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Egbaria A, Touma E, Cohen-Abadi M, Bisharat N. The use of splenic embolization in immune thrombocytopenia: A systematic review and meta-analysis. Br J Haematol 2024; 204:1966-1976. [PMID: 38544461 DOI: 10.1111/bjh.19418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 05/15/2024]
Abstract
The effectiveness of splenic embolization (SE) in treating refractory immune thrombocytopenia (ITP) remains uncertain. A systematic literature review was undertaken to assess the effectiveness and safety of SE in treating both paediatric and adult patients with ITP. We conducted an extensive search employing predefined criteria. We extracted platelet counts at baseline and at multiple intervals following SE, along with details of the proportion of embolized spleen parenchyma and the proportion of patients exhibiting complete or partial platelet count responses. We identified nine eligible reports for the analysis of effectiveness (228 patients) and 15 reports for the safety analysis (151 patients). Pooled estimates of complete response (platelet count >100 × 109/L) and overall response (platelet count >30 × 109/L) were 50.1% (95% CI: 38-62.3) and 74.4% (95% CI: 64.9-83.9) respectively. Most studies applied an embolization of at least 60% of the spleen parenchyma. Nearly all the patients suffered from mild adverse events (AEs), 1.3% suffered from serious AEs and one patient died (0.7%). In conclusion, SE resulted in an overall response rate in 74.4% of patients with ITP. However, this finding derives from uncontrolled studies of low to moderate quality.
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Affiliation(s)
- A Egbaria
- Department of Medicine D, Emek Medical Center, Clalit Health Services, Afula, Israel
| | - E Touma
- Department of Medicine D, Emek Medical Center, Clalit Health Services, Afula, Israel
| | - M Cohen-Abadi
- Research Center, Emek Medical Center, Clalit Health Services, Afula, Israel
| | - N Bisharat
- Department of Medicine D, Emek Medical Center, Clalit Health Services, Afula, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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2
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Britto J, Holbrook A, Sun H, Cserti-Gazdewich C, Prokopchuk-Gauk O, Hsia C, Khamisa K, Yenson PR, Sholzberg M, Olney HJ, Shivakumar S, Jones D, Merkeley H, Costello J, Jamula E, Arnold DM. Thrombopoietin Receptor Agonists and Other Second-Line Therapies for Immune Thrombocytopenia: A Narrative Review With a Focus on Drug Access in Canada. CLIN INVEST MED 2024; 47:13-22. [PMID: 38546381 DOI: 10.3138/cim-2024-2569] [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] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) is an autoimmune disease characterized by low platelet counts and increased risk of bleeding. After corticosteroids with or without intravenous immune globulin (first-line treatment), second-line treatment options include rituximab, splenectomy, thrombopoietin receptor agonists (TPO-RAs), and fostamatinib. In Canada, the choice of second-line therapy is influenced by access to medications. The goals of this narrative review are to 1) summarize the evidence for the use of TPO-RAs and other second-line therapies in ITP and 2) highlight differences in public funding criteria for TPO-RAs across provinces and territories in Canada. METHODS We conducted a literature review of second-line therapies for ITP. We solicited information on public funding programs for TPO-RAs in Canada from health care providers, pharmacists, and provincial ministries of health. RESULTS Head-to-head trials involving TPO-RAs, rituximab, splenectomy, and fostamatinib are lacking. There is substantial evidence of effect for TPO-RAs in improving platelet count levels, health-related quality of life, bleeding, and fatigue from placebo-controlled trials and observational studies; however, access to TPO-RAs through provincial funding programs in Canada is variable. Splenectomy failure is a prerequisite for the funding of TPO-RAs in Ontario, Manitoba, and Saskatchewan, but not in Alberta or Quebec. Other provinces either do not have access to public funding or funding is provided on a case-by-case basis. DISCUSSION TPO-RAs are effective second-line therapies for the treatment of ITP; however, access is variable across Canada, which results in health disparities and poor uptake of international treatment guidelines.
