1
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Arnold DM, Clerici B, Ilicheva E, Ghanima W. Refractory immune thrombocytopenia in adults: Towards a new definition. Br J Haematol 2023; 203:23-27. [PMID: 37642211 DOI: 10.1111/bjh.19075] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune haematological disorder characterized by immune-mediated thrombocytopenia and a variable risk of bleeding. Despite the availability of multiple treatment options, some patients are considered refractory since they do not achieve a platelet count response to multiple treatments and are at risk of bleeding. The term 'refractory' has been used to identify this patient group; however, with the advent of multiple lines of treatment, its meaning has become ambiguous. To address this issue, we reviewed previous definitions of refractory ITP, solicited the views of ITP experts and collected data from registries to inform a definition. Twenty ITP experts who attended the 7th Expert Meeting of the Intercontinental Cooperative ITP Study Group in September 2022 answered a web-based survey: 95% felt that there was a need for a new definition of refractory ITP for clinical and research purposes. The use of the term refractory, accompanied by a clear indication of the type and timing of failed treatments, was supported by 85% of respondents. Preliminary data on the frequency of refractory patients from the McMaster and Norwegian ITP Registries demonstrated that the proportion of adult ITP patients who had failed first-line therapy, rituximab, thrombopoietin receptor agonists, any immune suppressant medication and splenectomy ranged from 0.4% to 3.8%. We propose a definition of refractory ITP that could be evaluated in future studies.
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Affiliation(s)
- Donald M Arnold
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Bianca Clerici
- Department of Medicine, Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
- Dipartimento di Scienze della Salute, Struttura Complessa di Medicina Generale II, Ospedale San Paolo, Università degli Studi di Milano, Milan, Italy
| | | | - Waleed Ghanima
- Department of Research, Østfol Hospital, Sarpsborg, Norway
- Department of Hemato-Oncolology, Østfol Hospital, Sarpsborg, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University Hospital, University of Oslo, Oslo, Norway
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2
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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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3
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Vianelli N, Auteri G, Buccisano F, Carrai V, Baldacci E, Clissa C, Bartoletti D, Giuffrida G, Magro D, Rivolti E, Esposito D, Podda GM, Palandri F. Refractory primary immune thrombocytopenia (ITP): current clinical challenges and therapeutic perspectives. Ann Hematol 2022; 101:963-978. [PMID: 35201417 PMCID: PMC8867457 DOI: 10.1007/s00277-022-04786-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/01/2022] [Indexed: 01/19/2023]
Abstract
Chronic primary immune thrombocytopenia (ITP) can today benefit from multiple therapeutic approaches with proven clinical efficacy, including rituximab, thrombopoietin receptor agonists (TPO-RA), and splenectomy. However, some ITP patients are unresponsive to multiple lines of therapy with prolonged and severe thrombocytopenia. The diagnosis of refractory ITP is mainly performed by exclusion of other disorders and is based on the clinician's expertise. However, it significantly increases the risk of drug-related toxicity and of bleedings, including life-threatening events. The management of refractory ITP remains a major clinical challenge. Here, we provide an overview of the currently available treatment options, and we discuss the emerging rationale of new therapeutic approaches and their strategic combination. Particularly, combination strategies may target multiple pathogenetic mechanisms and trigger additive or synergistic effects. A series of best practices arising both from published studies and from real-life clinical experience is also included, aiming to optimize the management of refractory ITP.
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Affiliation(s)
- Nicola Vianelli
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Francesco Buccisano
- Dipartimento Di Biomedicina E Prevenzione, Università Tor Vergata, Rome, Italy
| | | | | | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | | | | | - Elena Rivolti
- Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniela Esposito
- Presidio Ospedaliero San G. Moscati Di Aversa - ASL Caserta, Caserta, Italy
| | - Gian Marco Podda
- Medicina III, Ospedale San Paolo, ASST Santi Paolo E Carlo, Dipartimento Di Scienze Della Salute, Università Degli Studi Di Milano, Milano, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.
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4
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Lassandro G, Palmieri VV, Palladino V, Accettura D, Valente R, Giordano P. Sport and Children with Immune Thrombocytopenia: Never Give Up. Curr Sports Med Rep 2019; 18:317-318. [PMID: 31503041 DOI: 10.1249/jsr.0000000000000631] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Giuseppe Lassandro
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro," Bari, ITALY.,Puglia Committee of Italian Sports Medicine Federation, Puglia, ITALY
| | - Viviana Valeria Palmieri
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro," Bari, ITALY
| | - Valentina Palladino
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro," Bari, ITALY
| | | | - Roberto Valente
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro," Bari, ITALY
| | - Paola Giordano
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro," Bari, ITALY
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5
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Li C, Li X, Huang F, Yang J, Wu A, Wang L, Qin D, Zou W, Wu J. Efficacy and Safety of Avatrombopag in Patients With Thrombocytopenia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2019; 10:829. [PMID: 31402863 PMCID: PMC6677019 DOI: 10.3389/fphar.2019.00829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/27/2019] [Indexed: 01/04/2023] Open
Abstract
Background: Avatrombopag is a novel oral, nonpeptide thrombopoietin receptor agonist (TPO-RA). A few studies have shown that avatrombopag is effective against thrombocytopenia. However, no systematic review has been conducted on the efficacy and safety of avatrombopag. Therefore, the aim of this study was to comprehensively assess the efficacy and safety of avatrombopag patients with thrombocytopenia. Methods: Databases including Medline, PubMed, Embase, the Cochrane Library and ClinicalTrials.gov were searched for randomized controlled trials that compared avatrombopag with placebo in patients with thrombocytopenia. The deadline was March 2019. Results: In total, 743 patients were analyzed in five clinical trials. Patients treated with avatrombopag achieved higher platelet response (OR: 17.71, 95% CI [11.01 to 28.48], p < 0.00001) than with placebo. Avatrombopag produced an absolute increment in platelet count (WMD: 31.13%, 95% CI [22.27 to 39.99], p < 0.00001) unlike the placebo. In addition, the incidence of serious adverse events (RR: 1.18, 95% CI [0.72 to 1.93], p = 0.51) and deaths (RR: 0.93, 95% CI [0.19 to 4.45], p = 0.93) in patients treated with avatrombopag was not significantly different from that in patients treated with placebo. The incidence of adverse events in patients treated with avatrombopag was slightly higher than that in patients treated with placebo (RR: 1.25, 95% CI [1.05 to 1.49], p = 0. 01) after one trial with high heterogeneity was removed. Conclusions: This meta-analysis showed that avatrombopag was an effective treatment for thrombocytopenia, but there is sufficient evidence to indicate that adverse events may occur.
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Affiliation(s)
- Chunlu Li
- Department of Chinese Materia Medica, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Laboratory of Chinese Materia Medica, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China
| | - Xiaoxuan Li
- Laboratory of Chinese Materia Medica, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China.,Department of Pharmacy, The Second People's Hospital of Yibin, Yibin, China
| | - Feihong Huang
- Laboratory of Chinese Materia Medica, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China.,Institute of Cardiovascular Research, The Key Laboratory of Medical Electrophysiology, Ministry of Education of China, Collaborative Innovation Center for Prevention and Treatment of Cardiovascular Disease of Sichuan Province, Medical Key Laboratory for Drug Discovery and Druggability Evaluation of Sichuan Province, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Luzhou, China
| | - Jing Yang
- Laboratory of Chinese Materia Medica, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China.,Institute of Cardiovascular Research, The Key Laboratory of Medical Electrophysiology, Ministry of Education of China, Collaborative Innovation Center for Prevention and Treatment of Cardiovascular Disease of Sichuan Province, Medical Key Laboratory for Drug Discovery and Druggability Evaluation of Sichuan Province, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Luzhou, China
| | - Anguo Wu
- Laboratory of Chinese Materia Medica, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China.,Institute of Cardiovascular Research, The Key Laboratory of Medical Electrophysiology, Ministry of Education of China, Collaborative Innovation Center for Prevention and Treatment of Cardiovascular Disease of Sichuan Province, Medical Key Laboratory for Drug Discovery and Druggability Evaluation of Sichuan Province, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Luzhou, China
| | - Long Wang
- Laboratory of Chinese Materia Medica, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China.,Institute of Cardiovascular Research, The Key Laboratory of Medical Electrophysiology, Ministry of Education of China, Collaborative Innovation Center for Prevention and Treatment of Cardiovascular Disease of Sichuan Province, Medical Key Laboratory for Drug Discovery and Druggability Evaluation of Sichuan Province, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Luzhou, China
| | - Dalian Qin
- Laboratory of Chinese Materia Medica, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China.,Institute of Cardiovascular Research, The Key Laboratory of Medical Electrophysiology, Ministry of Education of China, Collaborative Innovation Center for Prevention and Treatment of Cardiovascular Disease of Sichuan Province, Medical Key Laboratory for Drug Discovery and Druggability Evaluation of Sichuan Province, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Luzhou, China
| | - Wenjun Zou
- Department of Chinese Materia Medica, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jianming Wu
- Laboratory of Chinese Materia Medica, Department of Pharmacology, School of Pharmacy, Southwest Medical University, Luzhou, China.,Institute of Cardiovascular Research, The Key Laboratory of Medical Electrophysiology, Ministry of Education of China, Collaborative Innovation Center for Prevention and Treatment of Cardiovascular Disease of Sichuan Province, Medical Key Laboratory for Drug Discovery and Druggability Evaluation of Sichuan Province, Luzhou Key Laboratory of Activity Screening and Druggability Evaluation for Chinese Materia Medica, Luzhou, China.,Department of Pharmacy, Affiliated Hospital of Southwest Medical University, Luzhou, China
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6
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Yahia S, Wahba Y, El-Gilany AH, Abdelmabood S, El-Hadidy MA, Darwish A, Mansour AK. Psychiatric Disorders and Quality of Life in Egyptian Patients with Chronic Immune Thrombocytopenic Purpura: A Single Center Study. Indian J Hematol Blood Transfus 2019; 35:347-351. [PMID: 30988574 PMCID: PMC6439116 DOI: 10.1007/s12288-018-1031-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 10/08/2018] [Indexed: 01/19/2023] Open
Abstract
The impact of chronic immune thrombocytopenic purpura (ITP) on the psychological health and quality of life is evident among children and adolescents. We aimed to describe psychological disorders and assess quality of life in children with chronic ITP and compared their results with their healthy peers. A cross-sectional comparative study was carried out in a tertiary care university-affiliated hospital during a period from November, 2015 till April, 2018. We enrolled 119 children with chronic ITP and compared with 220 healthy peers. Relevant demographic and clinical data were collected and statistically analyzed. Quality of life for both patients and control groups was measured using pediatric quality of life inventory version 4 (Arabic one). Also psychiatric evaluation of both groups was done using Arabic version of Mini-International Neuropsychiatric Interview for Children (Mini-KID). Majority of patients (90.7%) exhibited mucocutaneous bleeding. Most of patients (61.3%) did not need any definitive treatment for chronic ITP while 38.6% received second line therapy. About one-third of the patients needed rescue medications to control active bleeding. The scores of all sub-scales of Peds QL 4.0 were significantly decreased among patients group when compared to their healthy peers (P < 0.001). General anxiety disorder and oppositional defiant disorders were the commonest psychiatric disorders among children with chronic ITP. Quality of life in children with chronic ITP is markedly impaired with occurrence of a variable spectrum of psychiatric disorders among the studied patients.
