1
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Zhang P, Cai Y, Ge F, Zhu Z, Sun K. The Incidence and Characteristics of Thrombosis in Patients with Immune thrombocytopenia: A Retrospective Cohort Study. Int J Gen Med 2024; 17:2021-2027. [PMID: 38736666 PMCID: PMC11088860 DOI: 10.2147/ijgm.s462276] [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] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/18/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction This study aims to investigate the incidence, clinical characteristics, and prognosis of thrombosis in Chinese patients with immune thrombocytopenia (ITP). Methods This was a single-center, retrospective study of adult patients with ITP at the Henan Provincial People's Hospital from January 2018 to June 2023. Results A total of 3216 adult patients with primary ITP were included in the study period, with 25 (0.93%) having thrombotic events. The average age of 25 patients with thrombosis is 62.76±12.79 years, including 11 males and 14 females. In addition, among the 25 thrombotic events, 19 cases were arterial thrombosis (AT), and 6 cases were venous thrombosis (VT). The incidence of AT is higher than that of VT (P=0.009). There was no obvious difference in clinical characteristics between the two groups. The median platelet count at the time of thrombosis in 25 patients was 35 (23, 52) ×109/L. At the onset of thrombosis, 23 patients (92.0%) had a low PLT (<100×109/L). One patient with ischemic stroke died in the hospital due to severe infection. Conclusion ITP may be considered a bleeding disorder with a high risk of thrombosis, and AT is more common than VT in the Chinese population.
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Affiliation(s)
- Ping Zhang
- Department of Hematology, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Yanan Cai
- Department of Hematology, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Fei Ge
- Department of Hematology, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Zunmin Zhu
- Department of Hematology, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Kai Sun
- Department of Hematology, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
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2
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Martínez-Carballeira D, Bernardo Á, Caro A, Soto I, Gutiérrez L. Pathophysiology, Clinical Manifestations and Diagnosis of Immune Thrombocytopenia: Contextualization from a Historical Perspective. Hematol Rep 2024; 16:204-219. [PMID: 38651450 PMCID: PMC11036214 DOI: 10.3390/hematolrep16020021] [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: 01/09/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/25/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by an isolated decrease in the platelet count and an increased risk of bleeding. The pathogenesis is complex, affecting multiple components of the immune system and causing both peripheral destruction of platelets and impaired central megakaryopoiesis and platelet production in the bone marrow. Here, we intend to contextualize the current knowledge on the pathophysiology, terminology, epidemiology, clinical manifestations, diagnosis, and prognosis of ITP from a historical perspective and the first references to the never-stopping garnering of knowledge about this entity. We highlight the necessity to better understand ITP in order to be able to provide ITP patients with personalized treatment options, improving disease prognosis and reducing the incidence or frequency of refractoriness.
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Affiliation(s)
- Daniel Martínez-Carballeira
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Ángel Bernardo
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Alberto Caro
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Inmaculada Soto
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), 33011 Oviedo, Spain; (Á.B.); (A.C.); (I.S.)
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
| | - Laura Gutiérrez
- Platelet Research Lab, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain;
- Department of Medicine, University of Oviedo, 33006 Oviedo, Spain
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3
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Lambert C, Maitland H, Ghanima W. Risk-based and individualised management of bleeding and thrombotic events in adults with primary immune thrombocytopenia (ITP). Eur J Haematol 2024; 112:504-515. [PMID: 38088207 DOI: 10.1111/ejh.14154] [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: 09/27/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 03/19/2024]
Abstract
Although bleeding is one of the main symptoms of primary immune thrombocytopenia (ITP), risk factors for bleeding have yet to be fully established. Low platelet count (PC; <20-30 × 109 /L) is generally indicative of increased risk of bleeding. However, PC and bleeding events cannot be fully correlated; many other patient- and disease-related factors are thought to contribute to increased bleeding risk. Furthermore, even though ITP patients have thrombocytopenia and are at increased risk of bleeding, ITP also carries higher risk of thrombotic events. Factors like older age and certain ITP treatments are associated with increased thrombotic risk. Women's health in ITP requires particular attention concerning haemorrhagic and thrombotic complications. Management of bleeding/thrombotic risk, and eventually antithrombotic therapies in ITP patients, should be based on individual risk profiles, using a tailored, patient-centric approach. Currently, evidence-based recommendations and validated tools are lacking to support decision-making and help clinicians weigh risk of bleeding against thrombosis. Moreover, evidence is lacking about optimal PC for achieving haemostasis in invasive procedures settings. Further research is needed to fully define risk factors for each event, enabling development of comprehensive risk stratification approaches. This review discusses risk-based and individualised management of bleeding and thrombosis risk in adults with primary ITP.
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Affiliation(s)
- Catherine Lambert
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Hillary Maitland
- Division of Hematology and Oncology, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Waleed Ghanima
- Department of Hemato-oncology, Østfold Hospital, Oslo University, Oslo, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
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Moulis G, Rueter M, Duvivier A, Mahévas M, Viallard JF, Comont T, Chèze S, Audia S, Ebbo M, Terriou L, Lega JC, Jeandel PY, Hemim I, Bozzi S, Daak A, Okada H, Bonnotte B, Michel M, Lapeyre-Mestre M, Godeau B. Difficult-to-treat primary immune thrombocytopenia in adults: Prevalence and burden. Results from the CARMEN-France registry. Br J Haematol 2024; 204:1476-1482. [PMID: 38267268 DOI: 10.1111/bjh.19288] [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: 07/15/2023] [Revised: 11/25/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024]
Abstract
The aim of this study was to assess the prevalence and the burden of difficult-to-treat primary ITP (pITP), defined by the need for another ITP treatment after romiplostim and eltrombopag. Adult patients were selected in the prospective, real-world CARMEN-France registry up to December 2021. Out of 821 adult patients with pITP, 29 had difficult-to-treat ITP (3.5%; 95% confidence interval [CI]: 2.3%-4.8% in total; 7.6%; 95% CI: 4.9%-10.2% of patients needing ≥2nd line treatment). The 3-year cumulative incidence of bleeding, infection and thrombosis was 100%, 24.1% and 13.8% respectively. The median cumulative duration of hospital stays was 31 days (median follow-up: 30.3 months).