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Affiliation(s)
- Joanne Britto
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anne Holbrook
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, McMaster University, Hamilton, Ontario, Canada
| | - Haowei Sun
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Christine Cserti-Gazdewich
- Department of Medicine/Division of Hematology, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Oksana Prokopchuk-Gauk
- Department of Pathology and Lab Medicine, University of Saskatchewan, Saskatchewan Health Authority, Canada
| | - Cyrus Hsia
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Karima Khamisa
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Paul R Yenson
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Michelle Sholzberg
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Harold J Olney
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Sudeep Shivakumar
- Division of Hematology, Nova Scotia Health Authority, Halifax, NS, Canada
| | - David Jones
- Department of Hematology, Eastern Health, Memorial University, Newfoundland & Labrador, Canada
| | - Hayley Merkeley
- Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jacqueline Costello
- Department of Hematology, Eastern Health, Memorial University, Newfoundland & Labrador, Canada
| | - Erin Jamula
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
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3
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Ogbue OD, Bahaj W, Kewan T, Ahmed R, Dima D, Willimas N, Durmaz A, Visconte V, Maskal SM, Gurnari C, Steven R, Maciejewski JP. Splenectomy outcomes in immune cytopenias: Treatment outcomes and determinants of response. J Intern Med 2024; 295:229-241. [PMID: 37953670 DOI: 10.1111/joim.13742] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND Splenectomy is commonly used to treat refractory immune-mediated cytopenia, but there are no established factors that are associated with response to the procedure. OBJECTIVES A cohort study was conducted to evaluate the hematologic and surgical outcomes of splenectomy in adult patients with immune cytopenias and identify preoperative factors associated with response. METHODS Data from the Cleveland Clinic Foundation for 1824 patients aged over 18 who underwent splenectomy from 2002 to 2020 were analyzed. RESULTS The study found that the most common indications for splenectomy were immune thrombocytopenic purpura (ITP) and autoimmune hemolytic anemia, with a median age of 55 years and median time from diagnosis to splenectomy of 11 months. Hematologic response rates were 74% overall, with relapse in 12% of cases. Postsplenectomy discordant diagnoses were present in 13% of patients, associated with higher relapse rates. Surgery-related complications occurred in 12% of cases, whereas only 3% of patients died from disease complications. On univariate analysis, preoperative factors associated with splenectomy treatment failure were ≥3 lines of pharmacologic treatment, whereas isolated thrombocytopenia, primary ITP, and age ≤40 years had a strong association with response. The multivariable regression confirmed that treatment failure with multiple lines of medical therapy was associated with the failure to respond to splenectomy. CONCLUSION Overall, the study demonstrates that splenectomy is an effective treatment option for immune-mediated cytopenias with a low complication rate.
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Affiliation(s)
- Olisaemeka D Ogbue
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Waled Bahaj
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tariq Kewan
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Hematology and Oncology, Yale University, New Haven, Connecticut, USA
| | - Ramsha Ahmed
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Danai Dima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nakisha Willimas
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arda Durmaz
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sara M Maskal
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Rosenblatt Steven
- Department of Hematology and Oncology, Yale University, New Haven, Connecticut, USA
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Foy P, Friedman KD, Michaelis LC. How I diagnose and treat thrombocytopenia in geriatric patients. Blood 2024; 143:214-223. [PMID: 37956435 DOI: 10.1182/blood.2022017634] [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: 10/14/2022] [Revised: 07/31/2023] [Accepted: 08/16/2023] [Indexed: 11/15/2023] Open
Abstract
ABSTRACT Thrombocytopenia in older individuals is a common but diagnostically challenging condition that has variable clinical impact to those who are affected. Diagnostic approach requires evaluation of the preexisting clinical conditions, detailed review of medications, and assessment for disorders that warrant urgent treatment. In this article, we describe a systematic approach to diagnosis of thrombocytopenia and present a schematic review for management strategies. Three clinical scenarios are presented that are relevant for their prevalence and management challenges in an older adult population. The first scenario addresses primary immune thrombocytopenia (ITP) and reviews different treatment options. The second one addresses complications of thrombocytopenia in management of the myelodysplastic syndrome. The last one reviews diagnostic challenges of drug-induced ITP.
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Affiliation(s)
- Patrick Foy
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Laura C Michaelis
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
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5
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Ba-Shammakh SA, Al-Zughali EA, Kalaji ZH, Al-Bourah AM, Al-Shami NA. Clinical Dilemmas in Immune Thrombocytopenic Purpura With Diffuse Alveolar Hemorrhage: Diagnosis, Treatment, and Outcomes. Cureus 2023; 15:e47300. [PMID: 38021484 PMCID: PMC10656495 DOI: 10.7759/cureus.47300] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
This report elucidates a unique case of a 39-year-old female with immune thrombocytopenic purpura (ITP) who developed a rare and severe complication: diffuse alveolar hemorrhage (DAH). Despite initial treatments for ITP, the patient experienced fluctuating platelet (PLT) counts and shortness of breath, which were later identified as symptoms of DAH. An urgent splenectomy improved the patient's platelet counts and overall condition. This case underscores the imperative to recognize DAH as a possible ITP complication, requiring clinicians' vigilance for prompt diagnosis and intervention. The intricate nature of ITP in adults necessitates individualized, patient-centered treatment approaches to enhance outcomes. This report provides invaluable insights into the clinical understanding and management of ITP and its complications through detailed analysis and documentation of the patient's treatment journey.