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Affiliation(s)
- Sohier Yahia
- Pediatrics Department, Faculty of Medicine, Mansoura University, Mansoura, 35516 Egypt
| | - Yahya Wahba
- Pediatrics Department, Faculty of Medicine, Mansoura University, Mansoura, 35516 Egypt
| | - Abdel-Hady El-Gilany
- Public Health Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Suzy Abdelmabood
- Pediatrics Department, Faculty of Medicine, Mansoura University, Mansoura, 35516 Egypt
| | | | - Ahmad Darwish
- Pediatrics Department, Faculty of Medicine, Mansoura University, Mansoura, 35516 Egypt
| | - Ahmed K. Mansour
- Pediatrics Department, Faculty of Medicine, Mansoura University, Mansoura, 35516 Egypt
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7
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Khelif A, Saleh MN, Salama A, Portella MDSO, Duh MS, Ivanova J, Grotzinger K, Roy AN, Bussel JB. Changes in health-related quality of life with long-term eltrombopag treatment in adults with persistent/chronic immune thrombocytopenia: Findings from the EXTEND study. Am J Hematol 2019; 94:200-208. [PMID: 30417939 PMCID: PMC6587804 DOI: 10.1002/ajh.25348] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 12/30/2022]
Abstract
Patients with persistent/chronic immune thrombocytopenia (cITP) have low platelet counts, increased risk of bleeding and bruising, and often suffer from reduced health‐related quality of life (HRQoL). cITP treatments may either improve HRQoL by increasing platelet counts or decrease it because of side effects. The open‐label EXTEND study (June 2006 to July 2015) evaluated long‐term safety, tolerability, and efficacy of eltrombopag (an oral thrombopoietin‐receptor‐agonist) in adults with cITP who completed a previous eltrombopag ITP trial. The final results of EXTEND were published and used to assess changes in patient‐reported HRQoL over time and association between HRQoL and platelet response. Four validated HRQoL instruments were administered: SF‐36v2 including physical component summary (PCS) and Mental Component Summary; Motivation and Energy Inventory Short Form (MEI‐SF); Fatigue Subscale of FACIT (FACIT‐Fatigue); and FACT‐Thrombocytopenia Subscale Six‐Item Extract (FACT‐Th6). For the 302 patients enrolled, median duration of eltrombopag treatment was 2.37 years. All 4 HRQoL instruments demonstrated positive mean changes from baseline over time adjusted for patient baseline characteristics and rescue therapy use, and had positive association with platelet response (platelet count ≥30 × 109/L; ≥50 × 109/L; and ≥50 × 109/L and >2 times baseline). Improvements from baseline started within 3 months and persisted through 5 years of treatment for FACIT‐Fatigue and FACT‐Th6 (P <.05 for nearly all time points); through 2.5 years for SF‐36v2 PCS and less consistently for the MEI‐SF. In conclusion, in addition to eltrombopag increasing platelet counts and reducing bleeding/bruising, it also alleviated fatigue, concerns about bleeding and bruising, and improved physical function in many patients, especially responders.
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Affiliation(s)
| | - Mansoor N. Saleh
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
| | | | | | | | | | | | - Anuja N. Roy
- Novartis Pharmaceuticals Corporation; East Hanover New Jersey
| | - James B. Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine; New York City New York
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8
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Giordano P, Lassandro G, di Meo NA, Palladino V, Lovrencic B, Spinelli M, Reale L, Jankovic M. A Narrative Approach to Describe QoL in Children With Chronic ITP. Front Pediatr 2019; 7:163. [PMID: 31134165 PMCID: PMC6513878 DOI: 10.3389/fped.2019.00163] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 04/08/2019] [Indexed: 01/19/2023] Open
Abstract
Objective: Primary immune thrombocytopenia (ITP) is a hemorrhagic disorder. Spontaneous recovery within 12 months occurs in the majority of pediatric patients. Nevertheless, in 20-30% of children the disease is chronic. The impact extends to the patients' families, whose everyday life, in terms of interpersonal relationships and financial status, is adversely affected. This study investigated the ability of a narrative instrument to improve the quality of life of pediatric chronic ITP patients and their families and quantified the familial burden imposed by the illness. Method: A quantitative survey and a narrative plot delivered through an online platform were adopted for the analysis. Results: Pediatricians of ten Italian Hematologic Centers explained the projects to patients and their family in the outpatient clinic. 70 caregivers of children with ITP filled the ad-hoc questionnaire. Data from 53 caregivers revealed the emotional impact of pediatric chronic ITP. The narrative approach highlighted the specific resources used by patients and their families to cope with the disease and its chronicity. Discussion: Caregivers underlined the need for "humaneness" in their interactions with clinical personnel. The majority of respondents provided positive feedback regarding the narrative project, defining the experience as "liberating" and improving their quality of life.
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Affiliation(s)
- Paola Giordano
- Department of Biomedical Science and Human Oncology-Pediatric Unit "B. Trambusti", University of Bari "Aldo Moro", Bari, Italy
| | - Giuseppe Lassandro
- Department of Biomedical Science and Human Oncology-Pediatric Unit "B. Trambusti", University of Bari "Aldo Moro", Bari, Italy
| | - Nicola Antonio di Meo
- Department of Biomedical Science and Human Oncology-Pediatric Unit "B. Trambusti", University of Bari "Aldo Moro", Bari, Italy
| | - Valentina Palladino
- Department of Biomedical Science and Human Oncology-Pediatric Unit "B. Trambusti", University of Bari "Aldo Moro", Bari, Italy
| | - Barbara Lovrencic
- Italian Immune Thrombocytopenia Patients Association, Caprino Veronese, Italy
| | - Marco Spinelli
- Foundation MBBM at San Gerardo Hospital, Pediatric Clinic University Milano-Bicocca, Monza, Italy
| | | | - Momcilo Jankovic
- Foundation MBBM at San Gerardo Hospital, Pediatric Clinic University Milano-Bicocca, Monza, Italy
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9
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Dolph M, Roy A, Bhor M, Hearnden J, Kwon CS, Forsythe A, Tremblay G, Briggs A. A decision framework for treating chronic immune thrombocytopenia with thrombopoietin receptor agonists. J Comp Eff Res 2018; 7:775-784. [DOI: 10.2217/cer-2018-0034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Aim: Eltrombopag and romiplostim are comparable second-line therapies in chronic immune thrombocytopenia. Treatment decisions are made in different contexts. A framework was created to outline decision pathways for physicians and payers. Materials & methods: The costs of drugs, administration, routine care, bleeding, other adverse events and mortality were included in the year-long calculation of total costs from a US private payer perspective. Treatment parameters and outcome data were obtained from relevant clinical trials. Results: The total cost per year, per patient of eltrombopag was US$51,000 versus US$76,000 for romiplostim. Drug costs and costs associated with bleeding-related events were the main drivers of cost difference. Conclusion: This framework facilitates decision-making in the management of chronic immune thrombocytopenia with eltrombopag and romiplostim.