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Affiliation(s)
- Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center, Toulouse University Hospital, Toulouse, France
| | - Manuela Rueter
- Clinical Investigation Center, Toulouse University Hospital, Toulouse, France
| | | | - Matthieu Mahévas
- Department of Internal Medicine, National Referral Center for Autoimmune Cytopenias, Créteil University Hospital, Créteil, France
| | | | - Thibault Comont
- Department of Internal Medicine, Toulouse Cancer University Hospital, Toulouse, France
| | - Stéphane Chèze
- Department of Hematology, Caen University Hospital, Caen, France
| | - Sylvain Audia
- Department of Internal Medicine, Dijon University Hospital, Dijon, France
| | - Mikaël Ebbo
- Department of Internal Medicine, Marseille University Hospital, Marseille, France
| | - Louis Terriou
- Department of Internal Medicine, Lille University Hospital, Lille, France
| | | | | | | | | | | | | | - Bernard Bonnotte
- Department of Internal Medicine, Dijon University Hospital, Dijon, France
| | - Marc Michel
- Department of Internal Medicine, National Referral Center for Autoimmune Cytopenias, Créteil University Hospital, Créteil, France
| | - Maryse Lapeyre-Mestre
- Clinical Investigation Center, Toulouse University Hospital, Toulouse, France
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Bertrand Godeau
- Department of Internal Medicine, National Referral Center for Autoimmune Cytopenias, Créteil University Hospital, Créteil, France
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Shen N, Qiao J, Jiang Y, Yan J, Wu R, Yin H, Zhu S, Li J. Thrombopoietin receptor agonists use and risk of thrombotic events in patients with immune thrombocytopenic purpura: A systematic review and meta‑analysis of randomized controlled trials. Biomed Rep 2024; 20:44. [PMID: 38357229 PMCID: PMC10865300 DOI: 10.3892/br.2024.1732] [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: 09/24/2023] [Accepted: 01/10/2024] [Indexed: 02/16/2024] Open
Abstract
Thrombopoietin receptor agonists (TPO-RAs) have a role in second-line immune thrombocytopenic purpura (ITP) treatment, binding to and activating thrombopoietin receptors on megakaryocyte membranes in the bone marrow. This promotes megakaryocyte maturation and increases platelet production. Despite a 2-6% incidence of thrombotic events during TPO-RA treatment, it remains uncertain whether TPO-RAs elevate thrombosis rates. A comprehensive search of electronic databases was conducted using the relevant search criteria. To assess the risk of bias, the included studies were assessed using the revised Cochrane Risk of Bias Assessment Tool 2.0, and a meta-analysis was performed using RevMan 5.4.1. A total of 1,698 patients with ITP were included from randomized controlled trials (RCTs). There were 26 thromboembolic events in the TPO-RAs group and 4 in the control group. However, there was no significant difference in the incidence of thrombotic events between the two groups [odds ratio (OR)=1.76, 95% confidence interval (CI): 0.78-4.00, P=0.18], even if the duration of treatment was >12 weeks (OR=2.46, 95% CI: 0.81-7.43, P=0.11). Subgroup analysis showed that none of the four drugs significantly increased the incidence of thrombotic events (romiplostim: OR=0.92, 95% CI: 0.14-6.13, P=0.93; eltrombopag: OR=2.32, 95% CI: 0.64-8.47, P=0.20; avatrombopag: OR=4.15, 95% CI: 0.20-85.23, P=0.36; and hetrombopag: OR=0.76, 95% CI: 0.03-18.76, P=0.87). There was also no significant difference in the results of the double-blinded placebo-controlled RCTs (OR=1.21, 95% CI: 0.41-3.58, P=0.73). Compared to patients with ITP who did not receive TPO-RA treatment, those receiving TPO-RA treatment did not exhibit a significantly increased risk of thrombotic events.
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Affiliation(s)
- Nan Shen
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
- Department of Hematology, The Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
| | - Jibing Qiao
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Yazhou Jiang
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Jingjing Yan
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Rang Wu
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Hanjun Yin
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Suyue Zhu
- Department of Pediatrics, Suqian Hospital Affiliated to Xuzhou Medical University, Suqian, Jiangsu 223800, P.R. China
| | - Jianqin Li
- Department of Hematology, The Children's Hospital of Soochow University, Suzhou, Jiangsu 215000, P.R. China
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Goncalves I, Lewis C, Grainger B, Dring R, Lee N, Pasricha SR, Szer J, Mason K. Thrombosis in patients with immune thrombocytopenia: incidence, risk, and clinical outcomes. Res Pract Thromb Haemost 2024; 8:102342. [PMID: 38444612 PMCID: PMC10912689 DOI: 10.1016/j.rpth.2024.102342] [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: 09/04/2023] [Revised: 01/17/2024] [Accepted: 01/26/2024] [Indexed: 03/07/2024] Open
Abstract
Background There is evidence that patients with immune thrombocytopenia (ITP) are at increased risk of thrombosis. However, the association of clinical- and treatment-related factors with thrombosis remains controversial. Objectives To evaluate the incidence and impact of risk factors for arterial and venous thromboembolism (VTE) in patients with ITP and characterize the clinical features and management of patients. Methods We performed a retrospective cohort study (January 1, 2011, to October 30, 2022) of adult patients diagnosed with ITP from an Australian tertiary hospital. The incidence rates of thrombosis were calculated in terms of person-years of follow-up. Multiadjusted Cox regression was used to estimate associations. Results A total of 220 patients with 1365 person-years of follow-up since ITP diagnosis revealed 26 (11.8%) patients with a total of 37 thrombosis events, 29 (78%) VTE and 8 (22%) arterial thromboembolism (ATE). The incidence rate of thrombosis was 2.71 (95% CI, 1.97-3.72) (0.66 [95% CI, 0.33-1.26] for arterial thromboembolism and 2.05 [95% CI, 1.42-2.95] for VTE) per 100 person-years. Mean age and median time to first thrombosis diagnosis was 56 and 2.13 years, respectively. Age, secondary ITP, lines of therapy, thrombosis risk factors, and thrombopoietin receptor agonist therapy were independently associated with thrombosis. Almost all patients (25 of 26, [96%]) had good ITP disease control prior to thrombosis diagnosis, and antithrombotic therapy was deliverable and well tolerated. Conclusion Diagnosis of thrombosis in patients with ITP, while infrequent, is of clinical significance. We identified from a heterogeneous real-world cohort that older patients with multiply-treated secondary ITP receiving thrombopoietin receptor agonists are at the highest risk.