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Affiliation(s)
- Saleh A Ba-Shammakh
- Department of General Surgery, The Islamic Hospital, Amman, JOR
- Department of General Surgery, Princess Rahma Teaching Hospital, Irbid, JOR
| | | | - Zeina H Kalaji
- Faculty of Medicine, The University of Jordan, Amman, JOR
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6
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Goshua G, Sinha P, Kunst N, Pischel L, Lee AI, Cuker A. Cost-effectiveness of second-line therapies in adults with chronic immune thrombocytopenia. Am J Hematol 2023; 98:122-130. [PMID: 35147241 PMCID: PMC9365880 DOI: 10.1002/ajh.26497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023]
Abstract
Major options for second-line therapy in adults with chronic immune thrombocytopenia (ITP) include splenectomy, rituximab, and thrombopoietin receptor agonists (TRAs). The American Society of Hematology guidelines recommend rituximab over splenectomy, TRAs over rituximab, and splenectomy or TRAs while noting a lack of evidence on the cost-effectiveness of these therapies. Using prospective, observational, and meta-analytic data, we performed the first cost-effectiveness analysis of second-line therapies in chronic ITP, from the perspective of the U.S. health system. Over a 20-year time-horizon, our six-strategy Markov model shows that a strategy incorporating early splenectomy, an approach at odds with current guidelines and clinical practice, is the cost-effective strategy. All four strategies utilizing TRAs in the first or second position cost over $1 million per quality-adjusted life-year, as compared to strategies involving early use of splenectomy and rituximab. In a probabilistic sensitivity analysis, early use of splenectomy and rituximab in either order was favored in 100% of 10 000 iterations. The annual cost of TRAs would have to decrease over 80% to begin to become cost-effective in any early TRA strategy. Our data indicate that effectiveness of early TRA and late TRA strategies is similar with the cost significantly greater with early TRA strategies. Contrary to current practice trends and guidelines, early use of splenectomy and rituximab, rather than TRAs, constitutes cost-effective treatment in adults with chronic ITP.
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Affiliation(s)
- George Goshua
- Section of Hematology, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Pranay Sinha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA
| | - Natalia Kunst
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Lauren Pischel
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Alfred Ian Lee
- Section of Hematology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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7
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Splenectomy of Immune Thrombocytopenic Purpura in the Era of New Medical Therapies: A Retrospective Cohort Study from a Tertiary Cancer Center in Egypt. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00316-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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8
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Park YH, Kim DY, Kim S, Choi YB, Shin DY, Kim JS, Lee WS, Mun YC, Jang JH, Lee JW, Kook H, Party OBOKAAW. Management of immune thrombocytopenia: 2022 update of Korean experts recommendations. Blood Res 2022; 57:20-28. [PMID: 35342042 PMCID: PMC8958378 DOI: 10.5045/br.2022.2022043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 01/19/2023] Open
Abstract
Despite the availability of therapies to treat patients with immune thrombocytopenia (ITP), there is currently little data from randomized trials to assist clinicians in managing patients. The evidence-based guidelines of the Korean Society of Hematology Aplastic Anemia Working Party (KSHAAWP) are intended to support patients and physicians in the management of ITP. Experts from the KSHAAWP discussed and described this guideline according to the current treatment situation for ITP in Korea and finalized the guidelines. The expert panel recommended the management of ITP in adult and pediatric patients with newly diagnosed, persistent, and chronic disease refractory to first-line therapy with minor bleeding. Management approaches include observation and administration of corticosteroids, intravenous immunoglobulin, anti-D immunoglobulin, and thrombopoietin receptor agonists. Currently, evidence supporting strong recommendations for various management approaches is lacking. Therefore, a large focus was placed on shared decision-making, especially regarding second-line treatment.
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Affiliation(s)
- Young Hoon Park
- Division of Hematology-Oncology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Dae-Young Kim
- Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji Univerisity, Seoul, Korea
| | - Seongkoo Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Bae Choi
- Department of Pediatrics, Ajou University School of Medicine, Ajou Univeristy Hospital, Suwon, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Won Sik Lee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Yeung-Chul Mun
- Division of Hematology-Oncology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hoon Kook
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Hwasun, Korea
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9
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Lee JY, Lee JH, Kim SA, Suh KJ, Kim JW, Kim SH, Lee JO, Kim JW, Kim YJ, Lee KW, Kim JH, Lee JS, Bang SM. Treatment patterns of thrombopoietin receptor agonists among adults with primary immune thrombocytopenia: A Korean nationwide population-based study. Thromb Res 2022; 213:114-118. [DOI: 10.1016/j.thromres.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/23/2022] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
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10
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Ozkok S, Kaygusuz Atagunduz I, Kara O, Sezgin A, Ozgumus T, Gecgel F, Firatli Tuglular T, Toptas T. Splenectomy in İmmune Thrombocytopenia: A Retrospective Analysis of 25-Year Follow-up Data from a Tertiary Health Clinic. Indian J Hematol Blood Transfus 2021; 38:516-521. [DOI: 10.1007/s12288-021-01467-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 07/05/2021] [Indexed: 11/24/2022] Open
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11
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Jaime-Pérez JC, Ramos-Dávila EM, Meléndez-Flores JD, Gómez-De León A, Gómez-Almaguer D. Insights on chronic immune thrombocytopenia pathogenesis: A bench to bedside update. Blood Rev 2021; 49:100827. [PMID: 33771403 DOI: 10.1016/j.blre.2021.100827] [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] [Received: 01/21/2021] [Revised: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 12/17/2022]
Abstract
Immune thrombocytopenia (ITP) is a heterogeneous disease with an unpredictable course. Chronicity can develop in up to two-thirds of adults and 20-25% of children, representing a significant burden on patients' quality of life. Despite acceptable responses to treatment, precise etiology and pathophysiology phenomena driving evolution to chronicity remain undefined. We analyzed reported risk factors for chronic ITP and associated them with proposed underlying mechanisms in its pathogenesis, including bone marrow (BM) microenvironment disturbances, clinical features, and immunological markers. Their understanding has diagnostic implications, such as screening for the presence of specific antibodies or BM examination employing molecular tools, which could help predict prognosis and recognize main pathogenic pathways in each patient. Identifying these underlying mechanisms could guide the use of personalized therapies such as all-trans retinoic acid, mTor inhibitors, FcRn inhibitors, oseltamivir, and others. Further research should lead to tailored treatments and chronic course prevention, improving patients' quality of life.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico.