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Affiliation(s)
- Mike Dolph
- Purple Squirrel Economics, New York, NY 10010, USA
| | - Anuja Roy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA
| | - Menaka Bhor
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA
| | | | | | | | | | - Andrew Briggs
- University of Glasgow, Glasgow, Scotland, G12 8QQ, UK
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10
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Depré F, Aboud N, Mayer B, Salama A. Efficacy and tolerability of old and new drugs used in the treatment of immune thrombocytopenia: Results from a long-term observation in clinical practice. PLoS One 2018; 13:e0198184. [PMID: 29856800 PMCID: PMC5983486 DOI: 10.1371/journal.pone.0198184] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 05/15/2018] [Indexed: 02/06/2023] Open
Abstract
Background Many patients with immune thrombocytopenia (ITP) may require special attention and long-term treatment. Little is known on the efficacy and tolerability of the drugs used in practice. Material and methods We retrospectively reviewed the results of therapy of 400 patients with chronic ITP. All Patients were treated at our institution between 1996–2016 under consideration of guidelines, general recommendations, and individual aspects, including gender, age, weight, comorbidity, patient’s medical history and bleeding risk. Results Treatment was not required in 25% of patients (n = 100) during observation. In treated patients (n = 300), the rate of patients that responded and tolerated treatment with prednisolone was 59% (52/88), with azathioprine 32% (29/90), with eltrombopag 49% (31/63), with romiplostim 59% 27/45, with IVIG (intravenous immunoglobulines) 75% (94/126), with anti-D 37% (19/52) and with dexamethasone 60% (25/42) patients. Eighteen treated patients (6%) entered sustained remission after treatment with various drugs. Twenty-six patients underwent splenectomy (Splx) resulting in sustained remission in 15 cases (60%). Only two patients remained refractory to Splx and to all used drugs. Discussion None of the currently available drugs used in the treatment of ITP are invariably safe and effective. Responses, the duration of response, intolerability, and the course of disease are unpredictable. Although the treatment of ITP has considerably improved in the recent years, the currently available drugs may rarely cure affected patients. The need for safe and effective therapy in ITP is evident. Optimal treatment decisions for each patient remains a challenge in many cases.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Azathioprine/adverse effects
- Azathioprine/therapeutic use
- Benzoates/adverse effects
- Benzoates/therapeutic use
- Child
- Child, Preschool
- Combined Modality Therapy
- Cyclosporine/adverse effects
- Cyclosporine/therapeutic use
- Dapsone/adverse effects
- Dapsone/therapeutic use
- Dexamethasone/adverse effects
- Dexamethasone/therapeutic use
- Drug Resistance
- Drug Therapy, Combination
- Female
- Humans
- Hydrazines/adverse effects
- Hydrazines/therapeutic use
- Immunoglobulins, Intravenous/adverse effects
- Immunoglobulins, Intravenous/therapeutic use
- Immunosuppressive Agents/adverse effects
- Immunosuppressive Agents/therapeutic use
- Male
- Middle Aged
- Prednisolone/adverse effects
- Prednisolone/therapeutic use
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/surgery
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Receptors, Fc/therapeutic use
- Recombinant Fusion Proteins/adverse effects
- Recombinant Fusion Proteins/therapeutic use
- Remission Induction
- Retrospective Studies
- Rho(D) Immune Globulin/adverse effects
- Rho(D) Immune Globulin/therapeutic use
- Rituximab/adverse effects
- Rituximab/therapeutic use
- Splenectomy
- Thrombopoietin/adverse effects
- Thrombopoietin/therapeutic use
- Treatment Outcome
- Young Adult
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Affiliation(s)
- Fabian Depré
- Institute of Transfusion Medicine, Charité Unversitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Nasra Aboud
- Institute of Transfusion Medicine, Charité Unversitätsmedizin Berlin, Berlin, Germany
| | - Beate Mayer
- Institute of Transfusion Medicine, Charité Unversitätsmedizin Berlin, Berlin, Germany
| | - Abdulgabar Salama
- Institute of Transfusion Medicine, Charité Unversitätsmedizin Berlin, Berlin, Germany
- * E-mail:
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11
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Li S, Molony JT, Cetin K, Wasser JS, Altomare I. Rate of bleeding-related episodes in elderly patients with primary immune thrombocytopenia: a retrospective cohort study. Curr Med Res Opin 2018; 34:209-216. [PMID: 28748715 DOI: 10.1080/03007995.2017.1360852] [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] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Immune thrombocytopenia (ITP) is characterized by low platelet counts and a tendency toward increased bleeding and bruising. We aimed to describe bleeding frequency and use of rescue ITP therapy to treat or prevent bleeding in elderly ITP patients in a real-world setting. METHODS Using Medicare 20% sample data, 2007-2012, we identified elderly (ages ≥67 years) Medicare fee-for-service enrollees diagnosed with primary ITP between 1 January 2009 and 30 September 2012. Bleeding-related episodes (BREs) were defined as ≥1 bleeding event or use of ITP therapies commonly considered for rescue or emergency therapy. BRE rates were examined for the cohort overall, by time since ITP onset, and by splenectomy status. Patients were followed from ITP onset until the earliest of death, disenrollment from fee-for-service coverage, or 31 December 2012. RESULTS We identified 3007 elderly patients diagnosed with primary ITP (mean [SD] age: 79.6 [7.5] years; 55% female); 2178 (72%) experienced at least one BRE (8867 BREs); 92 (3%) underwent splenectomy. Nearly half of BREs were defined by rescue therapy use alone. The overall rate was 1.72 BREs per patient-year (95% CI; 1.68-1.75); rates were higher during the first 3 months after ITP onset and after splenectomy. CONCLUSION Elderly ITP patients experienced about two BREs per patient-year after ITP onset. Most patients experienced at least one BRE. These real-world results demonstrate the importance of examining both bleeding and use of rescue or emergency ITP therapy in the assessment of disease burden in elderly patients with ITP.
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Affiliation(s)
- Shuling Li
- a Chronic Disease Research Group , Minneapolis Medical Research Foundation , Minneapolis , MN , USA
| | - Julia T Molony
- a Chronic Disease Research Group , Minneapolis Medical Research Foundation , Minneapolis , MN , USA
| | - Karynsa Cetin
- b Center for Observational Research , Amgen Inc. , Thousand Oaks , CA , USA
| | - Jeffrey S Wasser
- c Carole and Ray Neag Comprehensive Cancer Center , University of Connecticut School of Medicine , Farmington , CT , USA
| | - Ivy Altomare
- d Department of Medicine , Duke University School of Medicine , Durham , NC , USA
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12
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Agnelli Giacchello J, Valeri F, Boccadoro M, Borchiellini A. Thrombopoietin receptor agonists in patients with persistent or chronic immune thrombocytopenia. Eur J Haematol 2018; 100:304-307. [DOI: 10.1111/ejh.13014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Jacopo Agnelli Giacchello
- Regional Center for Hemorrhagic and Thrombotic Diseases; Haematology Unit; City of Health and Science University Hospital of Molinette; Turin Italy
| | - Federica Valeri
- Regional Center for Hemorrhagic and Thrombotic Diseases; Haematology Unit; City of Health and Science University Hospital of Molinette; Turin Italy
| | - Mario Boccadoro
- Regional Center for Hemorrhagic and Thrombotic Diseases; Haematology Unit; City of Health and Science University Hospital of Molinette; Turin Italy
| | - Alessandra Borchiellini
- Regional Center for Hemorrhagic and Thrombotic Diseases; Haematology Unit; City of Health and Science University Hospital of Molinette; Turin Italy
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13
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Panzer S, Pabinger I. Is oral all-trans retinoic acid plus danazol a refinement of second-line therapy for primary immune thrombocytopenia in adults? LANCET HAEMATOLOGY 2017; 4:e457-e458. [PMID: 28917656 DOI: 10.1016/s2352-3026(17)30167-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/22/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna 1090, Austria.
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna 1090, Austria
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14
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Trotter PB, Robb M, Summers D, Watson CJE, Clatworthy M, Bradley JA, Hill QA, Neuberger J. Donors With Immune Thrombocytopenia: Do They Pose a Risk to Transplant Recipients? Am J Transplant 2017; 17:796-802. [PMID: 27935215 DOI: 10.1111/ajt.14105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/26/2016] [Accepted: 10/21/2016] [Indexed: 01/25/2023]
Abstract
Transplant-mediated alloimmune thrombocytopenia (TMAT) from donors with immune thrombocytopenia (ITP) can result in significant bleeding complications in the recipient. The risk to a recipient of TMAT if they receive an organ from a donor with ITP is unknown. The outcomes of recipients of organs from deceased donors with ITP recorded in the UK Transplant Registry between 2000 and 2015 were reviewed. Twenty-one deceased organ donors had a predonation diagnosis of ITP. These donors were significantly more likely to have died from intracranial hemorrhage than were all other deceased organ donors (85% vs. 57%, p < 0.001). Organs from donors with ITP resulted in 49 organ transplants (31 kidney, 14 liver, four heart), with only one case of TMAT, which occurred in a liver transplant recipient and resulted in death from bleeding complications 18 days posttransplantation. The recipient of a kidney from the same organ donor was not affected. Unadjusted 5-year patient and graft survival was significantly worse for liver transplant recipients from donors with ITP compared with liver transplant recipients from donors without ITP (64% vs. 85%, p = 0.012). Organs from donors with ITP may be considered for transplantation, but livers should be used with caution.