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Affiliation(s)
- Isaac Goncalves
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Cameron Lewis
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Brian Grainger
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rebecca Dring
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Nora Lee
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Bendigo Hospital, Bendigo, Victoria, Australia
| | - Sant-Rayn Pasricha
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jeffrey Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kylie Mason
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
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7
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Provan D, Thachil J, Álvarez Román MT. Addressing thrombosis concerns in immune thrombocytopenia: the role of fostamatinib in immune thrombocytopenia management. Expert Rev Hematol 2024; 17:55-66. [PMID: 38369947 DOI: 10.1080/17474086.2024.2318345] [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: 06/06/2023] [Accepted: 02/09/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP), a disease that commonly presents with an increased risk of bleeding, can also paradoxically produce an increased risk of thromboembolic events. The risk of thromboembolism can be associated with patient-related factors (e.g. co-morbidities, age and history of thrombosis), disease-related factors (e.g. a greater proportion of younger, more reactive platelets, and the presence of microparticles and pro-inflammatory cytokines) and treatment-related factors (e.g. splenectomy, thrombopoietin receptor agonists, and IVIg). AREAS COVERED Aspects of the pathophysiology of ITP and the effects of treatment are discussed with emphasis on individualizing treatment based on the patient's thromboembolic risk, treatment options and preferences. EXPERT OPINION An increased understanding of the pathophysiology of ITP has led to the development of new agents such as fostamatinib, a spleen tyrosine kinase inhibitor. Further research into the factors contributing to the risks for bleeding and thromboembolic events can contribute to the development of more specific therapies for ITP and allow greater individualization of therapy based on each patient's medical history and clinical status.
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Affiliation(s)
- Drew Provan
- Department of Haematology, Emeritus Reader in Autoimmune Haematology, Barts & The London School of Medicine, London, UK
| | - Jecko Thachil
- Haemostasis and Thrombosis, Consultant in Haemostasis and Thrombosis, Manchester Royal Infirmary, Manchester, UK
| | - María Teresa Álvarez Román
- Head of the Haemostasis Unit, University Hospital La Paz, Autonomous University of Madrid, Madrid, Spain
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Simpson M, Narwal A, West E, Martin J, Bagot CN, Page AR, Watson HG, Whyte CS, Mutch NJ. Fibrinogenolysis and fibrinolysis in vaccine-induced immune thrombocytopenia and thrombosis. J Thromb Haemost 2023; 21:3589-3596. [PMID: 37734715 DOI: 10.1016/j.jtha.2023.09.007] [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: 08/14/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Vaccine-induced immune thrombocytopenia and thrombosis (VITT) is a rare syndrome associated with adenoviral vector vaccines for COVID-19. The syndrome is characterized by thrombosis, anti-platelet factor 4 (PF4) antibodies, thrombocytopenia, high D-dimer, and hypofibrinogenemia. OBJECTIVES To investigate abnormalities in fibrinolysis that contribute to the clinical features of VITT. METHODS Plasma samples from 18 suspected VITT cases were tested for anti-PF4 by ELISA and characterized as meeting criteria for VITT (11/18) or deemed unlikely (7/18; non-VITT). Antigen levels of PAI-1, factor XIII (FXIII), plasmin-α2antiplasmin (PAP), and inflammatory markers were quantified. Plasmin generation was quantified by chromogenic substrate. Western blotting was performed with antibodies to fibrinogen, FXIII-A, and plasminogen. RESULTS VITT patients 10/11 had scores indicative of overt disseminated intravascular coagulation, while 0/7 non-VITT patients met the criteria. VITT patients had significantly higher levels of inflammatory markers, IL-1β, IL-6, IL-8, TNFα, and C-reactive protein. In VITT patients, both fibrinogen and FXIII levels were significantly lower, while PAP and tPA-mediated plasmin generation were higher compared to non-VITT patients. Evidence of fibrinogenolysis was observed in 9/11 VITT patients but not in non-VITT patients or healthy controls. Fibrinogen degradation products were apparent, with obvious cleavage of the fibrinogen α-chain. PAP complex was evident in those VITT patients with fibrinogenolysis, but not in non-VITT patients or healthy donors. CONCLUSION VITT patients show evidence of overt disseminated intravascular coagulation and fibrinogenolysis, mediated by dysregulated plasmin generation, as evidenced by increased PAP and plasmin generation. These observations are consistent with the clinical presentation of both thrombosis and bleeding in VITT.
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Affiliation(s)
- Megan Simpson
- Aberdeen Cardiovascular & Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK. https://twitter.com/SimpsonMegan8
| | - Anuj Narwal
- Aberdeen Cardiovascular & Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Eric West
- Aberdeen Cardiovascular & Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Jill Martin
- Department of Haematology Laboratory, Aberdeen Royal Infirmary, Aberdeen, UK
| | | | - Andrew R Page
- Department of Haematology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Henry G Watson
- Aberdeen Cardiovascular & Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Claire S Whyte
- Aberdeen Cardiovascular & Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK. https://twitter.com/ClaireW63108369
| | - Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK.
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Allan HE, Vadgama A, Armstrong PC, Warner TD. Platelet ageing: A review. Thromb Res 2023; 231:214-222. [PMID: 36587993 DOI: 10.1016/j.thromres.2022.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/02/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Platelet ageing is an area of research which has gained much interest in recent years. Newly formed platelets, often referred to as reticulated platelets, young platelets or immature platelets, are defined as RNA-enriched and have long been thought to be hyper-reactive. This latter view is largely rooted in associations and observations in patient groups with shortened platelet half-lives who often present with increased proportions of newly formed platelets. Evidence from such groups suggests that an increased proportion of newly formed platelets is associated with an increased risk of thrombotic events and a reduced effectiveness of standard anti-platelet therapies. Whilst research has highlighted the existence of platelet subpopulations based on function, size and age within patient groups, the common intrinsic changes which occur as platelets age within the circulation are only just being explored. By understanding the changes that occur during the natural ageing processes of platelets, we may be able to identify the triggers for alterations in platelet life span and platelet reactivity. Here we review research on platelet ageing in the context of health and disease, paying particular attention to the experimental approaches taken and the robustness of conclusions that can be drawn.