| | - Eugenia M Ramos-Dávila
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Jesús D Meléndez-Flores
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Andrés Gómez-De León
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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12
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Avila ML, Amiri N, Pullenayegum E, Blanchette V, Imbach P, Kühne T. Long-term outcomes after splenectomy in children with immune thrombocytopenia: an update on the registry data from the Intercontinental Cooperative ITP Study Group. Haematologica 2020; 105:2682-2685. [PMID: 33131262 PMCID: PMC7604652 DOI: 10.3324/haematol.2019.236737] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Maria L. Avila
- Department of Pediatrics, University of Toronto, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nour Amiri
- Department of Pediatrics, University of Toronto, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eleanor Pullenayegum
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Victor Blanchette
- Department of Pediatrics, University of Toronto, Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Imbach
- Medical Faculty, University of Basel, Switzerland
| | - Thomas Kühne
- UKBB Universitäts-Kinderspital, Oncology/Hematology, Basel, Switzerland
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13
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American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv 2020; 3:3829-3866. [PMID: 31794604 DOI: 10.1182/bloodadvances.2019000966] [Citation(s) in RCA: 659] [Impact Index Per Article: 164.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/21/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Despite an increase in the number of therapies available to treat patients with immune thrombocytopenia (ITP), there are minimal data from randomized trials to assist physicians with the management of patients. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the management of ITP. METHODS In 2015, ASH formed a multidisciplinary guideline panel that included 8 adult clinical experts, 5 pediatric clinical experts, 2 methodologists with expertise in ITP, and 2 patient representatives. The panel was balanced to minimize potential bias from conflicts of interest. The panel reviewed the ASH 2011 guideline recommendations and prioritized questions. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence (up to May 2017) and formulate recommendations. RESULTS The panel agreed on 21 recommendations covering management of ITP in adults and children with newly diagnosed, persistent, and chronic disease refractory to first-line therapy who have non-life-threatening bleeding. Management approaches included: observation, corticosteroids, IV immunoglobulin, anti-D immunoglobulin, rituximab, splenectomy, and thrombopoietin receptor agonists. CONCLUSIONS There was a lack of evidence to support strong recommendations for various management approaches. In general, strategies that avoided medication side effects were favored. A large focus was placed on shared decision-making, especially with regard to second-line therapy. Future research should apply standard corticosteroid-dosing regimens, report patient-reported outcomes, and include cost-analysis evaluations.
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14
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Retrospective Analysis of Patients with Immune Thrombocytopenic Purpura. JOURNAL OF CONTEMPORARY MEDICINE 2020. [DOI: 10.16899/jcm.734474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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Cirasino L, Robino AM, Podda G, Andrès E, Despotovic JM, Elalfy M, Holbro A, Kondo T, Lambert MP, Loggetto SR, McCrae KR, Lee JW, Cattaneo M. Report of a 'consensus' on the lines of therapy for primary immune thrombocytopenia in adults, promoted by the Italian Gruppo di Studio delle Piastrine. Platelets 2020; 31:461-473. [PMID: 32314933 DOI: 10.1080/09537104.2020.1751105] [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: 01/23/2023]
Abstract
Despite the publication in 2009 of a paper on 'terms and definitions of immune thrombocytopenia' (ITP), some unresolved issues remain and are reflected by the disagreement in the treatment suggested for primary ITP in adults. Considering that these disagreements could be ascribed to non-shared goals, we generated a 'consensus' on some terms, definitions, and assertions useful for classifying the different lines of treatment for primary ITP in adults according to their indications and goals. Agreement on the appropriateness of the single assertions was obtained by consensus for the following indicators: 1. classification of four 'lines of therapy'; 2. acceptance of the expression 'sequences of disease' for the indications of the respective four lines of treatment; 3I . practicability of splenectomy; 3Ib . acceptance, with only some exceptions, of a 'timing for elective splenectomy of 12 months'; and 4a-d . 'goals of the four lines of therapy.' On the basis of the consensus, a classification of four lines of treatment for primary ITP in adults was produced. In our opinion, this classification, whose validity is not influenced by the recently published new guidelines of the American Society of Hematology (ASH) and reviews, could reduce the disagreement that still exists regarding the treatment of the disease.