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Affiliation(s)
- P B Trotter
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,Organ Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, UK
| | - M Robb
- Organ Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, UK
| | - D Summers
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,Organ Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, UK
| | - C J E Watson
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
| | - M Clatworthy
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
| | - J A Bradley
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
| | - Q A Hill
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - J Neuberger
- Organ Donation and Transplantation Directorate, NHS Blood and Transplant, Bristol, UK
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15
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Mayer B, Depré F, Ringel F, Salama A. New aspects on the efficacy of high-dose intravenous immunoglobulins in patients with autoimmune thrombocytopenia. Vox Sang 2016; 112:64-69. [DOI: 10.1111/vox.12467] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/06/2016] [Accepted: 09/15/2016] [Indexed: 12/18/2022]
Affiliation(s)
- B. Mayer
- Institute of Transfusion Medicine; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - F. Depré
- Institute of Transfusion Medicine; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - F. Ringel
- Institute of Transfusion Medicine; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - A. Salama
- Institute of Transfusion Medicine; Charité - Universitätsmedizin Berlin; Berlin Germany
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16
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Doobaree IU, Nandigam R, Bennett D, Newland A, Provan D. Thromboembolism in adults with primary immune thrombocytopenia: a systematic literature review and meta-analysis. Eur J Haematol 2016; 97:321-30. [DOI: 10.1111/ejh.12777] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Indraraj Umesh Doobaree
- Barts and The London School of Medicine and Dentistry; Blizard Institute; Queen Mary University of London; Whitechapel London UK
| | - Raghava Nandigam
- Barts and The London School of Medicine and Dentistry; Blizard Institute; Queen Mary University of London; Whitechapel London UK
| | - Dimitri Bennett
- Worldwide Epidemiology Department; R&D GlaxoSmithKline; Collegeville Pennsylvania USA
| | - Adrian Newland
- Barts and The London School of Medicine and Dentistry; Blizard Institute; Queen Mary University of London; Whitechapel London UK
| | - Drew Provan
- Barts and The London School of Medicine and Dentistry; Blizard Institute; Queen Mary University of London; Whitechapel London UK
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17
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Hindilerden F, Yönal-Hindilerden İ, Yenerel MN, Nalçacı M, Diz-Küçükkaya R. Rituximab Therapy in Adults with Refractory Symptomatic Immune Thrombocytopenia: Long-Term Follow-Up of 15 Cases. Turk J Haematol 2016; 34:72-80. [PMID: 27102929 PMCID: PMC5451692 DOI: 10.4274/tjh.2016.0086] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objective: This paper prospectively evaluates the long-term follow-up [mean ± standard deviation (SD) duration: 89.7±19.4 months] data of 15 patients (13 females and 2 males) with refractory symptomatic immune thrombocytopenia (ITP) treated with rituximab. Materials and Methods: Rituximab was administered at 375 mg/m2 weekly for a total of 4 doses. Complete response (CR) was defined as a platelet count of ≥100,000/mm3 and partial response (PR) as a platelet count of ≥30,000/mm3 but less than 100,000/mm3. Early response (ER) and late response (LR) were defined as response within 42 days and after 42 days of initiation of rituximab therapy, respectively. Sustained response (SR) was defined as response lasting for at least 6 months. Results: Mean age (±SD) at the start of rituximab was 46.6±11.3 years. Mean platelet count (±SD) prior to rituximab treatment was 17,400±8878/mm3. The mean time (±SD) between rituximab therapy and response to rituximab in early responders and late responders was 1.8±1.3 weeks and 10±2.8 weeks, respectively. Mean durations (±SD) of ER and LR were 51±47.2 months and 6±4.2 months, respectively. Seven of the 15 patients (46.7%) showed an initial response to rituximab (5 ER and 2 LR). The rate of SR over 6 months was 26.7% (4/15). Among the responders to rituximab, 3 (3/7, 42.9%) maintained their response 1 year after rituximab treatment and 2 (2/7, 28.6%) had ongoing response 5 years after initiation of rituximab. Two of the 7 patients (28.6%) still maintained their response 98 months after initiation of rituximab. All 5 initial responders with subsequent relapse achieved response from subsequent treatment modalities (3 CR, 2 PR). Conclusion: Our data confirm, over a long period of observation, that rituximab is safe and effective in the management of patients with chronic refractory primary ITP.
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Affiliation(s)
- Fehmi Hindilerden
- Bakırköy Sadi Konuk Training and Research Hospital, Clinic of Hematology, İstanbul, Turkey Phone: +90 212 414 71 71 E-mail:
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18
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Fiore M, Pillois X, Lorrain S, Bernard MA, Moore N, Sié P, Viallard JF, Nurden P. A diagnostic approach that may help to discriminate inherited thrombocytopenia from chronic immune thrombocytopenia in adult patients. Platelets 2016; 27:555-62. [PMID: 27025585 DOI: 10.3109/09537104.2016.1143920] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Inherited thrombocytopenia (IT) is a heterogeneous group of rare diseases that are often confused with immune thrombocytopenia (ITP). The objective of this study was to supply clinicobiological elements that allow a distinction to be drawn between IT and chronic ITP. We then compared 23 adult patients with IT and 9 patients with chronic ITP. Our study revealed six discriminating criteria: (i) an age of discovery <34 years: positive predictive value (PPV) = 88.2% [63.6; 98.5], (ii) a family history of thrombocytopenia: PPV = 100.0% [82.4; 100.0], (iii) a personal history of bleeding: PPV = 100% [76.8; 100.0], (iv) a mean platelet volume >11 fL: PPV = 93.3% [68.1; 99.8], (v) an excess of giant platelets on blood smear: 100.0% [76.8; 100.0], and (vi) a percentage >44% of platelets with a surface area >4 µm(2) in electron microscopy: PPV = 83.3% [58.6; 96.4]. If at least three of these criteria were combined, it was possible to distinguish IT from chronic ITP with 91.3% [72.0; 98.9] sensitivity and PPV = 100.0% [66.4; 100.0] specificity. The secondary objective of this study was to assess the prevalence of potential IT diagnosis in patients with chronic thrombocytopenia of uncertain origin. Applying our diagnostic approach to a series of 20 cases allowed us to estimate that 40% of them could be suffering from IT. Finally, our diagnostic approach may help to correctly distinguish IT from chronic ITP, particularly in the context of macrothrombocytopenia.
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Affiliation(s)
- Mathieu Fiore
- a Laboratory of Haematology , Bordeaux University Hospital Centre , Pessac , France.,b Reference Centre for Platelet Disorders , Bordeaux University Hospital Centre , Pessac , France
| | - Xavier Pillois
- b Reference Centre for Platelet Disorders , Bordeaux University Hospital Centre , Pessac , France
| | - Simon Lorrain
- c Clinical Investigation Centre , Bordeaux University Hospital Centre , Bordeaux , France
| | - Marie-Agnès Bernard
- c Clinical Investigation Centre , Bordeaux University Hospital Centre , Bordeaux , France
| | - Nicholas Moore
- c Clinical Investigation Centre , Bordeaux University Hospital Centre , Bordeaux , France
| | - Pierre Sié
- b Reference Centre for Platelet Disorders , Bordeaux University Hospital Centre , Pessac , France.,d Laboratory of Haematology , Toulouse University Hospital Centre , Toulouse , France
| | | | - Paquita Nurden
- b Reference Centre for Platelet Disorders , Bordeaux University Hospital Centre , Pessac , France.,f Rythmology and Cardiac Modeling Institute (LIRYC) , Xavier Arnozan Hospital Centre , Pessac , France
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19
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Zhang H, Wang L, Quan M, Huang J, Wu P, Lu Q, Fang Y. Health-related quality of life in children with chronic immune thrombocytopenia in China. Health Qual Life Outcomes 2016; 14:45. [PMID: 26979950 PMCID: PMC4792088 DOI: 10.1186/s12955-016-0445-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/07/2016] [Indexed: 01/19/2023] Open
Abstract
Background The concept of health-related quality of life (HRQoL) was brought up decades ago and has been well utilized in many different areas. Regarding immune thrombocytopenia (ITP) management, much work has been done to emphasize the necessity of taking HRQoL into consideration. However, data on HRQoL of children with chronic ITP remain rare. Methods This is a cross-sectional study. Children with chronic ITP aged from 2 to 18 and their parents were recruited. Participants completed the Pediatric Quality of Life Inventory™ (PedsQL™) and Kids’ ITP Tools (KIT) questionnaires at only one time. The Pearson’s correlation was examined between these measures for the pooled samples. Results A total of 42 families participated. Mean child self-report scores of KIT and PedsQL™ were 78.60 (SD = 12.40) and 85.13 (SD = 14.12), respectively, corresponding to parent proxy report scores, which were 73.40 (SD = 19.96) and 85.10 (SD = 13.56), respectively. Mean score of KIT parent impact report was only 40.39 (SD = 19.96). Significantly higher KIT scores (self-report and parent proxy) were observed in children with PLT more than 30 × 10*9/L compared to others, and this difference was even more noticeable in the PedsQL™ parent proxy report group (p < 0.001). As with intravenous immunoglobulin, the statistics difference appeared only in KIT child self-report group (p = 0.03), while for bone marrow examination, the difference appeared only in PedsQL™ parent proxy report group (p = 0.01). A negative relationship was apparent between duration of disease and scores. Gender and use of corticosteroids had no impact on the KIT and PedsQL™ scores here. Internal consistency reliability was demonstrated with Cronbach’s alpha for all scales above the acceptable level of 0.89 (range from 0.88 to 0.97). There was a substantial concordance (p < 0.001) between the child and parent proxy scores (ICC for KIT is 0.59, ICC for PedsQL™ is 0.85). Meanwhile, KIT scores are correlated with PedsQL™ (r = 0.75 for child self report, r = 0.61 for parent proxy report). Conclusions ITP affects HRQoL of children and parents. Parents are much more concerned with the disease than their children, which seriously influence their HRQoL as a result. The cross-culture translated KIT is reliable and valid with acceptable correlation to the PedsQL™. KIT provides valuable information of childhood ITP and will be a reliable outcome measure for further clinical research on HRQoL.
