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Shimano KA, Grace RF, Despotovic JM, Neufeld EJ, Klaassen RJ, Bennett CM, Ma C, London WB, Neunert C. Phase 3 randomised trial of eltrombopag versus standard first-line pharmacological management for newly diagnosed immune thrombocytopaenia (ITP) in children: study protocol. BMJ Open 2021; 11:e044885. [PMID: 34452956 PMCID: PMC8404450 DOI: 10.1136/bmjopen-2020-044885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 08/06/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Immune thrombocytopaenia (ITP) is an acquired disorder of low platelets and risk of bleeding. Although many children can be observed until spontaneous remission, others require treatment due to bleeding or impact on health-related quality of life. Standard first-line therapies for those who need intervention include corticosteroids, intravenous immunoglobulin and anti-D globulin, though response to these agents may be only transient. Eltrombopag is an oral thrombopoietin receptor agonist approved for children with chronic ITP who have had an insufficient response to corticosteroids, intravenous immunoglobulin or splenectomy. This protocol paper describes an ongoing open-label, randomised trial comparing eltrombopag to standard first-line management in children with newly diagnosed ITP. METHODS AND ANALYSIS Randomised treatment assignment is 2:1 for eltrombopag versus standard first-line management and is stratified by age and by prior treatment. The primary endpoint of the study is platelet response, defined as ≥3 of 4 weeks with platelets >50×109/L during weeks 6-12 of therapy. Secondary outcomes include number of rescue therapies needed during the first 12 weeks, proportion of patients who do not need ongoing treatment at 12 weeks and 6 months, proportion of patients with a treatment response at 1 year, and number of second-line therapies used in weeks 13-52, as well as changes in regulatory T cells, iron studies, bleeding, health-related quality of life and fatigue. A planned sample size of up to 162 randomised paediatric patients will be enrolled over 2 years at 20 sites. ETHICS AND DISSEMINATION The study has been approved by the centralised Baylor University Institutional Review Board. The results are expected to be published in 2023. TRIAL REGISTRATION NUMBER NCT03939637.
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Affiliation(s)
- Kristin A Shimano
- UCSF Benioff Children's Hospital, San Francisco, California, USA
- Pediatrics, UCSF, San Francisco, California, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Jenny M Despotovic
- Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Ellis J Neufeld
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Carolyn M Bennett
- Pediatrics, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Wendy B London
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Biostatistics, Harvard Medical School, Boston, Massachusetts, USA
| | - Cindy Neunert
- Pediatrics, Columbia University Medical School, New York, New York, USA
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2
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Crow AR, Kapur R, Koernig S, Campbell IK, Jen CC, Mott PJ, Marjoram D, Khan R, Kim M, Brasseit J, Cruz-Leal Y, Amash A, Kahlon S, Yougbare I, Ni H, Zuercher AW, Käsermann F, Semple JW, Lazarus AH. Treating murine inflammatory diseases with an anti-erythrocyte antibody. Sci Transl Med 2020; 11:11/506/eaau8217. [PMID: 31434758 DOI: 10.1126/scitranslmed.aau8217] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 02/08/2019] [Accepted: 07/11/2019] [Indexed: 12/13/2022]
Abstract
Treatment of autoimmune and inflammatory diseases typically involves immune suppression. In an opposite strategy, we show that administration of the highly inflammatory erythrocyte-specific antibody Ter119 into mice remodels the monocyte cellular landscape, leading to resolution of inflammatory disease. Ter119 with intact Fc function was unexpectedly therapeutic in the K/BxN serum transfer model of arthritis. Similarly, it rapidly reversed clinical disease progression in collagen antibody-induced arthritis (CAIA) and collagen-induced arthritis and completely corrected CAIA-induced increase in monocyte Fcγ receptor II/III expression. Ter119 dose-dependently induced plasma chemokines CCL2, CCL5, CXCL9, CXCL10, and CCL11 with corresponding alterations in monocyte percentages in the blood and liver within 24 hours. Ter119 attenuated chemokine production from the synovial fluid and prevented the accumulation of inflammatory cells and complement components in the synovium. Ter119 could also accelerate the resolution of hypothermia and pulmonary edema in an acute lung injury model. We conclude that this inflammatory anti-erythrocyte antibody simultaneously triggers a highly efficient anti-inflammatory effect with broad therapeutic potential.