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Affiliation(s)
| | - Anna M Robino
- Medicina B3, Ospedale Niguarda Ca' Granda , Milano, Italy
| | - GianMarco Podda
- Medicina 2 ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano , Milano, Italy
| | - Emmanuel Andrès
- Clinique Médicale B Hôpitaux Universitaires de Strasbourg (HUS) , Strasbourg, France
| | | | - Mohsen Elalfy
- Faculty of Medicine, Ain Shams University Hospitals Cairo , Egypt
| | - Andreas Holbro
- Blood Transfusion Center SRC and Hematology, University Hospital Basel, Swiss Red Cross , Basel, Switzerland
| | - Tadakazu Kondo
- Department of Hematology/Oncology, Graduate School of Medicine, Kyoto University , Kyoto, Japan
| | - Michele P Lambert
- The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA, USA
| | - Sandra R Loggetto
- Department of Pediatric Hematology, Sabara Pediatric Hospital , Sao Paulo, Brazil
| | - Keith R McCrae
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic Lerner College of Medicine , Cleveland, OH, USA
| | - Jong Wook Lee
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, the Catholic University of Korea , Seoul, Korea
| | - Marco Cattaneo
- Medicina 2 ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano , Milano, Italy
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16
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Abstract
PURPOSE OF REVIEW Medical therapies for the treatment of immune thrombocytopenia (ITP) complicating SLE are increasingly being investigated as alternatives to splenectomy and IVIG. The purpose of this review is to highlight the therapies that are utilized in the treatment of primary ITP and ITP secondary to lupus. RECENT FINDINGS Corticosteroids are still the standard initial treatment of ITP, with the addition of IVIG when a rapid response is needed. There are few studies dedicated to assessing the efficacy of disease-modifying antirheumatic (DMARD), biologic, and nonimmunosuppressive agents as treatment for lupus thrombocytopenia/lupus ITP. Rituximab and thrombopoeitin mimetics have been the most extensively studied therapies for primary ITP in recent years. Results of trials show adequate initial responses; however, the duration of therapy and sustainability of responses are variable. Splenectomy is less often utilized. SUMMARY Although corticosteroids, intravenous immunoglobulin and splenectomy have proven to be effective measures to treat immune thrombocytopenia, newer studies have demonstrated positive outcomes of immunosuppressives and thrombopoeitin mimetics. In most cases, the reported duration of therapy was not prolonged. More studies are needed to fully assess the effect of medical therapy in lupus ITP and to determine how long to continue maintenance therapy.
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17
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Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, Ghanima W, Godeau B, González-López TJ, Grainger J, Hou M, Kruse C, McDonald V, Michel M, Newland AC, Pavord S, Rodeghiero F, Scully M, Tomiyama Y, Wong RS, Zaja F, Kuter DJ. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv 2019; 3:3780-3817. [PMID: 31770441 PMCID: PMC6880896 DOI: 10.1182/bloodadvances.2019000812] [Citation(s) in RCA: 572] [Impact Index Per Article: 114.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/18/2019] [Indexed: 01/19/2023] Open
Abstract
Over the last decade, there have been numerous developments and changes in treatment practices for the management of patients with immune thrombocytopenia (ITP). This article is an update of the International Consensus Report published in 2010. A critical review was performed to identify all relevant articles published between 2009 and 2018. An expert panel screened, reviewed, and graded the studies and formulated the updated consensus recommendations based on the new data. The final document provides consensus recommendations on the diagnosis and management of ITP in adults, during pregnancy, and in children, as well as quality-of-life considerations.
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Affiliation(s)
- Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University and Canadian Blood Services, Hamilton, ON, Canada
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Beng H Chong
- St. George Hospital, NSW Health Pathology, University of New South Wales, Sydney, NSW, Australia
| | - Nichola Cooper
- Department of Haematology, Hammersmith Hospital, London, United Kingdom
| | | | - Waleed Ghanima
- Departments of Research, Medicine and Oncology, Østfold Hospital Trust, Grålum, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Bertrand Godeau
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | | | - John Grainger
- Department of Haematology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Ming Hou
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, China
| | | | - Vickie McDonald
- Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Marc Michel
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Adrian C Newland
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sue Pavord
- Haematology Theme Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, United Kingdom
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Osaka, Japan
| | - Raymond S Wong
- Sir YK Pao Centre for Cancer and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy; and
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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18
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Samson M, Fraser W, Lebowitz D. Treatments for Primary Immune Thrombocytopenia: A Review. Cureus 2019; 11:e5849. [PMID: 31754584 PMCID: PMC6830854 DOI: 10.7759/cureus.5849] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/04/2019] [Indexed: 01/02/2023] Open
Abstract
Immune thrombocytopenic purpura (ITP) is an autoimmune condition that affects nearly 1:10,000 people in the world. It is traditionally defined by a platelet count of less than 100 x 109L, but treatment typically depends on symptomology rather than on the platelet count itself. For primary idiopathic ITP, corticosteroids have been the standard first-line of treatment for symptomatic patients, with the addition of intravenous immune globulin (IVIG) or Rho(D) immune globulin (anti-RhD) for steroid-resistant cases. In cases of refractory or non-responsive ITP, second-line therapy includes splenectomy or rituximab, a monoclonal antibody against the CD20 antigen (anti-CD20). In patients who continue to have severe thrombocytopenia and symptomatic bleeding despite first- and second-line treatments, the diagnosis of "chronic refractory ITP" is appropriate, and third-line treatments are evaluated. This manuscript describes the efficacy of different treatment options for primary ITP and introduces the reader to various third-line options that are emerging as a means of treating chronic refractory ITP.