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Affiliation(s)
- Heng Zhang
- Department of Hematology and Oncology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Li Wang
- Department of Hematology and Oncology, Children's hospital of Hebei province, Shijiazhuang, China
| | - Meijie Quan
- Department of Hematology and Oncology, Children's hospital of Hebei province, Shijiazhuang, China
| | - Jie Huang
- Department of Hematology and Oncology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Peng Wu
- Department of Hematology and Oncology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Qin Lu
- Department of Hematology and Oncology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Yongjun Fang
- Department of Hematology and Oncology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China.
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20
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Tsukune Y, Komatsu N. Management of Adult Chronic Immune Thrombocytopenia in Japan: Patient and Hematologist Perspectives from a Multi-center Cross-sectional Questionnaire Survey. Intern Med 2016; 55:2379-85. [PMID: 27580537 DOI: 10.2169/internalmedicine.55.6407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The objective of this study was to explore the perspective of hematologists and their patients regarding the management of adult chronic immune thrombocytopenia (ITP). Methods This was a multi-center, questionnaire-based, cross-sectional study conducted between 2012 and 2013 throughout Japan. Patients Hematologists, members of the Japanese Society of Hematology in 171 institutions, and their patients were invited to participate in this study. The hematologists were mainly asked about their treatment strategies, while patients were asked about their opinion of the applied treatments, treatment effect, impact on their quality of life (QOL), and treatment satisfaction. Results Questionnaires from 204 hematologists and 213 patients were collected. One hundred sixty hematologists (78.4%) started treatment based on the patient's platelet count. Corticosteroids were considered to be the most effective treatment (44.1%). Forty-six percent of hematologists responded that treatment would be started after the platelet count fell below 20×10(9)/L with bleeding symptoms, compared to 62.9% for patients with no bleeding symptoms. A platelet count of 50×10(9)/L or lower was acceptable for 94.0% of hematologists and 66.8% of patients. Fatigue was most frequently experienced by patients (44.6%). Patients also experienced psychological symptoms (feeling of anxiety or depressive mood: 29.1%, labyrinthitis: 23.5%). While 70.6% of hematologists assumed that the patient QOL was impaired to a moderate to substantial degree, the QOL was impaired in 34.3% of patients. Conclusion A substantial gap which exists between hematologists and their patients highlights a need for better understanding of potential conflicts for establishing effective strategies for ITP management.
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Affiliation(s)
- Yutaka Tsukune
- Department of Hematology, Juntendo University School of Medicine, Japan
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21
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Hlusi A, Szotkowski T, Indrak K. Refractory immune thrombocytopenia. Successful treatment with repeated cyclosporine A: two case reports. Clin Case Rep 2015; 3:337-41. [PMID: 26185623 PMCID: PMC4498837 DOI: 10.1002/ccr3.182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 11/26/2014] [Accepted: 10/25/2014] [Indexed: 11/20/2022] Open
Abstract
Treatment of chronic, severe refractory immune thrombocytopenia after splenectomy is difficult. Only less data exist on clinical use of cyclosporine A (CyA) in the management of refractory ITP. In this report, we describe two cases in which standard immunosuppressive therapy, other immunosuppression including cyclosporine A or splenectomy had no therapeutic effect. Even after splenectomy, recommended procedures were inefficient and critical thrombocytes count persisted. After repeated administration of cyclosporine A which had been ineffective prior to splenectomy; however, both patients achieved long-term complete remission of the ITP. Side effects of CyA were moderate. The presented cases have confirmed the potential therapeutic effect of CyA in refractory post-SE ITP.
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Affiliation(s)
- Antonin Hlusi
- Department of Hemato-Oncology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc Olomouc, Czech Republic
| | - Tomas Szotkowski
- Department of Hemato-Oncology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc Olomouc, Czech Republic
| | - Karel Indrak
- Department of Hemato-Oncology, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc Olomouc, Czech Republic
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Vaughn JE, Anwer F, Deeg HJ. Treatment of refractory ITP and Evans syndrome by haematopoietic cell transplantation: is it indicated, and for whom? Vox Sang 2015; 110:5-11. [PMID: 26178735 DOI: 10.1111/vox.12314] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 12/13/2022]
Abstract
Several lines of therapy have been established for patients with immune thrombocytopenia (ITP) and Evans syndrome. However, these therapies generally require prolonged administration, lead to profound immunosuppression and increased infectious risk, and are often poorly tolerated. While most patients with these disorders will respond to first-line steroid therapy, others will prove refractory or intolerant to multiple treatments. In these patients (and possibly even selected patients who are not considered refractory), autologous or allogeneic haematopoietic stem cell transplantation (HCT) may provide definitive therapy. We review the literature on the treatment of ITP and Evans syndrome with HCT and discuss its use in the management of these disorders. We also pose, for the purpose of discussion, research questions that will be important to address if HCT is to be considered a viable option for more patients with these diseases.
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Affiliation(s)
- J E Vaughn
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
| | - F Anwer
- University of Arizona Cancer Center, Tucson, AZ, USA
| | - H J Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA, USA
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23
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Amirifard H, Barzkar F, Fazeli SA, Hashemi SM. An unusual occurrence of Kleine-Levin syndrome in a man with refractory immune thrombocytopenic purpura: a case report. J Med Case Rep 2015; 9:76. [PMID: 25885480 PMCID: PMC4399116 DOI: 10.1186/s13256-015-0536-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 01/29/2015] [Indexed: 11/21/2022] Open
Abstract
Introduction Kleine-Levin syndrome is an extremely rare neurological entity characterized by recurrent episodes of hypersomnia which are sometimes associated with compulsive hyperphagia and behavioral changes. Autoimmunity has recently been proposed as a factor contributing to its pathogenesis. Immune thrombocytopenic purpura is a relatively common autoimmune disease showing a lot of complexity and uncertainty regarding its treatment regimens and its refractory nature in some cases. Case presentation A 32-year-old Persian White man visited his private hematologist complaining of recent episodes of epistaxis and appearance of petechial lesions 24 hours after receiving a meningococcal vaccine. He had a history of immune thrombocytopenic purpura 13 years before his presentation. Based on his history and laboratory findings, his condition was diagnosed as a relapse of immune thrombocytopenic purpura and was managed accordingly. He did not respond to first-line corticosteroid regimens and later developed neurological symptoms as recurrent episodes of hypersomnia and hyperphagia. After a complete clinical and paraclinical evaluation and ruling out other possible conditions, he was given a diagnosis of Kleine-Levin syndrome. He was followed up for his immune thrombocytopenic purpura and received different treatment regimens none of which were adequately successful except intravenous immunoglobulin that was only temporarily effective. He has had 4 documented self-limited episodes of Kleine-Levin syndrome since his initial presentation. Conclusions Immune thrombocytopenic purpura may be associated with meningococcal vaccination in adulthood. Responses to treatment in immune thrombocytopenic purpura vary among patients. Our patient only had a transient acceptable response to intravenous immunoglobulin while all other options failed to improve his platelet count. Concurrence of immune thrombocytopenic purpura and Kleine-Levin syndrome supports the role of autoimmunity as the proposed pathophysiological mechanism of Kleine-Levin syndrome.
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Affiliation(s)
- Hamed Amirifard
- Department of Neurology, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - Farzaneh Barzkar
- Students' Scientific Research Center, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - Seyed Amirhossein Fazeli
- Department of Internal Medicine, School of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - Seyed Mehdi Hashemi
- Department of Hematology, Zahedan University of Medical Sciences, Zahedan, Iran. .,Ali-Ebne-Abitaleb hospital, Zahedan, Iran.