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Affiliation(s)
- Andrew R Crow
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Rick Kapur
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada.,Department of Hematology and Transfusion Medicine, Lund University, Lund 221 84, Sweden.,Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, 1066 CX Amsterdam, Netherlands
| | - Sandra Koernig
- CSL Limited, Bio21 Institute, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Ian K Campbell
- CSL Limited, Bio21 Institute, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Chao-Ching Jen
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Patrick J Mott
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Danielle Marjoram
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Ramsha Khan
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Michael Kim
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Jennifer Brasseit
- CSL Behring, Research, CSL Biologics Research Center, Bern, Switzerland
| | - Yoelys Cruz-Leal
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Alaa Amash
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Simrat Kahlon
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Issaka Yougbare
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Heyu Ni
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada.,Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Adrian W Zuercher
- CSL Behring, Research, CSL Biologics Research Center, Bern, Switzerland
| | - Fabian Käsermann
- CSL Behring, Research, CSL Biologics Research Center, Bern, Switzerland
| | - John W Semple
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada.,Department of Hematology and Transfusion Medicine, Lund University, Lund 221 84, Sweden.,Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada.,Department of Pharmacology, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Alan H Lazarus
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada. .,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada.,Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada
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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: 549] [Impact Index Per Article: 109.8] [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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4
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Yildiz I, Ozdemir N, Celkan T, Soylu S, Karaman S, Canbolat A, Dogru O, Erginoz E, Apak H. Initial Management of Childhood Acute Immune Thrombocytopenia: Single-Center Experience of 32 Years. Pediatr Hematol Oncol 2016; 32:406-14. [PMID: 26154620 DOI: 10.3109/08880018.2015.1040931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an acute self-limited disease of childhood, mostly resolving within 6 months irrespective of whether therapy is given or not. Treatment options when indicated include corticosteroids, intravenous immune globulin (IVIG), and anti-RhD immunoglobulin. We reviewed our 32 years' experience for first-line therapy of acute ITP. Five hundred forty-one children (mean age: 5.3 years) diagnosed and treated for ITP were evaluated retrospectively. Among 491 acute ITP patients, IVIG was used in 27%, high-dose steroids in 27%, low-dose steroids in 20%, anti-D immunoglobulin G (IgG) in 2%, and no therapy in 22%. When the initial response (platelets >50 × 10(9)/L) to first-line treatment modalities were compared, 89%, 84%, and 78% patients treated by low-dose steroids, high-dose steroids, and IVIG responded to treatment, respectively (P > .05). Mean time to recovery of platelets was 16.8, 3.8, and 3.0 days in patients treated with low-dose steroids, high-dose steroids, and IVIG, respectively (P < .0001). Thrombocytopenia recurred in 23% of low-dose steroid, 39% of high-dose steroid, and in 36% of IVIG (P < .0001) treatment groups. Of 108 patients who were observed alone, 4 (3%) had a recurrence on follow-up and only 2 of these required treatment subsequently. Recurrence was significantly less in no therapy group compared with children treated with 1 of the 3 options of pharmacotherapy (P < .0001). Response rates were similar between patients treated by IVIG and low- and high-dose steroids; however, time to response was slower in patients treated with low-dose steroids compared with IVIG and high-dose steroids.
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Affiliation(s)
- Inci Yildiz
- a Department of Pediatric Hematology-Oncology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Nihal Ozdemir
- a Department of Pediatric Hematology-Oncology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Tiraje Celkan
- a Department of Pediatric Hematology-Oncology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Selen Soylu
- a Department of Pediatric Hematology-Oncology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Serap Karaman
- a Department of Pediatric Hematology-Oncology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Aylin Canbolat
- a Department of Pediatric Hematology-Oncology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Omer Dogru
- a Department of Pediatric Hematology-Oncology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Ethem Erginoz
- b Department of Public Health, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
| | - Hilmi Apak
- a Department of Pediatric Hematology-Oncology, Cerrahpasa Medical Faculty , Istanbul University , Istanbul , Turkey
