapy costs.
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Affiliation(s)
| | | | - Jameel Nazir
- Swedish Orphan Biovitrum (Sobi™), Stockholm, Sweden
| | | | - Koo Wilson
- Swedish Orphan Biovitrum (Sobi™), Stockholm, Sweden
| | - Wojciech Jurczak
- Maria Sklodowska-Curie National Research Institute of Oncology, Kraków, Poland
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20
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Liang Y, Rascati K, Richards K. Prevalence of primary immune thrombocytopenia and related healthcare resource utilization among Texas Medicaid beneficiaries. Curr Med Res Opin 2021; 37:1315-1322. [PMID: 33910428 DOI: 10.1080/03007995.2021.1923469] [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] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To estimate the prevalence of primary immune thrombocytopenia (ITP) and describe ITP-associated healthcare resource utilization (HRU) among Texas Medicaid beneficiaries. METHODS A retrospective analysis using 2012-2015 Texas Medicaid claims data was conducted to estimate the annual prevalence of ITP. HRU was summarized for the 12-month period following initial ITP diagnosis. Logistic regression and generalized linear model were used to investigate predictors for all-cause and ITP-related HRU. RESULTS The average annual prevalence of ITP was 17.0 per 100,000 persons; higher among females vs males (17.4 vs 13.6 per 100,000) and highest among adults aged ≥ 65 years (36.7 per 100,000). Among 325 patients included in the HRU analyses, 49.2% received ITP therapies. More than half of patients had at least one all-cause emergency department (ED) visit (70.5%) and/or hospitalization (56.0%). One-third (32.6%) experienced at least one ITP-related ED visit and 40.3% had at least one ITP-related hospitalization. Compared to adults aged 18-49 with ITP, children aged 0-4 (odds ratio [OR] = 3.65, p = .0008) and aged 5-17 (OR = 2.68, p = .0074) were more likely to have an ITP-related hospitalization; children aged 0-4 (OR = 4.36, p = .0005) and children aged 5-17 (OR = 4.09, p = .0005) were more likely to have an ITP-related ED visit during the follow-up period. CONCLUSION There are 17 patients diagnosed with ITP for every 100,000 Texas Medicaid enrollees annually, with higher prevalence in females and the elderly. Children are more likely to experience hospitalizations and ED visits associated with ITP. ITP patients in Texas Medicaid utilize more healthcare resources compared to the general Medicaid population.
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Affiliation(s)
- Yi Liang
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Karen Rascati
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- TxCORE-Texas Center for Health Outcomes Research and Education, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Kristin Richards
- Health Outcomes Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- TxCORE-Texas Center for Health Outcomes Research and Education, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
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21
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Song F, Al-Samkari H. Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice. J Blood Med 2021; 12:653-664. [PMID: 34345191 PMCID: PMC8323851 DOI: 10.2147/jbm.s259101] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune process resulting in increased destruction and inadequate production of platelets that can result in bleeding, fatigue, and reduced health-related quality of life. While treatment is not required for many patients with ITP, the occurrence of bleeding manifestations, severe thrombocytopenia, and requirement for invasive procedures are among the reasons necessitating initiation of therapy. Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are typical first-line and rescue treatments, but these agents typically do not result in a durable remission in adult patients. Most patients requiring treatment therefore require subsequent line therapies, such as thrombopoietin receptor agonists (TPO-RAs), rituximab, fostamatinib, splenectomy, or a number of other immunosuppressive agents. In this focused review, we discuss management of adult ITP in the acute and chronic settings.
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Affiliation(s)
- Fei Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA.,Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
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22
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Ashraf S, Alsharedi M. COVID-19 induced immune thrombocytopenic purpura: case report. Stem Cell Investig 2021; 8:14. [PMID: 34386543 DOI: 10.21037/sci-2020-060] [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: 10/23/2020] [Accepted: 04/29/2021] [Indexed: 11/06/2022]
Abstract
Immune thrombocytopenic purpura (ITP) is an autoimmune state of decreased platelets caused by antibody or T-cell mediated destruction of platelets through the reticuloendothelial system and impairment of their production. Symptoms of ITP include bleeding usually from nose or gums, easy bruising, petechiae commonly of lower extremities, menorrhagia, hematuria, hematemesis, hematochezia and most dreadful, intra cranial hemorrhage. Molecular mimicry between viral antigens and host platelet antigens forming cross-reactive anti-platelet autoantibodies may lead to increased platelet clearance in ITP associated with viral infections. One of the many viruses associated with this is the Coronavirus disease 2019 (COVID-19). It has caused a devastating pandemic. It can activate innate and adaptive immune responses. It has numerous signs and symptoms including but not limited to dyspnea, fever, cough, fatigue, myalgias, loss of taste and smell. It leads to diseases such as pneumonia, acute respiratory distress syndrome, thrombosis and cardiomyopathy. Hematologic manifestations include thrombocytopenia and more commonly lymphopenia. Treatment includes steroids, immune globulin, romiplostim, eltrombopag, rituximab or splenectomy. Contact sports should be avoided due to risk of intra cranial bleeding with head impact. Nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin should be used with caution since they impair platelet function. We discuss a patient with COVID-19 who developed thrombocytopenia thought to be due to ITP. Not much is known about the association between the two. It is important to keep this differential in mind when taking care of patients with COVID-19 who develop thrombocytopenia.