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Affiliation(s)
- Harriet E Allan
- Centre for Immunobiology, Blizard Institute, Barts & the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom.
| | - Ami Vadgama
- Centre for Immunobiology, Blizard Institute, Barts & the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Paul C Armstrong
- Centre for Immunobiology, Blizard Institute, Barts & the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Timothy D Warner
- Centre for Immunobiology, Blizard Institute, Barts & the London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
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10
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Nielsen MH, Bor MV. Management of Recurrent Venous Thromboembolism in Severe Immune Thrombocytopenia: A Case Report and a Review of the Literature. Hamostaseologie 2023. [PMID: 37907247 DOI: 10.1055/a-2159-8722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
We report a case of a 58-year-old man with recurrent unprovoked deep vein thrombosis (DVT) and severe immune thrombocytopenia (ITP) with a platelet count of 19 × 109/L. We further review studies reporting venous thromboembolism (VTE) in patients with severe ITP (≤ 35 × 109/L) and identified 14 patients highlighting VTE risk factors and management of these patients. The present case had several risk factors for VTE (previous DVT, obesity, heterozygosity for factor V Leiden mutation, and previous splenectomy). The patient was initially treated with low-molecular-weight heparin followed by long-term apixaban treatment. The literature review together with our case demonstrates that VTE in severe ITP (≤ 35 × 109/L) can occur in patients with VTE risk factors and antithrombotic management of these patients can be achieved without bleeding depending on severity of thrombocytopenia either by full or reduced dose of anticoagulation together with ITP therapy.
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Affiliation(s)
- Mathias Haargaard Nielsen
- Haematology Unit, Department of Internal Medicine, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Mustafa Vakur Bor
- Thrombosis Research, Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
- Thrombosis and Anticoagulation Clinic, Department of Clinical Biochemistry, University Hospital of Southern Denmark, Esbjerg, Denmark
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11
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Mingot-Castellano ME, Canaro Hirnyk M, Sánchez-González B, Álvarez-Román MT, Bárez-García A, Bernardo-Gutiérrez Á, Bernat-Pablo S, Bolaños-Calderón E, Butta-Coll N, Caballero-Navarro G, Caparrós-Miranda IS, Entrena-Ureña L, Fernández-Fuertes LF, García-Frade LJ, Gómez del Castillo MDC, González-López TJ, Grande-García C, Guinea de Castro JM, Jarque-Ramos I, Jiménez-Bárcenas R, López-Ansoar E, Martínez-Carballeira D, Martínez-Robles V, Monteagudo-Montesinos E, Páramo-Fernández JA, Perera-Álvarez MDM, Soto-Ortega I, Valcárcel-Ferreiras D, Pascual-Izquierdo C. Recommendations for the Clinical Approach to Immune Thrombocytopenia: Spanish ITP Working Group (GEPTI). J Clin Med 2023; 12:6422. [PMID: 37892566 PMCID: PMC10607106 DOI: 10.3390/jcm12206422] [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: 09/04/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is a complex autoimmune disease whose hallmark is a deregulation of cellular and humoral immunity leading to increased destruction and reduced production of platelets. The heterogeneity of presentation and clinical course hampers personalized approaches for diagnosis and management. In 2021, the Spanish ITP Group (GEPTI) of the Spanish Society of Hematology and Hemotherapy (SEHH) updated a consensus document that had been launched in 2011. The updated guidelines have been the reference for the diagnosis and management of primary ITP in Spain ever since. Nevertheless, the emergence of new tools and strategies makes it advisable to review them again. For this reason, we have updated the main recommendations appropriately. Our aim is to provide a practical tool to facilitate the integral management of all aspects of primary ITP management.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, 41013 Sevilla, Spain
| | | | | | - María Teresa Álvarez-Román
- Hematology Department, Hospital Universitario La Paz-IdiPAZ, Universidad Autónoma de Madrid, 28046 Madrid, Spain;
| | | | - Ángel Bernardo-Gutiérrez
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - Silvia Bernat-Pablo
- Hematology Department, Hospital Universitario de la Plana, 12540 Villarreal, Spain;
| | | | - Nora Butta-Coll
- Hematology Department, Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), 28046 Madrid, Spain;
| | | | | | - Laura Entrena-Ureña
- Hematology Department, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
| | - Luis Fernando Fernández-Fuertes
- Hematology Department, Complejo Hospitalario Universitario Insular Materno-Infantil, 35016 Las Palmas de Gran Canaria, Spain;
| | - Luis Javier García-Frade
- Hematology Department, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León, 47012 Valladolid, Spain;
| | | | | | | | | | - Isidro Jarque-Ramos
- Hematology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Elsa López-Ansoar
- Hematology Department, Complejo Hospitalario Universitario de Vigo, 36312 Vigo, Spain;
| | | | | | | | | | - María del Mar Perera-Álvarez
- Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, 35010 Las Palmas de Gran Canaria, Spain;
| | - Inmaculada Soto-Ortega
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - David Valcárcel-Ferreiras
- Hematology Department, Vall d’Hebron Instituto de Oncología (VHIO), Universitat Autònoma de Barcelona, 08035 Barcelona, Spain;
| | - Cristina Pascual-Izquierdo
- Hematology Department, Hospital General Universitario Gregorio Marañón (HGUGM) Madrid, Instituto de Investigación Gregorio Marañón, 28007 Madrid, Spain;
- Spanish Immune Thrombocytopenia Group, 28040 Madrid, Spain
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12
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Grover SP, Mackman N, Bendapudi PK. Heat shock protein 47 and venous thrombosis: letting sleeping bears lie. J Thromb Haemost 2023; 21:2648-2652. [PMID: 37473845 DOI: 10.1016/j.jtha.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Steven P Grover
- University of North Carolina Blood Research Center, The University of North Carolina at Chapel Hill, North Carolina, USA; Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, North Carolina, USA.