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5
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Eghbali A, Azadmanesh P, Bagheri B, Taherahmadi H, Sadeghi Sedeh B. Comparison between IV immune globulin (IVIG) and anti-D globulin for treatment of immune thrombocytopenia: a randomized open-label study. Fundam Clin Pharmacol 2016; 30:385-9. [DOI: 10.1111/fcp.12198] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/09/2016] [Accepted: 03/15/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Aziz Eghbali
- Department of Pediatrics; Arak University of Medical Sciences; Arak Iran
| | - Peyman Azadmanesh
- Department of Pediatrics; Arak University of Medical Sciences; Arak Iran
| | - Bahador Bagheri
- Department of Pharmacology; Semnan University of Medical Sciences; Semnan Iran
| | - Hasan Taherahmadi
- Department of Pediatrics; Arak University of Medical Sciences; Arak Iran
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6
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Yacobovich J, Abu-Ahmed S, Steinberg-Shemer O, Goldberg T, Cohen M, Tamary H. Anti-D treatment for pediatric immune thrombocytopenia: Is the bad reputation justified? Semin Hematol 2016; 53 Suppl 1:S64-6. [DOI: 10.1053/j.seminhematol.2016.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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7
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Labarque V, Van Geet C. Clinical practice: immune thrombocytopenia in paediatrics. Eur J Pediatr 2014; 173:163-72. [PMID: 24390128 DOI: 10.1007/s00431-013-2254-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 12/17/2013] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a disease affecting both children and adults. It is defined as acquired isolated thrombocytopenia caused by the autoimmune production of anti-platelet antibodies. Childhood ITP most frequently occurs in young children who have been previously well, although a viral respiratory tract infection often precedes thrombocytopenia. A benign and self-limiting course is common, but major bleeding complications such as intracranial haemorrhage may occur. Yet one cannot predict which child will have a prolonged course of thrombocytopenia and who will develop an intracranial haemorrhage. In children without atypical characteristics, only minimal diagnostic investigations are needed, and most paediatric ITP patients do not need platelet-enhancing therapy even though various treatment options are available. A "watch and wait" strategy should be considered in paediatric patients with mild disease. Steroids, intravenous immunoglobulin G or anti-D immunoglobulin are the current first-line therapeutic measures for children at risk for severe bleeding. When life-threatening bleeding occurs, a combination of therapies is needed. In this review, we summarise the current knowledge on primary ITP in children and adolescents.
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Affiliation(s)
- Veerle Labarque
- Department of Paediatric Haemato-Oncology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium,
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8
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Loggetto SR, Braga JAP, Veríssimo MPDA, Bernardo WM, Medeiros L, Hoepers ATDC. Guidelines on the treatment of primary immune thrombocytopenia in children and adolescents: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Guidelines Project: Associação Médica Brasileira - 2012. Rev Bras Hematol Hemoter 2014; 35:417-27. [PMID: 24478609 PMCID: PMC3905825 DOI: 10.5581/1516-8484.20130124] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 10/16/2013] [Indexed: 01/19/2023] Open
Affiliation(s)
| | | | | | - Wanderley Marques Bernardo
- Faculdade de Medicina da Universidade de São Paulo - USP, São Paulo, Brazil ; Associação Médica Brasileira - AMB, São Paulo, Brazil
| | | | - Andrea Thives de Carvalho Hoepers
- Centro de Hematologia e Hemoterapia de Santa Catarina - HEMOSC, Florianópolis, SC, Brazil ; Universidade Federal de Santa Catarina - UFSC, Florianópolis, SC, Brazil
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9
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Sirachainan N, Anurathapan U, Chuansumrit A, Songdej D, Wongwerawattanakoon P, Hutspardol S, Kitpoka P. Intramuscular anti-D in chronic immune thrombocytopenia children with severe thrombocytopenia. Pediatr Int 2013; 55:e146-8. [PMID: 24330299 DOI: 10.1111/ped.12179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 05/15/2013] [Accepted: 06/27/2013] [Indexed: 01/19/2023]
Abstract
Nine patients with chronic immune thrombocytopenia and platelet counts <20 × 10(9) /L, with a median age of 7.8 (3.8-15.5) years, received three phases of 10 mcg/kg/dose of intramuscular anti-D. Phase 1 was anti-D daily for 5 days, followed by phase 2, anti-D weekly for 12 weeks and withheld when platelet counts ≥ 20 × 10(9) /L, and then phase 3 was anti-D once every 2 weeks for 24 weeks. According to the International Working Group criteria, in phase 1, 66.7% of patients responded to the treatment. In phases 2 and 3, 11.1% (0-41.7%) and 7.7% (0-33.3%) of total episodes of follow up, respectively, responded to the treatment. Therefore, intramuscular anti-D given at a dose of 10 mcg/kg for 5 days is an alternative method to raise platelet counts in chronic immune thrombocytopenia children with severe thrombocytopenia where the intravenous form of anti-D is not available.