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Affiliation(s)
- Margot Samson
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - William Fraser
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - David Lebowitz
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
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19
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Lucchini E, Fanin R, Cooper N, Zaja F. Management of immune thrombocytopenia in elderly patients. Eur J Intern Med 2018; 58:70-76. [PMID: 30274902 DOI: 10.1016/j.ejim.2018.09.005] [Citation(s) in RCA: 6] [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: 06/29/2018] [Revised: 07/08/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Abstract
Despite the improvement in understanding its pathogenesis and the introduction of novel treatment options, the management of primary immune thrombocytopenia (ITP) still remains challenging. Considering its increased incidence with aging and prolonged life-expectancy, ITP is often diagnosed in elderly patients, a subset that deserves some special precautions. Ensure the diagnosis is a crucial step, and carefully attention must be given in excluding other causes of thrombocytopenia, especially among older people that frequently suffer from many comorbidities. When it comes to treatment decision, it is worth keeping into account that the elderly have an increased risk of bleeding, thrombosis and infections, that they often require many concomitant therapies, including antiplatelet or anticoagulant agents, and that treatment-related toxicities are often increased and sometimes more dangerous that the disease itself. There are not dedicated guidelines, and only few specific studies. Steroids with or without IVIG remain the first-line treatment. Splenectomy is less effective than in youngers and burdened by an increased thrombotic and infectious risk. Rituximab is a good option in non-immunocompromised patients, but long-term remissions are few. Eltrombopag and romiplostim have a good safety and efficacy profile, and have become a prominent drug in this subset, even if they are associated with a possible increased risk of thrombosis, and long-term toxicity is unknown. Other drugs, such as dapsone and danazol, have a well-known efficacy and safety profile, and still represent a valid option among elderly patients.
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Affiliation(s)
- Elisa Lucchini
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy.
| | - Renato Fanin
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy
| | | | - Francesco Zaja
- S.C. Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
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20
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Neunert CE, Cooper N. Evidence-based management of immune thrombocytopenia: ASH guideline update. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:568-575. [PMID: 30504359 PMCID: PMC6245979 DOI: 10.1182/asheducation-2018.1.568] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In 1996 and 2011, the American Society of Hematology (ASH) supported efforts to create guidelines for the diagnosis and management of patients with immune thrombocytopenia (ITP). These guidelines used different approaches to arrive at recommendations for testing and treatment. Despite differences in methodology, in both cases there was a paucity of randomized trials to inform recommendations. As data on the diagnosis and management of ITP expands, the ASH Committee on Quality is dedicated to maintaining updated guidelines representing recent evidence and guideline methodology. Here, we will review the updated ASH guidelines on ITP with a focus on recommendations with new understanding and future research to close knowledge gaps.
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Affiliation(s)
- Cindy E Neunert
- Department of Pediatrics, Columbia University Medical Center, New York, NY; and
| | - Nichola Cooper
- Imperial College Health Care NHS Trust, Hammersmith Hospital, London, UK
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21
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Tastaldi L, Krpata DM, Prabhu AS, Petro CC, Haskins IN, Perez AJ, Alkhatib H, Colturato I, Tu C, Lichtin A, Rosen MJ, Rosenblatt S. Laparoscopic splenectomy for immune thrombocytopenia (ITP): long-term outcomes of a modern cohort. Surg Endosc 2018; 33:475-485. [DOI: 10.1007/s00464-018-6321-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/29/2018] [Indexed: 01/19/2023]
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22
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Kühne T. Advances in chemical pharmacotherapy for the treatment of pediatric immune thrombocytopenia. Expert Opin Pharmacother 2018; 19:667-676. [PMID: 29589486 DOI: 10.1080/14656566.2018.1458091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder of heterogeneous pathophysiological mechanisms. Treatment endpoints include elevation of platelets and reduction of bleeding risk, elevation of quality of life, reduction of concomitant therapies and prevention from bleeding. Persistent and chronic ITP is more common in adults but occurs in children. Standard therapies include corticosteroids and immunoglobulins, both associated with side effects. There are new treatments, such as thrombopoietin-receptor agonists and promising investigational drugs. AREAS COVERED Experience from the management of adults is valuable for children with persistent and chronic symptomatic ITP. In this review first- and second-line therapies, but also investigational drugs for children with ITP are discussed. EXPERT OPINION Although time-consuming and based on experience, children with no or mild bleeding can be safely managed with a watch and wait strategy. Chronic symptomatic immune thrombocytopenia is an area of second-line treatments based on a highly individualized approach. Furthermore, there are investigational drugs, which may also be of benefit for children with chronic symptomatic ITP.