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Affiliation(s)
- Sara Ashraf
- Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - Mohamed Alsharedi
- Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
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23
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U.S. Population-Based background incidence rates of medical conditions for use in safety assessment of COVID-19 vaccines. Vaccine 2021; 39:3666-3677. [PMID: 34088506 PMCID: PMC8118666 DOI: 10.1016/j.vaccine.2021.05.016] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/20/2021] [Accepted: 05/05/2021] [Indexed: 11/21/2022]
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic has had a devastating impact on global health, and has resulted in an unprecedented, international collaborative effort to develop vaccines to control the outbreak, protect human lives, and avoid further social and economic disruption. Mass vaccination campaigns are underway in multiple countries and are expected worldwide once more vaccine becomes available. Some early candidate vaccines use novel platforms, such as mRNA encapsulated in lipid nanoparticles, and relatively new platforms, such as replication-deficient viral vectors. While these new vaccine platforms hold promise, limited safety data in humans are available. Serious health outcomes linked to vaccinations are rare, and some outcomes may occur incidentally in the vaccinated population. Knowledge of background incidence rates of these medical conditions is a critical component of vaccine safety monitoring to aid in the assessment of adverse events temporally associated with vaccination and to put these events into context with what would be expected due to chance alone. A list of 22 potential adverse events of special interest (AESI), including neurologic, autoimmune, and cardiovascular disorders, was compiled by subject matter experts at the U.S. Food and Drug Administration and the Centers for Disease Control and Prevention. The most recently available U.S. background rates for these medical conditions, overall and by age, sex, and race/ethnicity (when available), were sourced from reported statistics (data published by medical panels/ associations or federal government reports), and literature reviews in PubMed. This review provides estimates of background incidence rates for medical conditions that may be monitored or studied as AESI during safety surveillance and research for COVID-19 vaccines and other new vaccines.
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Helms JM, Ansteatt KT, Roberts JC, Kamatam S, Foong KS, Labayog JMS, Tarantino MD. Severe, Refractory Immune Thrombocytopenia Occurring After SARS-CoV-2 Vaccine. J Blood Med 2021; 12:221-224. [PMID: 33854395 PMCID: PMC8040692 DOI: 10.2147/jbm.s307047] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/15/2021] [Indexed: 12/13/2022] Open
Abstract
The rollout of the SARS-CoV-2 vaccine is underway, and millions have already been vaccinated. At least 25 reports of "immune thrombocytopenia" (ITP) or "thrombocytopenia" following the Moderna or Pfizer vaccine have been added to the Vaccine Adverse Event Reporting System (VAERS) in the US. ITP is a rare but known complication of several vaccinations. SARS-CoV-2 vaccine is new, with a novel mechanism of action, and understanding the epidemiology, clinical manifestations, treatment success and natural history of post-vaccination thrombocytopenia is evolving. We report a 74-year-old man who developed refractory thrombocytopenia within one day of receiving the Moderna SARS-CoV-2 vaccine. Several hours after vaccination, he developed significant epistaxis and cutaneous purpura. Severe thrombocytopenia was documented the following day, and he developed extremity weakness and encephalopathy with facial muscle weakness. Over a 14-day period, thrombocytopenia was treated first with high dose dexamethasone, intravenous immunoglobulin, platelet transfusions, rituximab, plasma exchange (for presumed acute inflammatory demyelinating polyneuropathy (AIDP)), and four daily doses of the thrombopoietin receptor agonist (TPO-RA) eltrombopag (Promacta™), without a platelet response. Three days later, he received the TPO-RA romiplostim (Nplate™). Five days later, his platelet count began to rise and by post-vaccination day 25, his platelet count was in the normal range. Thrombocytopenia was refractory to frontline and second-line treatment. The eventual rise in his platelet count suggests that one or both TPO-RAs may have impacted platelet recovery. Possibly, but less likely given the temporality, the drug-induced thrombocytopenia was subsiding. The aggressive use of immunosuppressive treatment may jeopardize the intended purpose of the SARS-CoV-2 vaccine, and earlier use of non-immunosuppressive second-line treatment for vaccine-related severe thrombocytopenia, such as with TPO-RAs, should be considered. While it is imperative to continue the global vaccination program, vigilance to the occurrence of post-vaccination severe thrombocytopenia is warranted.