| | - Nigel Mackman
- University of North Carolina Blood Research Center, The University of North Carolina at Chapel Hill, North Carolina, USA; Division of Hematology, Department of Medicine, The University of North Carolina at Chapel Hill, North Carolina, USA
| | - Pavan K Bendapudi
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Center for the Development of Therapeutics, The Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
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13
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Ollier N, Piel-Julian ML, Mahévas M, Viallard JF, Comont T, Chèze S, Audia S, Ebbo M, Terriou L, Lega JC, Jeandel PY, Bonnotte B, Michel M, Lapeyre-Mestre M, Godeau B, Moulis G. Platelet count threshold for hemorrhage in patients with immune thrombocytopenia treated with antiplatelet agents. Blood 2023; 142:1099-1101. [PMID: 37478400 DOI: 10.1182/blood.2023020311] [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: 03/01/2023] [Revised: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023] Open
Abstract
A significant proportion of older patients with immune thrombocytopenia (ITP) also have clinical indications for treatment of cardiovascular disease with antiplatelet agents. Ollier and colleagues sought to determine the frequency of bleeding in patients with ITP on aspirin therapy, finding that the pattern of bleeding, segregated by platelet count, is similar to that observed in other adults with ITP not on aspirin. They show that a platelet count of <20 × 109/L is associated with most bleeding in ITP patients on antiplatelet agents.
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Affiliation(s)
- Natasha Ollier
- Department of Internal Medicine, Toulouse University Hospital, France
| | | | - Matthieu Mahévas
- Department of Internal Medicine, National Referral Center for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est Créteil University, France
| | | | - Thibault Comont
- Department of Internal Medicine, Toulouse University Institute for Cancer, France
| | - Stéphane Chèze
- Department of Hematology, Caen University Hospital, France
| | - Sylvain Audia
- Department of Internal Medicine, Dijon University Hospital, France
| | - Mikaël Ebbo
- Department of Internal Medicine, Marseille University Hospital, Assistance Publique-Hôpitaux de Marseille, France
| | - Louis Terriou
- Department of Internal Medicine, Lille University Hospital, France
| | - Jean-Christophe Lega
- Department of Internal Medicine, Lyon University Hospital, Hôpitaux Civils de Lyon, France
| | | | - Bernard Bonnotte
- Department of Internal Medicine, Dijon University Hospital, France
| | - Marc Michel
- Department of Internal Medicine, National Referral Center for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est Créteil University, France
| | - Maryse Lapeyre-Mestre
- Clinical Investigation Center 1436, Team PEPSS (PharmacoEpidemiology, Populations, cohortS, biomarkerS), Toulouse University Hospital, France
- Department of Clinical Pharmacology, Toulouse University Hospital, France
| | - Bertrand Godeau
- Department of Internal Medicine, National Referral Center for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est Créteil University, France
| | - Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, France
- Clinical Investigation Center 1436, Team PEPSS (PharmacoEpidemiology, Populations, cohortS, biomarkerS), Toulouse University Hospital, France
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14
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Hendrickson BA, Agarwal A, Bennett D, Kübler J, McShea C, Tremmel L. Value and Implementation of the Aggregate Safety Assessment Plan. Pharmaceut Med 2023; 37:171-181. [PMID: 37072647 DOI: 10.1007/s40290-023-00470-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 04/20/2023]
Abstract
Aggregate safety assessment involves evaluation of the totality of safety data to characterize the emerging safety profile of a product. The Drug Information Association-American Statistical Association Interdisciplinary Safety Evaluation scientific working group recently published an approach to developing an Aggregate Safety Assessment Plan (ASAP). Creation of an ASAP facilitates a consistent approach to safety data collection and analysis across studies and minimizes important missing data at the time of regulatory submission. A critical aspect of the ASAP is identification of the Safety Topics of Interest (STOI). The STOI, as defined in the ASAP, comprises adverse events (AEs), which have the potential to impact the benefit: risk profile of a product and typically require specialized data collection or analyses. While there are clear benefits to developing an ASAP for a drug development program, multiple concerns may be encountered with implementation. This article uses the examples of two STOIs to demonstrate the benefits and efficiencies gained with implementation of the ASAP in safety planning as well as in optimally characterizing the emerging safety profile of a product.
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Affiliation(s)
| | | | - Dimitri Bennett
- Takeda Development Center Americas, Inc., Global Evidence and Outcomes, Cambridge, MA, USA
| | - Jürgen Kübler
- QSciCon, Quantitative Scientific Consulting, Marburg, Germany
| | - Cynthia McShea
- UCB Biosciences, Statistical Science and Innovation, Morrisville, NC, USA
| | - Lothar Tremmel
- CSL Behring, Quantitative Clinical Sciences and Reporting, King of Prussia, PA, USA
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15
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Olivas-Mazón R, Almécija Muñoz A, León JL, Nova Lozano C. Venous sinus thrombosis in a patient with immune thrombocytopenia. An Pediatr (Barc) 2023; 98:241-243. [PMID: 36841675 DOI: 10.1016/j.anpede.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/13/2022] [Indexed: 02/27/2023] Open
Affiliation(s)
- Raquel Olivas-Mazón
- Unidad de Oncohematología Pediátrica, Hospital Clínico Universitario de Valencia, Valencia, Spain.