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Rijcken E, Mees ST, Bisping G, Krueger K, Bruewer M, Senninger N, Mennigen R. Laparoscopic splenectomy for medically refractory immune thrombocytopenia (ITP): a retrospective cohort study on longtime response predicting factors based on consensus criteria. Int J Surg 2014; 12:1428-33. [PMID: 25448666 DOI: 10.1016/j.ijsu.2014.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 09/14/2014] [Accepted: 10/18/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Laparoscopic splenectomy has been proposed to be the standard therapy for adult patients with medically refractory immune thrombocytopenia (ITP). However, due to inconsistent definitions of response, variable rates of long term response have been reported. Furthermore, new medical treatment options are currently challenging the role of splenectomy. The aims of this study were to (1) analyze long term response after splenectomy according to recently defined consensus criteria, (2) identify possible predictive response factors. METHODS A case series of 72 consecutive patients with ITP undergoing laparoscopic splenectomy was retrospectively studied using univariate and multivariate analysis as well as logrank tests. RESULTS Median follow-up was 32 (2-110) months. Mortality was 0% and morbidity was 8.2%. Response to splenectomy was achieved in of 63/72 patients (87.5%). Loss of response occurred in 19/63 (30.2%) in median after 3 (range 2-42) months. Preoperative platelet counts after boosting with steroids and immunoglobulins as well as the postoperative rise in platelet counts were statistically significant factors for response upon both univariate and multivariate analysis, whereas age, gender, body mass index, ASA classification, disease duration, accessory spleens, splenic weight, conversion to open surgery, or perioperative complications were not. Patients with a postoperative rise in platelet counts >150,000/μL had a significant better chance on stable long term response than those with a smaller increment (P < 0.001). CONCLUSIONS Laparoscopic splenectomy is an effective and safe treatment option in order to obtain stable long term response in patients with ITP. Perioperative platelet counts are predictive factors of long term response.
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Affiliation(s)
- Emile Rijcken
- Department of General and Visceral Surgery, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building W1, D-48149 Muenster, Germany.
| | - Soeren Torge Mees
- Department of General and Visceral Surgery, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building W1, D-48149 Muenster, Germany
| | - Guido Bisping
- Mathias Spital Rheine, Frankenburgstr. 31, D-48431 Rheine, Germany
| | - Kristin Krueger
- Department of General and Visceral Surgery, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building W1, D-48149 Muenster, Germany
| | - Matthias Bruewer
- St. Franziskus Hospital Muenster, Hohenzollernring 72, D-48145 Muenster, Germany
| | - Norbert Senninger
- Department of General and Visceral Surgery, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building W1, D-48149 Muenster, Germany
| | - Rudolf Mennigen
- Department of General and Visceral Surgery, Muenster University Hospital, Albert-Schweitzer-Campus 1, Building W1, D-48149 Muenster, Germany
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Li C, Zheng L. The pharmacology and clinical application of thrombopoietin receptor agonists. Int J Hematol 2014; 100:529-39. [DOI: 10.1007/s12185-014-1660-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 08/14/2014] [Accepted: 08/20/2014] [Indexed: 12/17/2022]
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Watanabe T, Matsumura Y, Minowa M, Suzuki H, Notsuda H, Hara Y, Kimura S, Okada Y, Kondo T. Remission of newly diagnosed immune thrombocytopenia after lung cancer resection. Ann Thorac Surg 2014; 97:e105-7. [PMID: 24694449 DOI: 10.1016/j.athoracsur.2013.12.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 11/13/2013] [Accepted: 12/18/2013] [Indexed: 11/19/2022]
Abstract
Secondary immune thrombocytopenia is a rare paraneoplastic syndrome of lung cancer. We report a case of pulmonary pleomorphic carcinoma with newly diagnosed secondary immune thrombocytopenia. On referral, the patient's complete blood cell count was normal; however, it showed marked thrombocytopenia after 1 month. Blood biochemistry and bone marrow puncture showed normal findings. We speculated that he had immune thrombocytopenia associated with the lung cancer and planned lung resection. Sleeve middle and lower lobectomy was successfully performed with preoperative intravenous immunoglobulin and intraoperative platelet transfusion. His platelet count was restored and maintained a normal level at 8 months after the operation.
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Affiliation(s)
- Tatsuaki Watanabe
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan; Division of Chest Surgery, Center of Respiratory Medicine, Ohta Nishinouchi Hospital, Koriyama, Japan.
| | - Yuji Matsumura
- Division of Chest Surgery, Center of Respiratory Medicine, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Muneo Minowa
- Division of Chest Surgery, Center of Respiratory Medicine, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Hirotoshi Suzuki
- Division of Chest Surgery, Center of Respiratory Medicine, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Hirotsugu Notsuda
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan; Division of Chest Surgery, Center of Respiratory Medicine, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Yasuka Hara
- Division of Respiratory Medicine, Center of Respiratory Medicine, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Satoru Kimura
- Center of Hematopoietic Diseases, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Takashi Kondo
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
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Salama A. Current treatment options for primary immune thrombocytopenia. Expert Rev Hematol 2014; 4:107-18. [DOI: 10.1586/ehm.10.76] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Nyo MTL, Kalla AA. Thrombocytopenia and thrombosis: a double-edged sword. Clin Rheumatol 2013; 33:587-90. [PMID: 24196990 DOI: 10.1007/s10067-013-2416-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/18/2013] [Indexed: 01/08/2023]
Abstract
Severe thrombocytopenia with bleeding associated with a life-threatening thrombotic manifestation in the setting of antiphospholipid syndrome is a major diagnostic and therapeutic challenge for the clinician. Hemorrhage is a less common complication than thrombosis in patients with APS, although severe thrombocytopenia can sometimes result in bleeding. There are no evidence-based guidelines regarding the management of a patient with severe thrombocytopenia associated with a major thrombotic manifestation. In this case report, we review the literature reporting the difficulties in management of such patient.
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Affiliation(s)
- Myat Tun Lin Nyo
- Department of Medicine, Division of Rheumatology, Medical University of Southern Africa, MEDUNSA 0204, P O Box 625, Pretoria, South Africa,
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High-dose methylprednisolone pulse therapy upregulated FcγRIIb expression on B cells in primary Sjögren's syndrome patients with thrombocytopenia. Clin Rheumatol 2013; 32:1783-90. [PMID: 23917390 DOI: 10.1007/s10067-013-2344-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 06/26/2013] [Accepted: 07/11/2013] [Indexed: 10/26/2022]
Abstract
Abnormalities in B cell are characteristic feature of primary Sjögren's syndrome (pSS). As FcγRIIb is a key regulator of B cells, the objective of this study is to investigate the role of the inhibitory receptor FcγRIIb in B cells from pSS patients, and whether glucocorticoid can affect B cell subpopulations or FcγRIIb expression. Thirty pSS patients and 15 healthy controls were enrolled in this study. The results showed that the percentage of memory CD19(+)CD27(+) B cells was significantly lower in pSS patients compared to in healthy controls. FcγRIIb expression on memory CD19(+)CD27(+) B cells from active pSS patients was significantly reduced compared with those from inactive or healthy controls. The level of FcγRIIb on memory CD19(+)CD27(+) B cells from active pSS patients was negatively correlated with anti-SSA antibody titers and Sjögren's syndrome disease activity index. After a high-dose methylprednisolone pulse therapy for 3 days, FcγRIIb expression on memory B cells was upregulated, with the raised level of platelets. In vitro, dexamethasone could elevate FcγRIIb expression on B cells of pSS patients in a dose-dependent manner. Taken together, our data suggest that the upregulation of FcγRIIb may be expected to be a new therapeutic strategy in pSS patients.
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Hirakawa T, Kato J, Takahashi S, Suzuki H, Akita M, Inoue I, Deguchi H, Hiraoka S, Okada H, Yamamoto K. Disparity in clinical care for patients with inflammatory bowel disease between specialists and non-specialists. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojgas.2013.31010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Singhal R, Gudimetla V, Stewart A, Luscombe KL, Charalambous CP. Perioperative care of a patient with refractory idiopathic thrombocytopenic purpura undergoing total knee arthroplasty. Knee Surg Relat Res 2012; 24:245-8. [PMID: 23269964 PMCID: PMC3526763 DOI: 10.5792/ksrr.2012.24.4.245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 09/21/2012] [Accepted: 10/24/2012] [Indexed: 11/05/2022] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder leading to low platelet count and an increased risk of bleeding. Major joint replacement surgery in a patient with ITP can be associated with severe postoperative bleeding. We present our experience of perioperative management in a patient with severe refractory chronic idiopathic thrombocytopenic purpura who successfully underwent a cemented total knee replacement.