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Affiliation(s)
- Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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10
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Deel MD, Kong M, Cross KP, Bertolone SJ. Absolute lymphocyte counts as prognostic indicators for immune thrombocytopenia outcomes in children. Pediatr Blood Cancer 2013; 60:1967-74. [PMID: 24038723 DOI: 10.1002/pbc.24628] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 05/15/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Recent studies reviewing immune mechanisms of immune thrombocytopenia (ITP) have suggested acute and chronic forms may represent distinct immunopathological disorders. This study evaluated absolute lymphocyte counts (ALCs) as predictors for ITP outcomes. PROCEDURE CBCs with differential counts were ascertained at presentation, 3, 6, and 12 months for 204 patients. Receiver operating characteristic (ROC) curves were used to determine cutoff values. Logistic regression models and recursive partitioning were used to evaluate which variables were significantly associated with outcomes. RESULTS ALC values at presentation were not independently predictive of disease duration. However, ALC values at 3 months were significant predictors. Sixty-eight percent (40/59) of patients >8 years of age and 43% (20/46) of patients ≤ 8 years who had an ALC ≤ 3,000/μl at 3 months developed chronic ITP. This compares to chronic rates of only 25% (3/12) and 2% (2/87) of patients >8 and ≤ 8 years, respectively, with an ALC > 3,000/μl at 3 months. Further, 92% (60/65) of patients who developed chronic ITP had a 3-month ALC ≤ 3,000/μl. An ALC > 3,000/μl at 3 months is a strong predictor for platelet recovery as only 5% (5/99) of these patients developed chronic ITP. CONCLUSION This study suggests progression to lower lymphocyte counts over the first few months of disease is a strong predictor for chronic ITP, allowing for risk stratification of patients, particularly when used in conjunction with other known predictors. Further research is needed to confirm these findings and to fully investigate the pathophysiological mechanisms responsible for this association.
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Affiliation(s)
- Michael D Deel
- Department of Pediatrics, School of Medicine, University of Louisville, Louisville, Kentucky; Norton's Kosair Children's Hospital, Louisville, Kentucky
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11
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A comparison of intravenous immunoglobulin (2 g/kg totally) and single doses of anti-D immunoglobulin at 50 μg/kg, 75 μg/kg in newly diagnosed children with idiopathic thrombocytopenic purpura: Ankara hospital experience. Blood Coagul Fibrinolysis 2013; 24:505-9. [PMID: 23470649 DOI: 10.1097/mbc.0b013e32835e5337] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We conducted this prospective randomized trial of intravenous immunoglobulin (IVIG) treatment in children with newly diagnosed immune thrombocytopenic purpura (ITP) to compare the efficacy of IVIG to standard and higher doses of anti-D IVIG. Seventy-eight patients who were previously untreated and between the age of 1 and 18 years with newly diagnosed acute ITP and a platelet concentration less than 20×10/l were eligible for enrollment. In this study IVIG treatment was compared with two different doses of anti-D. Study patients were randomized to receive treatment according to one of the two single anti-D IVIG doses [50 μg/kg (n=19) or 75 μg/kg (n=20)] or 2 g/kg (400 mg/kg per day, 5 day) total dose of IVIG (n=39). There is a significant increase of 24th hour, 48th hour, 72nd hour, 7th day and 30th day platelet counts in IVIG (2 g/kg, total dose) group compared to anti-D IVIG 50 μg/kg and anti-D IVIG 75 μg/kg groups. However, there were no difference between 24th hour, 48th hour, 72nd hour, 7th day and 30th day platelet counts across anti-D IVIG 50 μg/kg and anti-D IVIG 75 μg/kg groups. In conclusion, this study suggests that IVIG is well tolerated and significantly more effective than standard and high-dose anti-D IVIG for the treatment of newly diagnosed ITP in children. Apart from this, we believe that IVIG might be the first-line treatment of these patients. Regarding this issue further prospective studies comparing different IVIG treatment regimens with anti-D IVIG treatment regimens are needed.
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12
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Thompson JC, Klima J, Despotovic JM, O'Brien SH. Anti-D immunoglobulin therapy for pediatric ITP: before and after the FDA's black box warning. Pediatr Blood Cancer 2013; 60:E149-51. [PMID: 23813881 DOI: 10.1002/pbc.24633] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 05/15/2013] [Indexed: 01/19/2023]
Abstract
In March 2010, the Food and Drug Administration (FDA) issued a black box warning for anti-D immunoglobulin (anti-D), an approved treatment for immune thrombocytopenia (ITP). It is unknown if and how clinical practice at U.S children's hospitals has since changed. We sought to describe inpatient anti-D usage, laboratory monitoring, and anti-D complications before and after the FDA warning. Using the Pediatric Health Information System, we collected data from 41 children's hospitals. There was a modest but statistically significant decrease in anti-D usage from pre-warning to post-warning. Severe complication rates were very low and did not change appreciably.