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Affiliation(s)
- Thomas Kühne
- a Division of Oncology/Hematology , University Children's Hospital , Basel , Switzerland
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23
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Rodeghiero F. A critical appraisal of the evidence for the role of splenectomy in adults and children with ITP. Br J Haematol 2018; 181:183-195. [DOI: 10.1111/bjh.15090] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Francesco Rodeghiero
- Haematology Project Foundation; Affiliated to the Department of Cell Therapy and Haematology; S. Bortolo Hospital; Vicenza Italy
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24
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Abstract
There are numerous congenital and acquired causes of thrombocytopenia. Thrombocytopenia could be a result of decreased bone marrow production, increased consumption, increased destruction, splenic sequestration or a combination of these causes. In this review, we have focused on some of the serious acquired causes of thrombocytopenia. There have been some significant advances in our understanding of the pathophysiology, diagnostic testing, and treatment of immune thrombocytopenia, heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, and atypical hemolytic uremic syndrome over the past five years. These advances have resulted in a significant decrease in mortality and morbidity of patients with these disorders. Despite these advances, we are still faced with numerous unanswered questions in the pathophysiology and management of these complex thrombocytopenic disorders.
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Affiliation(s)
- Srikanth Nagalla
- Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Ravindra Sarode
- Division of Transfusion Medicine and Hemostasis, Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
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25
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Splenectomy for immune thrombocytopenia: down but not out. Blood 2018; 131:1172-1182. [PMID: 29295846 DOI: 10.1182/blood-2017-09-742353] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/29/2017] [Indexed: 01/19/2023] Open
Abstract
Splenectomy is an effective therapy for steroid-refractory or dependent immune thrombocytopenia (ITP). With the advent of medical alternatives such as rituximab and thrombopoietin receptor antagonists, the use of splenectomy has declined and is generally reserved for patients that fail multiple medical therapies. Splenectomy removes the primary site of platelet clearance and autoantibody production and offers the highest rate of durable response (50% to 70%) compared with other ITP therapies. However, there are no reliable predictors of splenectomy response, and long-term risks of infection and cardiovascular complications must be considered. Because the long-term efficacy of different second-line medical therapies for ITP have not been directly compared, treatment decisions must be made without supportive evidence. Splenectomy continues to be a reasonable treatment option for many patients, including those with an active lifestyle who desire freedom from medication and monitoring, and patients with fulminant ITP that does not respond well to medical therapy. We try to avoid splenectomy within the first 12 months after ITP diagnosis for most patients to allow for spontaneous or therapy-induced remissions, particularly in older patients who have increased surgical morbidity and lower rates of response, and in young children. Treatment decisions must be individualized based on patients' comorbidities, lifestyles, and preferences. Future research should focus on comparing long-term outcomes of patients treated with different second-line therapies and on developing personalized medicine approaches to identify subsets of patients most likely to respond to splenectomy or other therapeutic approaches.
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26
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Jang JH, Kim JY, Mun YC, Bang SM, Lim YJ, Shin DY, Choi YB, Yhim HY, Lee JW, Kook H. Management of immune thrombocytopenia: Korean experts recommendation in 2017. Blood Res 2017; 52:254-263. [PMID: 29333401 PMCID: PMC5762735 DOI: 10.5045/br.2017.52.4.254] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/03/2017] [Accepted: 12/13/2017] [Indexed: 12/31/2022] Open
Abstract
Management options for patients with immune thrombocytopenia (ITP) have evolved substantially over the past decades. The American Society of Hematology published a treatment guideline for clinicians referring to the management of ITP in 2011. This evidence-based practice guideline for ITP enables the appropriate treatment of a larger proportion of patients and the maintenance of normal platelet counts. Korean authority operates a unified mandatory national health insurance system. Even though we have a uniform standard guideline enforced by insurance reimbursement, there are several unsolved issues in real practice in ITP treatment. To optimize the management of Korean ITP patients, the Korean Society of Hematology Aplastic Anemia Working Party (KSHAAWP) reviewed the consensus and the Korean data on the clinical practices of ITP therapy. Here, we report a Korean expert recommendation guide for the management of ITP.