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Affiliation(s)
- Rohit Singhal
- Department of Trauma and Orthopaedics, Leighton Hospital, Crewe, United Kingdom
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Aoki T, Harada Y, Matsubara E, Suzuki T, Oyama T, Kasai M, Uchida T, Ogura M. Thrombopoietin receptor agonists in refractory immune thrombocytopenia: differential responses to eltrombopag and romiplostim: a case report and possible explanations. J Clin Pharm Ther 2012; 37:729-32. [DOI: 10.1111/j.1365-2710.2012.01353.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Brown TM, Horblyuk RV, Grotzinger KM, Matzdorff AC, Pashos CL. Patient-reported treatment burden of chronic immune thrombocytopenia therapies. BMC BLOOD DISORDERS 2012; 12:2. [PMID: 22436142 PMCID: PMC3350461 DOI: 10.1186/1471-2326-12-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 03/22/2012] [Indexed: 01/06/2023]
Abstract
Background Chronic immune thrombocytopenia (ITP) is a debilitating autoimmune disorder that causes a reduction in blood platelets and increased risk of bleeding. ITP is currently managed with various pharmacologic therapies and splenectomy. This study was conducted to assess patient perceived and reported treatment side effects, as well as the perceived burden or bother, and need to reduce or stop treatment, associated with these side effects among adult patients with chronic ITP. Methods A Web-enabled survey was administered to members of a US-based ITP patient support group. Patients reported demographic and clinical characteristics, ITP treatments' side effects for treatments received since diagnosed, level of bother (or distress), and need to reduce or stop treatment, associated with side effects. Current and past exposure was assessed for five specific treatment types: corticosteroids (CS), intravenous immunoglobulin (IVIg), anti-D immunoglobulin (anti-D), rituximab (RT), and splenectomy (SPL), as well as for other patient-referenced therapies (captured as "other"). Results The survey was completed by 589 patients; 78% female, 89% white, mean age 48 years (SD = 14.71), and 68% reported a typical low platelet count of < 50,000/μL. Current or past treatment with CS was reported by 92% (n = 542) of patients, 56% (n = 322) for IVIg, 36% (n = 209) for anti-D, 36% (n = 213) for RT, and 39% (n = 227) for SPL. A substantial proportion of CS-treated patients reported side effects (98%, P < 0.05), were highly bothered by their side effects (53.1%, P < 0.05), and reported the need to stop or reduce treatment due to side effects (37.8%, P < 0.05). Among patients reporting side effects of treatment, significant associations were noted for the number of side effects, aggregate bother of reported side effects, and the need to stop or reduce treatment (all P < 0.05). Conclusions Current ITP treatments, particularly corticosteroids, are associated with multiple bothersome side effects that may lead to patients stopping or reducing therapy. Open, informed and complete communication between clinician and patient regarding both the benefits and the side effects of ITP treatment may better prepare patients for their prescribed regimens.
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Affiliation(s)
| | | | | | - Axel C Matzdorff
- Department of Hematology and Oncology, Caritasklinikum Saarbruecken, St. Theresia, Saarbruecken, Germany
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Reversible bone marrow reticulin fibrosis as a side effect of romiplostim therapy for the treatment of chronic refractory immune thrombocytopenia. Pathology 2011; 43:520-2. [PMID: 21753725 DOI: 10.1097/pat.0b013e328348fecc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Roca M, Muñiz-Diaz E, Mora J, Romero-Zayas I, Ramón O, Roig I, Pujol-Moix N. The scintigraphic index spleen/liver at 30 minutes predicts the success of splenectomy in persistent and chronic primary immune thrombocytopenia. Am J Hematol 2011; 86:909-13. [PMID: 21948335 DOI: 10.1002/ajh.22147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 07/08/2011] [Accepted: 07/13/2011] [Indexed: 11/09/2022]
Abstract
UNLABELLED Splenectomy is considered the second-line of treatment in patients with chronic primary immune thrombocytopenia (ITP) in whom glucocorticoids have failed. Some patients do not respond to splenectomy or they have postoperative complications. Based on our previous experience using kinetic and scintigraphic parameters, we did a retrospective study with the aim of comparing all these parameters as a means of predicting the success of splenectomy in persistent and chronic primary ITP. Forty-one consecutive patients with chronic primary ITP refractory to prednisone, who had been splenectomized, were included in the study. The response to splenectomy was assessed by evaluating bleeding and platelet counts before and at different times after surgery. A complete platelet kinetic study was performed before the splenectomy using autologous (111) In-labeled platelets. The scintigraphic parameters measured included different indices between spleen/heart, liver/hearth, and spleen/liver. Thirty-six patients gave a complete response after splenectomy and five patients did not respond. A statistically significant difference between both groups was found with initial platelet recovery and with some scintigraphic indices which also showed a variable prediction value for the success of splenectomy. Among these indices, the spleen/liver at 30 minutes demonstrated a predictive value with a 100% of sensitivity and a 100% of specificity. CONCLUSION some platelet kinetic parameters and scintigraphic indices, in particular the spleen/liver at 30 minutes, were useful to predict the outcome of splenectomy in persistent and chronic primary ITP and, therefore, they should be taken into account when deciding whether or not to perform a splenectomy.
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Affiliation(s)
- Manel Roca
- Department of Nuclear Medicine, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
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Fang B, Mai L, Li N, Song Y. Favorable response of chronic refractory immune thrombocytopenic purpura to mesenchymal stem cells. Stem Cells Dev 2011; 21:497-502. [PMID: 21711157 DOI: 10.1089/scd.2011.0231] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Seven patients with chronic refractory immune thrombocytopenic purpura (ITP) received adipose tissue-derived mesenchymal stem cells (AMSC) from haplo-identical family donors. The AMSC dose was 2.0×10(6)/kg. No side effects were noted after the AMSC infusions. Overall responses were reached in all patients and sustained response rate was 57.1% (4/7). The serum levels of transforming growth factor β1 (TGF-β1), interleukin (IL)-4, and IL-10 were significantly elevated, whereas those of interferon-γ (IFN-γ) and IL-2 were significantly decreased after AMSC administration, compared with those in the patients with active ITP. During follow-up, the cytokine profiles in patients maintaining sustained response remained stable compared with the post-treatment level, but IFN-γ and IL-2 levels were significantly increased, and those of TGF-β1, IL-4, and IL-10 were significantly reduced again in relapsed patients. AMSC therapy seems to represent reasonable salvage treatment in severe, chronic refractory ITP by causing a shift in the Th1/Th2 cytokine balance to the same levels as normal controls.
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Affiliation(s)
- Baijun Fang
- Henan Key Laboratory of Experimental Haematology, Henan Institute of Haematology, Henan Tumor Hospital, Zhengzhou University, Zhengzhou, China
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Stasi R. Pathophysiology and therapeutic options in primary immune thrombocytopenia. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:262-73. [PMID: 21251458 PMCID: PMC3136592 DOI: 10.2450/2010.0080-10] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/12/2010] [Accepted: 10/11/2010] [Indexed: 01/11/2023]
Affiliation(s)
- Roberto Stasi
- Department of Haematology, St George's Hospital, Blackshaw Road, London, United Kingdom.
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Abstract
Strategies aimed at stimulating platelet production are a rational approach to the treatment of patients with primary immune thrombocytopenia, as, for many of them, the low platelet count is a consequence of ineffective megakaryopoiesis. Recently, intense clinical trial activity in immune thrombocytopenia has been reported for second-generation thrombopoietic agents. These novel molecules bear no structural resemblance to thrombopoietin, but still bind and activate the thrombopoietin receptor. One of these agents is eltrombopag (formerly SB497115), an orally available, small organic compound. Randomized trials have shown the short-term efficacy of eltrombopag in elevating the platelet count of most adult patients with immune thrombocytopenia unresponsive to at least one standard treatment. No significant adverse events were observed, but long-term safety data are still lacking. Ongoing studies will reveal the potential of this agent in the management of immune thrombocytopenia for long-term maintenance therapy, as well as its relative benefit compared with standard-of-care treatment.
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Affiliation(s)
- Roberto Stasi
- Department of Medical Sciences, Regina Apostolorum Hospital, Via S Francesco 50, Albano Laziale, Italy.
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Cheng G, Saleh MN, Marcher C, Vasey S, Mayer B, Aivado M, Arning M, Stone NL, Bussel JB. Eltrombopag for management of chronic immune thrombocytopenia (RAISE): a 6-month, randomised, phase 3 study. Lancet 2011; 377:393-402. [PMID: 20739054 DOI: 10.1016/s0140-6736(10)60959-2] [Citation(s) in RCA: 381] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Eltrombopag is an oral thrombopoietin receptor agonist for the treatment of thrombocytopenia. We aimed to compare the response to once daily eltrombopag versus placebo in patients with chronic immune thrombocytopenia during a 6-month period. METHODS We undertook a phase 3, double-blind, placebo-controlled study in adults with previously treated immune thrombocytopenia of more than 6 months' duration who had baseline platelet counts lower than 30,000 per μL. Patients were randomly allocated (in a 2:1 ratio) treatment with local standard of care plus 50 mg eltrombopag or matching placebo once daily for 6 months. Randomisation was done centrally with a computer-generated randomisation schedule and was stratified by baseline platelet count (≤ 15,000 per μL), use of treatment for immune thrombocytopenia, and splenectomy status. Patients, investigators, and those assessing data were masked to allocation. Dose modifications were made on the basis of platelet response. Patients were assessed for response to treatment (defined as a platelet count of 50,000-400,000 per μL) weekly during the first 6 weeks and at least once every 4 weeks thereafter; the primary endpoint was the odds of response to eltrombopag versus placebo. Analysis was by intention to treat. This study is registered at ClinicalTrials.gov, number NCT00370331. FINDINGS Between Nov 22, 2006, and July 31, 2007, 197 patients were randomly allocated to treatment groups and were included in the intention-to-treat analysis (135 eltrombopag, 62 placebo). 106 (79%) patients in the eltrombopag group responded to treatment at least once during the study, compared with 17 (28%) patients in the placebo group. The odds of responding were greater in patients in the eltrombopag group compared with those in the placebo group throughout the 6-month treatment period (odds ratio 8·2, 99% CI 3·59-18·73; p<0·0001). 37 (59%) patients receiving eltrombopag reduced concomitant treatment versus ten (32%) patients receiving placebo (p=0·016). 24 (18%) patients receiving eltrombopag needed rescue treatment compared with 25 (40%) patients receiving placebo (p=0·001). Three (2%) patients receiving eltrombopag had thromboembolic events compared with none in patients on placebo. Nine (7%) eltrombopag-treated patients and two (3%) in the placebo group had mild increases in alanine aminotransferase concentration, and five (4%) eltrombopag-treated patients (vs none allocated to placebo) had increases in total bilirubin. Four (7%) patients taking placebo had serious bleeding events, compared with one (<1%) patient treated with eltrombopag. INTERPRETATION Eltrombopag is effective for management of chronic immune thrombocytopenia, and could be particularly beneficial for patients who have not responded to splenectomy or previous treatment. These benefits should be balanced with the potential risks associated with eltrombopag treatment. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Gregory Cheng
- Chinese University of Hong Kong, Shatin, NT, Hong Kong SAR, China.