| | - Ara Almécija Muñoz
- Unidad de Oncohematología Pediátrica, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - José L León
- Departamento de Neurorradiología, Grupo Biomédico Ascires-Universitats, Valencia, Spain
| | - Cristina Nova Lozano
- Unidad de Oncohematología Pediátrica, Hospital Clínico Universitario de Valencia, Valencia, Spain
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16
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Rodeghiero F. Recent progress in ITP treatment. Int J Hematol 2023; 117:316-330. [PMID: 36622549 DOI: 10.1007/s12185-022-03527-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 01/10/2023]
Abstract
In this review, the recently approved drugs avatrombopag and fostamatinib, which were not extensively covered within 2019 international recommendations for ITP, will be discussed in some detail. Avatrombopag appears more convenient than eltrombopag as it does not require dietary restrictions or subcutaneous administration like romiplostim. However, data on quality of life (QoL) are lacking and the rate of thromboembolic events in exposed patients is not negligible. Efficacy of fostamatinib, an inhibitor of macrophagic activity, is supported by placebo-controlled trials in patients refractory to several therapies, including TPO-RA. While hypertension and diarrhea have been reported, only one minor thrombotic event occurred in 146 exposed patients. In addition, several new treatment combinations and new agents entered clinical investigation in recent years. In a UK trial, combining mycophenolate mofetil with corticosteroids as first line therapy was more effective than corticosteroids alone, but at the cost of worse QoL. No combination, including oseltamivir or all-trans retinoic acid or danazol, resulted in convincing evidence of superior efficacy and safety when used in first or later lines of treatment. Agents targeting specific mechanisms are also discussed: sutimlimab (complement inhibitor); rilzabrutinib (BTK inhibitor) and efgartigimod (modified Fc fragment inhibiting FcRn). Only efgartigimod has completed phase 3 investigation.
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Affiliation(s)
- Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Hematology, "S. Bortolo" Hospital, Contrà San Francesco 41, 36100, Vicenza, Italy.
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17
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Crickx E, Mahévas M, Michel M, Godeau B. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging 2023; 18:115-130. [PMID: 36726813 PMCID: PMC9885884 DOI: 10.2147/cia.s369574] [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: 10/26/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
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Affiliation(s)
- Etienne Crickx
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris, Université Paris-Est-Créteil, Paris, France,INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Correspondence: Bertrand Godeau, Service de Médecine Interne, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), 51 avenue du maréchal de Lattre de Tassigny, Créteil, 94000, France, Tel +331 49 81 29 05, Fax +331 49 81 29 02, Email
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18
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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: 9] [Impact Index Per Article: 9.0] [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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19
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Lucchesi A, Fattizzo B, De Stefano V, Ruggeri M, Siragusa S, Vianelli N, Zaja F, Rodeghiero F. Use and positioning of fostamatinib in the management of primary chronic immune thrombocytopenia: an Italian expert opinion. Ther Adv Hematol 2023. [DOI: 10.1177/20406207221147777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
Fostamatinib, a spleen tyrosine kinase (Syk) inhibitor, represents a new therapeutic opportunity for patients with immune thrombocytopenia (ITP) in Europe and Italy. However, the positioning of this drug in patient’s therapeutic sequence is undefined within the most recent international guidelines. The conclusions from a consensus meeting between Italian experts, whose task was to outline the profile of the ideal candidate to receive fostamatinib, are reported here. A modified Delphi methodology was used to achieve shared statements, which were reported in a narrative form. In particular, the panelists examined the strengths and weaknesses of the registration studies in terms of clinical outcomes, the safety profile of fostamatinib, the drug’s impact on the quality of life of patients with chronic ITP, and the potential benefits of its use in the pandemic era. Although the experience with thrombopoietin receptor agonists (TPO-RAs) and the amount of data from real-world studies suggest the preferential use of these drugs as a second-line treatment in most patients, the absence of an increased thrombotic risk in the clinical trials could make fostamatinib a reasonable choice in patients with an increased risk of vascular events. An unstable platelet count during TPO-RAs might also justify a switch to the Syk inhibitor, which is more likely to stabilize the platelet count in responders. Fostamatinib may be preferred to immunosuppressors during the SARS-CoV-2 pandemic, in patients at infectious risk, or in case of contraindication to splenectomy. Finally, the novel mechanism of action makes it an attractive drug in multi-refractory patient.
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Affiliation(s)
- Alessandro Lucchesi
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) ‘Dino Amadori’, Meldola, Italy
| | - Bruno Fattizzo
- Department of Oncology and Onco-Hematology, University of Milan, via Festa del Perdono 7, 20122 Milan, Italy
- SC Ematologia, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valerio De Stefano
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University, Policlinico Universitario ‘A. Gemelli’ IRCCS, Rome, Italy
| | - Marco Ruggeri
- Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo, Palermo, Italy
| | - Nicola Vianelli
- Istituto di Ematologia ‘Seràgnoli’, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Zaja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
- UCO Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
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20
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Swan D, Thachil J. Challenges in managing patients on anticoagulation: Thrombocytopenia, resumption after bleeding and recurrent thrombosis. J R Coll Physicians Edinb 2022; 52:341-349. [PMID: 36317384 DOI: 10.1177/14782715221134720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Prescribing of anticoagulation is increasing worldwide. This is partly reflective of an aging population with cardiovascular comorbidities such as arrhythmias and prosthetic heart valves, alongside improvements in cancer treatments and survival. In this review, we discuss three common challenges faced by clinicians. These concern the management of patients with thrombosis and thrombocytopenia, resumption of anticoagulation in patients with a history of gastrointestinal or intracranial haemorrhage, and how to approach and treat a patient with recurrent thrombosis on anticoagulation. We consider the available evidence including relevant published recommendations and propose practical management suggestions to aid clinicians faced with these dilemmas.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, St James Hospital, Dublin, Ireland
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
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21
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Higuchi T, Hoshi T, Toriyama M, Nakajima A, Haruki K. Infrequent Thrombotic Complications in Japanese Patients with Warm Autoimmune Hemolytic Anemia. Intern Med 2022; 62:1441-1447. [PMID: 36171129 DOI: 10.2169/internalmedicine.0541-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Patients with autoimmune hemolytic anemia (AIHA) are considered to be at an increased risk of thrombosis, and prophylaxis for venous thromboembolism (VTE) is often recommended. However, the occurrence of thrombosis in Asian patients has not been specifically studied. Thrombotic complications and features of Japanese warm AIHA (WAIHA) patients were studied to see if Japanese patients were at an increased risk of thrombosis and should receive prophylaxis for VTE. Patients and Methods Forty-seven consecutive patients with warm WAIHA were retrospectively studied. Twenty-nine patients were diagnosed as primary cases and 18 as secondary cases, and 10 patients were diagnosed with Evans syndrome. Results No patient presented with thrombosis, and over a median observation period of 15 months, 3 patients had ischemic cerebral vascular accidents. However, all three of those patients had other known risks for thrombosis, with only one taking thrombotic prophylaxis. No venous thrombosis occurred in any patients during the follow-up period. There was no mortality associated with thrombosis. D-dimer levels were often elevated in patients with WAIHA, indicating that the coagulation was activated in a considerable number of patients, but not to such a level as to be associated with clinically overt thrombosis. Conclusion Thrombotic complications occur infrequently in Japanese WAIHA patients, and these individuals do not appear to be at a particularly increased risk of thrombosis because of WAIHA. The indication of VTE prophylaxis should be determined individually, considering other risks.