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Affiliation(s)
- Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Yoon Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yeung-Chul Mun
- Department of Internal Medicine, Ewha Womans' University School of Medicine, Seoul, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeon Jung Lim
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Korea
| | - Young Bae Choi
- Department of Pediatrics, Chung-Ang University Hospital, Seoul, Korea
| | - Ho-Young Yhim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hoon Kook
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Hwasun, Korea
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27
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Safety and efficacy of long-term treatment of chronic/persistent ITP with eltrombopag: final results of the EXTEND study. Blood 2017; 130:2527-2536. [PMID: 29042367 DOI: 10.1182/blood-2017-04-748707] [Citation(s) in RCA: 201] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 10/04/2017] [Indexed: 01/19/2023] Open
Abstract
In phase 2/3 trials, eltrombopag treatment of 6 months or less in patients with chronic/persistent immune thrombocytopenia (ITP) increased platelet counts and reduced bleeding. The open-label EXTEND study evaluated long-term safety and efficacy of eltrombopag in adults with ITP who had completed a previous eltrombopag study. For the 302 patients enrolled, median duration of eltrombopag treatment was 2.37 years (2 days-8.76 years). Median platelet counts increased to 50 × 109/L or more by week 2 and were sustained throughout the treatment period. Overall, 259 patients (85.8%) achieved a response (platelet count ≥50 × 109/L at least once in the absence of rescue), and 133 (52%) of 257 patients achieved a continuous response of 25 weeks or longer. Responses in patients with platelet counts lower than 15 × 109/L, more previous therapies, and/or splenectomy were somewhat lower. Thirty-four (34%) of 101 patients receiving concomitant ITP medication discontinued 1 or more medication. In patients with assessments, bleeding symptoms (World Health Organization grades 1-4) decreased from 57% at baseline to 16% at 1 year. Forty-one patients (14%) withdrew because of adverse events. Hepatobiliary adverse events (n = 7), cataracts (n = 4), deep vein thrombosis (n = 3), cerebral infarction (n = 2), headache (n = 2), and myelofibrosis (n = 2) occurred in more than 1 patient; the remaining adverse events occurred only once. Rates of thromboembolic events (6%) and hepatobiliary adverse events (15%) did not increase with treatment duration past 1 year. EXTEND demonstrated that long-term use of eltrombopag was effective in maintaining platelet counts of 50 × 109/L or more and reducing bleeding in most patients with ITP of more than 6 months' duration. Important adverse events (eg, thrombosis, hepatobiliary, and bone marrow fibrosis) were infrequent. (ClinicalTrials.gov:NCT00351468).
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28
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Lambert MP, Gernsheimer TB. Clinical updates in adult immune thrombocytopenia. Blood 2017; 129:2829-2835. [PMID: 28416506 PMCID: PMC5813736 DOI: 10.1182/blood-2017-03-754119] [Citation(s) in RCA: 259] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/10/2017] [Indexed: 12/25/2022] Open
Abstract
Immune thrombocytopenia (ITP) occurs in 2 to 4/100 000 adults and results in variable bleeding symptoms and thrombocytopenia. In the last decade, changes in our understanding of the pathophysiology of the disorder have led to the publication of new guidelines for the diagnosis and management of ITP and standards for terminology. Current evidence supports alternatives to splenectomy for second-line management of patients with persistently low platelet counts and bleeding. Long-term follow-up data suggest both efficacy and safety, in particular, for the thrombopoietin receptor agonists and the occurrence of late remissions. Follow-up of patients who have undergone splenectomy for ITP reveals significant potential risks that should be discussed with patients and may influence clinician and patient choice of second-line therapy. Novel therapeutics are in development to address ongoing treatment gaps.
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MESH Headings
- Adult
- Female
- Hemorrhage/blood
- Hemorrhage/diagnosis
- Hemorrhage/physiopathology
- Hemorrhage/therapy
- Humans
- Male
- Platelet Count
- Practice Guidelines as Topic
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/physiopathology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Receptors, Thrombopoietin/agonists
- Receptors, Thrombopoietin/metabolism
- Splenectomy
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Affiliation(s)
- Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA; and
| | - Terry B Gernsheimer
- Division of Hematology, University of Washington School of Medicine, Seattle, WA
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29
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Zufferey A, Kapur R, Semple JW. Pathogenesis and Therapeutic Mechanisms in Immune Thrombocytopenia (ITP). J Clin Med 2017; 6:jcm6020016. [PMID: 28208757 PMCID: PMC5332920 DOI: 10.3390/jcm6020016] [Citation(s) in RCA: 295] [Impact Index Per Article: 42.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/04/2017] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is a complex autoimmune disease characterized by low platelet counts. The pathogenesis of ITP remains unclear although both antibody-mediated and/or T cell-mediated platelet destruction are key processes. In addition, impairment of T cells, cytokine imbalances, and the contribution of the bone marrow niche have now been recognized to be important. Treatment strategies are aimed at the restoration of platelet counts compatible with adequate hemostasis rather than achieving physiological platelet counts. The first line treatments focus on the inhibition of autoantibody production and platelet degradation, whereas second-line treatments include immunosuppressive drugs, such as Rituximab, and splenectomy. Finally, third-line treatments aim to stimulate platelet production by megakaryocytes. This review discusses the pathophysiology of ITP and how the different treatment modalities affect the pathogenic mechanisms.
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Affiliation(s)
- Anne Zufferey
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- The Toronto Platelet Immunobiology Group, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
| | - Rick Kapur
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- The Toronto Platelet Immunobiology Group, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- Canadian Blood Services, Toronto, ON M5B 1W8, Canada.
| | - John W Semple
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- The Toronto Platelet Immunobiology Group, St. Michael's Hospital, Toronto, ON M5B 1W8, Canada.
- Canadian Blood Services, Toronto, ON M5B 1W8, Canada.
- Department of Pharmacology, Medicine, and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5B 1W8, Canada.
- Division of Hematology and Transfusion Medicine, Lund University, 221 84 Lund, Sweden.
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