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Affiliation(s)
- Joel C Thompson
- Pediatric Residency Program, Nationwide Children's Hospital, Columbus, Ohio
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Despotovic JM, Neunert CE. Is anti-D immunoglobulin still a frontline treatment option for immune thrombocytopenia? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:283-285. [PMID: 24319192 DOI: 10.1182/asheducation-2013.1.283] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A 5-year-old boy presents with platelet count of 2×10(9)/L and clinical and laboratory evidence of immune thrombocytopenia. He has epistaxis and oral mucosal bleeding. Complete blood count reveals isolated thrombocytopenia without any decline in hemoglobin and he is Rh+. You are asked if anti-D immunoglobulin is an appropriate initial therapy for this child given the 2010 Food and Drug Administration "black-box" warning.
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Bredlau AL, Semple JW, Segel GB. Management of immune thrombocytopenic purpura in children: potential role of novel agents. Paediatr Drugs 2011; 13:213-23. [PMID: 21692546 DOI: 10.2165/11591640-000000000-00000] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The treatment of immune thrombocytopenic purpura (ITP) in children is controversial, requiring individualized assessment of the patient and consideration of treatment options. If the platelet count is >10 000/μL and the patient is asymptomatic, a 'watch and wait' strategy is appropriate since most children with ITP will recover completely without pharmacotherapy. If therapy is indicated because of bleeding or a platelet count <10 000/μL, then treatment with glucocorticoids, intravenous immunoglobulin (IVIg), or anti-D are possible initial choices. Glucocorticoid treatment is the least expensive and is our usual first choice of therapy. Its use assumes that the blood counts and blood film have been evaluated to ensure the absence of evidence of alternative diagnoses, such as thrombotic thrombocytopenic purpura or incipient acute leukemia. IVIg is expensive and often causes severe headache, nausea and vomiting, and requires hospitalization at our institution. Anti-D therapy is also expensive and can only be used in patients who are Rhesus D positive. These therapies, even if only transiently effective, can be repeated if necessary. Children usually recover from newly diagnosed ITP, with or without multiple courses of medical therapy. If the disease becomes 'persistent' with severe thrombocytopenia and/or bleeding, and is no longer responsive to the three first-line therapies, the next approach includes the use of thrombopoietin receptor agonists or rituximab. When the disease persists for more than 1 year, it is considered chronic, and, if symptomatic, it may become necessary to consider third-line therapies, including splenectomy, alternative immunosuppressive agents, or combination or investigative chemoimmunotherapy. This review considers the indications, mechanism of action, and effectiveness of the traditional and novel treatment options for patients with ITP.
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Affiliation(s)
- Amy Lee Bredlau
- Department of Pediatrics, Division of Hematology/Oncology, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Affiliation(s)
- Roberto Stasi
- Department of Haematology, St George’s Hospital, London
| | - Adrian C. Newland
- Department of Haematology, Barts and the London NHS Trust, London, UK
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Kane I, Kalpatthi R. Comparison of intravenous immunoglobulin and high dose anti-D immunoglobulin as initial therapy for childhood immune thrombocytopenic purpura: response Özsoylu. Br J Haematol 2011; 152:784-5. [DOI: 10.1111/j.1365-2141.2010.08434.x] [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]
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17
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Özsoylu Ş. Comparison of intravenous immunoglobulin and high dose anti-D immunoglobulin as initial therapy for childhood immune thrombocytopenic purpura. Br J Haematol 2011; 152:783-4. [DOI: 10.1111/j.1365-2141.2010.08435.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Acquired and inherited platelet disorders can present with bleeding symptoms during adolescence. Platelet disorders include disorders of platelet number and disorders of platelet function. In adolescent females with platelet disorders, menorrhagia is a common presenting bleeding symptom. Other associated bleeding symptoms are also primarily mucocutaneous, including epistaxis and bruising. Excessive bleeding may also occur after hemostatic challenges. Diagnosis of disorders of platelet function usually requires light transmission platelet aggregometry. Management of menorrhagia in the adolescent with platelet disorders requires both hematologic and gynecologic treatment.
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Affiliation(s)
- Claire S Philipp
- University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
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