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Affiliation(s)
- Takakazu Higuchi
- Blood Transfusion Department, Dokkyo Medical University Saitama Medical Center, Japan
| | - Takao Hoshi
- Clinical Laboratory, Dokkyo Medical University Saitama Medical Center, Japan
| | - Mitsuru Toriyama
- Blood Transfusion Department, Dokkyo Medical University Saitama Medical Center, Japan
| | - Atsuko Nakajima
- Clinical Laboratory, Dokkyo Medical University Saitama Medical Center, Japan
| | - Kosuke Haruki
- Clinical Laboratory, Dokkyo Medical University Saitama Medical Center, Japan
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22
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Molecular Pathogenesis of Endotheliopathy and Endotheliopathic Syndromes, Leading to Inflammation and Microthrombosis, and Various Hemostatic Clinical Phenotypes Based on "Two-Activation Theory of the Endothelium" and "Two-Path Unifying Theory" of Hemostasis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091311. [PMID: 36143988 PMCID: PMC9504959 DOI: 10.3390/medicina58091311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/05/2022] [Accepted: 09/14/2022] [Indexed: 12/21/2022]
Abstract
Endotheliopathy, according to the “two-activation theory of the endothelium”, can be triggered by the activated complement system in critical illnesses, such as sepsis and polytrauma, leading to two distinctly different molecular dysfunctions: (1) the activation of the inflammatory pathway due to the release of inflammatory cytokines, such as interleukin 6 and tumor necrosis factor-α, and (2) the activation of the microthrombotic pathway due to the exocytosis of hemostatic factors, such as ultra-large von Willebrand factor (ULVWF) multimers and FVIII. The former promotes inflammation, including inflammatory organ syndrome (e.g., myocarditis and encephalitis) and multisystem inflammatory syndrome (e.g., cytokine storm), and the latter provokes endotheliopathy-associated vascular microthrombotic disease (VMTD), orchestrating thrombotic thrombocytopenic purpura (TTP)-like syndrome in arterial endotheliopathy, and immune thrombocytopenic purpura (ITP)-like syndrome in venous endotheliopathy, as well as multiorgan dysfunction syndrome (MODS). Because the endothelium is widely distributed in the entire vascular system, the phenotype manifestations of endotheliopathy are variable depending on the extent and location of the endothelial injury, the cause of the underlying pathology, as well as the genetic factor of the individual. To date, because the terms of many human diseases have been defined based on pathological changes in the organ and/or physiological dysfunction, endotheliopathy has not been denoted as a disease entity. In addition to inflammation, endotheliopathy is characterized by the increased activity of FVIII, overexpressed ULVWF/VWF antigen, and insufficient ADAMTS13 activity, which activates the ULVWF path of hemostasis, leading to consumptive thrombocytopenia and microthrombosis. Endothelial molecular pathogenesis produces the complex syndromes of inflammation, VMTD, and autoimmunity, provoking various endotheliopathic syndromes. The novel conceptual discovery of in vivo hemostasis has opened the door to the understanding of the pathogeneses of many endotheliopathy-associated human diseases. Reviewed are the hemostatic mechanisms, pathogenesis, and diagnostic criteria of endotheliopathy, and identified are some of the endotheliopathic syndromes that are encountered in clinical medicine.
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Thachil J, Carrier M, Lisman T. Anticoagulation in thrombocytopenic patients - Time to rethink? J Thromb Haemost 2022; 20:1951-1956. [PMID: 35716055 DOI: 10.1111/jth.15789] [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: 04/22/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 01/19/2023]
Abstract
One of the difficult clinical situations in the anticoagulation era is how to give these medications to patients with significantly reduced platelet counts. The concern is the heightened bleeding risk, and the current practice is to apply a certain platelet count threshold below which the use of anticoagulant is deemed unsafe. However, this is not an evidence-based approach especially because the thresholds arose from studies in patients with acute leukemia. In this forum article, we discuss the bleeding risk estimation in thrombocytopenic patients when the decreased counts may not be related to marrow underproduction and aim to identify possible markers which can help in this risk estimation beyond platelet counts. We exhort future studies to include a combination of these markers, which may then guide us to administer safe anticoagulation in patients with severe thrombocytopenia.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
| | - Marc Carrier
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ton Lisman
- Department of Surgery, Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere 2022; 6:e750. [PMID: 35924068 PMCID: PMC9281983 DOI: 10.1097/hs9.0000000000000750] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/01/2022] [Indexed: 01/19/2023] Open
Abstract
In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.
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Taweevisit M, Nimitpanya P, Thorner PS. Excessive Subchorionic Fibrinoid Deposition as a Component of Massive Perivillous Fibrin Deposition: A Case With Maternal Immune Thrombocytopenia. Pediatr Dev Pathol 2022; 25:466-469. [PMID: 34989279 DOI: 10.1177/10935266211069331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Maternal floor infarction (MFI) and massive perivillous fibrin deposition (MPFD) are overlapping placental disorders of unknown etiology, associated with adverse obstetric outcome, and a significant risk of recurrence. We describe a 31-year-old mother with asymptomatic thrombocytopenia throughout pregnancy and a positive lupus anticoagulant. She delivered a normal female neonate at term, whose weight was small for gestational age, with a placenta weighing less than the 10th percentile. Placental examination showed MPFD together with excessive subchorionic fibrinoid deposition. The placenta showed diffuse C4d deposition and an immune-mediated reaction was postulated for the pathogenesis of the placental changes. We suggest that excessive subchorionic fibrinoid deposition may be part of the morphologic spectrum of MFI/MPFD.