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Affiliation(s)
- Jackie M Helms
- The Bleeding and Clotting Disorders Institute, Peoria, IL, USA
| | | | - Jonathan C Roberts
- The Bleeding and Clotting Disorders Institute, Peoria, IL, USA
- Department of Medicine, University of Illinois College of Medicine-Peoria, Peoria, IL, USA
| | - Sravani Kamatam
- Department of Medicine, Saint Francis Medical Center, Peoria, IL, USA
| | - Kap Sum Foong
- Department of Medicine, University of Illinois College of Medicine-Peoria, Peoria, IL, USA
- Department of Medicine, Saint Francis Medical Center, Peoria, IL, USA
| | - Jo-mel S Labayog
- Department of Medicine, OSF Sacred Heart Medical Center, Danville, IL, USA
| | - Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, Peoria, IL, USA
- Department of Medicine, University of Illinois College of Medicine-Peoria, Peoria, IL, USA
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Park SH, Kwak SG, Kim JY. Incidence and prevalence of immune thrombocytopenia under the copayment waiver policy for pediatric patients in Korea: Data from the National Health Claims Database. Lupus 2021; 30:655-660. [PMID: 33593162 DOI: 10.1177/0961203321995247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The purpose of this study was to investigate the epidemiology of immune thrombocytopenia (ITP) under the copayment waiver policy for pediatric patients in Korea. The data were collected from the National Health Insurance Claims Database of Korea. ITP was identified based on the diagnostic code D69.38 from the Korean Standard Classification of Diseases. Patients between one and 18 years old, who had at least one health insurance claim for ITP as a final diagnosis, from 1 January 2016, to 31 December 2017, were analyzed. Prevalent cases were defined as patients who used, at least one time, any medical services coded as D69.38. Incident cases were defined as patients who did not use D69.38 coded medical services during the prior year and were newly registered in 2017. The prevalence and incidence of ITP were 24.53 and 13.39 per 100,000 persons. The peak rates were observed in 1-year-old patients. The gender-specific prevalence of ITP was significantly higher in one-year-old males than females. According to the change-point analysis, we found that the prevalence and incidence diminished rapidly at the ages of four and three, respectively. This Korean population-based epidemiological study of ITP provided meaningful insights into the current epidemiology of ITP and demonstrated the implications of interpreting epidemiologic studies to reflect age categorizing and health care system characteristics.
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Affiliation(s)
- Sung-Hoon Park
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Sang Gyu Kwak
- Department of Medical Statistics, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Ji Yoon Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea
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Lal LS, Said Q, Andrade K, Cuker A. Second-line treatments and outcomes for immune thrombocytopenia: A retrospective study with electronic health records. Res Pract Thromb Haemost 2020; 4:1131-1140. [PMID: 33134779 PMCID: PMC7590333 DOI: 10.1002/rth2.12423] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Second-line treatment for immune thrombocytopenia (ITP) is not well reported for patients treated in real-world clinical settings. OBJECTIVE The purpose of this study was to compare outcomes of four second-line treatments for ITP. PATIENTS/METHODS Included adult patients had at least two medical records containing ITP diagnoses and second-line eltrombopag, romiplostim, rituximab, or splenectomy. Date of treatment initiation or splenectomy was set as index date, between July 1, 2008, and March 31, 2017. Patients had first-line corticosteroid or intravenous immune globulin treatment and continuous database activity from 6 months before to 12 months after index. Patient characteristics, treatment patterns, platelet counts, bleeding-related episodes (BREs), and thrombotic events (TEs) were compared by second-line treatment cohort. RESULTS The sample included 3332 patients (mean age, 60.5 years; 52.3% female): eltrombopag (5.8%), romiplostim (9.9%), rituximab (73.3%), and splenectomy (11.0%). Patients having splenectomy were younger, more likely female and commercially insured, and less likely to require a third line of treatment than medical regimen cohorts. Proportions of patients having treatment-free (≥180 days with no second-line index or rescue agent) periods varied significantly (P = .01) by regimen: 33% for eltrombopag, 23% for romiplostim, 26% for rituximab, and 17% for splenectomy. All regimens significantly improved platelet counts, while TE and BRE rates differed significantly (P = .03 and P = .01, respectively) when all treatment groups were compared. CONCLUSIONS Over an average 7-year follow-up, all second-line regimens improved platelet counts, but eltrombopag yielded the highest proportion of patients with completely treatment-free periods of at least 180 days.
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Affiliation(s)
- Lincy S. Lal
- Optum Health Economics and Outcomes ResearchEden PrairieMNUSA
| | - Qayyim Said
- Novartis Pharmaceuticals CorporationEast HanoverNJUSA
| | | | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
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