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Affiliation(s)
- Mana Taweevisit
- Department of Pathology, Faculty of Medicine, 26683Chulalongkorn University, Pathumwan, Thailand.,King Chulalongkorn Memorial Hospital and Thai Red Cross Society, Pathumwan, Thailand
| | - Panachai Nimitpanya
- King Chulalongkorn Memorial Hospital and Thai Red Cross Society, Pathumwan, Thailand.,Department of Obstetrics and Gynecology, Faculty of Medicine, 26683ChulalongkornUniversity, Pathumwan, Thailand
| | - Paul S Thorner
- Department of Pathology, Faculty of Medicine, 26683Chulalongkorn University, Pathumwan, Thailand.,Department of Laboratory Medicine and Pathobiology, 7938University of Toronto, Toronto, ON, Canada
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Olivas-Mazón R, Almécija Muñoz A, León JL, Nova Lozano C. Trombosis de senos venosos en paciente con trombocitopenia inmune. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Celiac Disease and Thrombotic Events: Systematic Review of Published Cases. Nutrients 2022; 14:nu14102162. [PMID: 35631302 PMCID: PMC9144428 DOI: 10.3390/nu14102162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023] Open
Abstract
Extraintestinal manifestations of celiac disease (CD) should be considered, even in patients without typical intestinal symptoms. The aim of our study is to examine the literature regarding the occurrence of thrombotic events in CD, and to synthesize the data from case reports and case series. A systematic review of the literature was conducted by searching the Pub-Med/MEDLINE database, from the date of database inception to January 2022, to identify published cases and case series on this topic, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 55 cases were included in the study. The majority of patients were previously healthy individuals, with no comorbidities. In less than one-third of the cases (30.91%), the diagnosis of CD was established before the onset of thrombosis, while in the remaining cases (34.54%), thrombosis preceded the diagnosis or was diagnosed concomitantly with CD. The most common sites for thrombosis occurrence were hepatic veins (30.91%), while thrombosis of cerebral blood vessels, deep venous thrombosis of lower extremities, and pulmonary thromboembolism were less frequent. Thrombosis was most commonly isolated to one site only (78.18%). In 69.09% of cases (n = 38), some form of anticoagulation, along with a gluten-free diet, was initiated.
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Voigtlaender M, Langer F. Management of Vascular Thrombosis in Patients with Thrombocytopenia. Hamostaseologie 2021; 42:19-28. [PMID: 34933376 DOI: 10.1055/a-1675-7824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Platelets play critical roles in hemostasis and thrombosis. While low platelet counts increase the risk of bleeding, antithrombotic drugs, including anticoagulants and antiplatelet agents, are used to treat thromboembolic events. Thus, the management of thrombosis in patients with low platelet counts is challenging with hardly any evidence available to guide treatment. Recognition of the underlying cause of thrombocytopenia is essential for assessing the bleeding risk and tailoring therapeutic options. A typical clinical scenario is the occurrence of venous thromboembolism (VTE) in cancer patients experiencing transient thrombocytopenia during myelosuppressive chemotherapy. In such patients, the severity of thrombocytopenia, thrombus burden, clinical symptoms, and the timing of VTE relative to thrombocytopenia must be considered. In clinical practice, distinct hematological disorders characterized by low platelet counts and a thrombogenic state require specific diagnostics and treatment. These include the antiphospholipid syndrome, heparin-induced thrombocytopenia (HIT) and (spontaneous) HIT syndromes, disseminated intravascular coagulation, and paroxysmal nocturnal hemoglobinuria.
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Affiliation(s)
- Minna Voigtlaender
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Florian Langer
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
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Abstract
Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a life-threatening complication described after administration of recombinant adenoviral vector encoding the spike protein antigen of Severe Acute Respiratory Syndrome CoronaVirus-2. The syndrome is characterized by platelet consumption and thrombosis. High levels of antibodies to platelet factor 4 (PF4)–polyanion complexes were identified in many patients with VITT by enzyme-linked immunosorbent assay (ELISA). A 64-year-old woman presented with thrombocytopenia, right renal vein thrombosis with renal infarction, right intra-right atrium and intra-right ventricle thrombosis and pulmonary embolism after ChAdOx1-S vaccine administration. ELISA for antibodies to PF4–polyanion complexes tested positive, while functional tests were not. Thrombocytopenia was refractory to intravenous immunoglobulins and corticosteroids. Eltrombopag was introduced and platelet gradually rose to normal values. VITT is a novel complication yet to be understood. The clinical case we reported highlights the difficulties in the management of this disorder and discloses a new potential therapy in refractory conditions.
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Chen F, McDonald V, Newland A. Experts' review: the emerging roles of romiplostim in immune thrombocytopenia (ITP). Expert Opin Biol Ther 2021; 21:1383-1393. [PMID: 34313512 DOI: 10.1080/14712598.2021.1960979] [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: 10/20/2022]
Abstract
INTRODUCTION The management of ITP has in recent years been transformed from reliance on immunosuppressants and splenectomy to targeted therapy with thrombopoietin receptor agonists (TPO-RA) that directly stimulate platelet production in the bone marrow. This has reduced the long-term infective complications and toxicities associated with the use of potent immunosuppressants and splenectomy. The welltolerated romiplostim, itself a novel drug construct called peptibody, has established itself, alongside other TPO-RA as the preferred 2nd line therapy in major international guidelines on treatment of ITP. AREAS COVERED This review summarizes the data from early licensing trials of romiplostim and discusses the real-world experience to date, the unexpected emerging data on treatment-free long-term remission achieved using TPO-RA, and the case for its early introduction in the therapeutic pathway. The emerging risk of thrombosis is also discussed. EXPERT OPINION The use of romiplostim and other TPO-RA will be increasingly brought forward in the management pathway of ITP with the prospect of modifying the long-term outcome of the disease by increasing sustained treatment-free remission. With the prospect of several new targeted therapies been introduced into clinical practice, TPO-RA will likely be a key component of future combination therapies for difficult cases.
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Affiliation(s)
- Frederick Chen
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Vickie McDonald
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry,QMUL, London, UK
| | - Adrian Newland
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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