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Clausen MR, Segel E, Brandsborg M, d′Amore F. Very long-term remission induced by short-term rituximab monotherapy in a patient with heavily pretreated, chronic immune thrombocytopenic purpura. Eur J Haematol 2011; 86:256-9. [DOI: 10.1111/j.1600-0609.2010.01561.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Albayrak M, Balcik OS, Aki SZ, Gokmen A, Ceran F, Yokus O, Dagdas S, Ayli M, Ozet G. Evaluation of 143 cases of immune thrombocytopenic purpura with regards to clinical course and response to treatment. Eurasian J Med 2010; 42:120-3. [PMID: 25610140 DOI: 10.5152/eajm.2010.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Accepted: 10/05/2010] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Immune thrombocytopenic purpura (ITP) is also known as idiopathic thrombocytopenic purpura. Increased platelet destruction and insufficient platelet production are both responsible for its etiopathogenesis. ITP can be diagnosed after excluding other possible causes of thrombocytopenia. MATERIALS AND METHODS One hundred forty-three cases of chronic ITP that were monitored in a hematology clinic were retrospectively evaluated. All cases received first line treatment of 1 mg/kg/day prednisolone. Corticosteroid nonresponsive (CN) cases and corticosteroid-dependent (CD) cases underwent splenectomies. RESULTS The rate of CN/CD cases was found to be 53% (n=76). Sixty-six percent of these cases (n=50) underwent splenectomies. The ratio of non-responsive cases to relapse cases after splenectomy (SN/SR) was 30% (n=15). The total number of cases was 41, including those without splenectomy (n=26) and with SY/SR (n=15). Helicobacter pylori (Hp) eradication, immunosuppressive agents and danazol treatments were administered to patients (n=10, n=14 and n=4, respectively). Currently, 13 patients are being monitored without treatment. Fifteen patients who were non-responsive to Hp eradication treatment, immunosuppressive treatment or danazol treatment are still being monitored without any treatment. CONCLUSION Optimal treatment is not available for splenectomy-resistant cases of ITP. The response rates for Hp eradication treatment, immunosuppressive treatments and anabolic agents are low. Therefore, larger studies with more patients are required using new agents, such as thrombopoietin (TPO) receptor agonists and anti-CD20 monoclonal antibodies.
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Affiliation(s)
- Murat Albayrak
- Department of Hematology, Diskapi Yildirim Beyazit Education and Research Hospital, Ankara, Turkey
| | - Ozlem Sahin Balcik
- Department of Hematology, Medical School, Fatih University, Ankara, Turkey
| | - Sahika Zeynep Aki
- Department of Hematology, Medical School, Gazi University, Ankara, Turkey
| | - Ayla Gokmen
- Department of Hematology, Medical School, Zonguldak Karaelmas University, Zonguldak, Turkey
| | - Funda Ceran
- Department of Hematology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Osman Yokus
- Department of Hematology, Istanbul Okmeydani Education and Research Hospital, Istanbul, Turkey
| | - Simten Dagdas
- Department of Hematology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Meltem Ayli
- Department of Hematology, Medical School, Ufuk University, Ankara, Turkey
| | - Gulsum Ozet
- Department of Hematology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Han JJ, Baek SK, Lee JJ, Kim SY, Cho KS, Yoon HJ. Long-term outcomes of a 5-year follow up of patients with immune thrombocytopenic purpura after splenectomy. THE KOREAN JOURNAL OF HEMATOLOGY 2010; 45:197-204. [PMID: 21120210 PMCID: PMC2983037 DOI: 10.5045/kjh.2010.45.3.197] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 08/12/2010] [Accepted: 09/02/2010] [Indexed: 01/15/2023]
Abstract
Background The long-term outcomes of adult patients with immune thrombocytopenic purpura (ITP) after splenectomy are not clear. Methods We retrospectively analyzed 31 patients who underwent splenectomy after diagnosis of ITP at our institution between 1990 and 2009. Long-term follow-up was defined as a follow-up that lasted 1 year or more from splenectomy to the last follow-up. Results The overall response rate to splenectomy was 84%. However, the response rate at 6 and 12 months decreased to 77% and 68%, respectively. During the 6 years of median follow-up after splenectomy, 11 patients (35%) relapsed. The long-term response rate was 55%. The long-term follow-up of 26 patients after responding to splenectomy showed that the median time from splenectomy to relapse was 19 months in the partial response (PR) group; however, there was no relapse after 9 months in the complete response (CR) group. Variables, including age, were not predictive of the long-term response after splenectomy. Additional treatment in patients who did not respond or relapsed after splenectomy was mostly effective. After a median follow-up of 7 years (range: 1-25 years) from the diagnosis, there were 2 deaths, including one due to spontaneous bleeding after repair of duodenal ulcer perforation. Conclusion Although splenectomy is safe and effective, the response rate after splenectomy continuously decreases over time. The duration of response is different between the patients that achieved CR and those that achieved PR. Factors, including age, were not predictors of a response to splenectomy.
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Affiliation(s)
- Jae Joon Han
- Department of Hematology-Oncology, School of Medicine, Kyung Hee University, Seoul, Korea
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Should medical treatment options be exhausted before splenectomy is performed in adult ITP patients? A debate. Ann Hematol 2010; 89:1185-95. [DOI: 10.1007/s00277-010-1066-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 08/22/2010] [Indexed: 12/23/2022]
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Eltrombopag: an update on the novel, non-peptide thrombopoietin receptor agonist for the treatment of immune thrombocytopenia. Ann Hematol 2010; 89 Suppl 1:67-74. [DOI: 10.1007/s00277-010-0953-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 03/22/2010] [Indexed: 12/14/2022]
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Zhao H, Du W, Wang D, Gu D, Xue F, Ge J, Sui T, Yang R. Single nucleotide polymorphism in the methyl-CpG binding domain 4 Gene and the risk for immune thrombocytopenic purpura in Chinese population. Platelets 2010; 21:132-6. [DOI: 10.3109/09537100903474365] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Nomura S, Kurata Y, Tomiyama Y, Takubo T, Hasegawa M, Saigo K, Nishikawa M, Higasa S, Maeda Y, Hayashi K. Effects of bisphosphonate administration on the bone mass in immune thrombocytopenic purpura patients under treatment with steroids. Clin Appl Thromb Hemost 2009; 16:622-7. [PMID: 19959489 DOI: 10.1177/1076029609350889] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Immune thrombocytopenic purpura (ITP) is an acquired hemorrhage condition involving accelerated platelet consumption caused by antiplatelet autoantibodies. Although various therapeutic strategies are used to treat patients with ITP, the standard treatment method is steroid therapy. The most important problem with steroid administration may be a prolonged use tendency in many cases, because there are many refractory chronic patients. To elucidate the effects of glucocorticoid on bone mineral density (BMD) in patients with ITP, we retrospectively evaluated the relationship between BMD and the total dose of glucocorticoid or the mean daily dose given. We observed decreased BMD in 66.7% of the patients with ITP to whom glucocorticoid was given, although normal bone BMD was observed in 28.6% of patients with ITP treated without steroids. The mean level of BMD was markedly decreased in steroid-treated patients compared with nonsteroid-treated patients (P < .01). The relationship between BMD and the total dose of glucocorticoid (P = .023) or the mean daily dose revealed a negative correlation (P = .022). Administration of bisphosphonate revealed a significant increase in bone mass in patients at 6 and 12 months after the start of bisphosphonate treatment, despite the aggravation of thrombocytopenia. In conclusion, glucocorticoid-induced osteoporosis was observed in patients with ITP, similar to situation seen in patients with other diseases. Bisphosphonate may be an effective agent for the prevention and treatment of glucocorticoid-induced osteoporosis in patients with ITP scheduled to receive long-term steroid treatment.
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Saleh MN, Fisher M, Grotzinger KM. Analysis of the impact and burden of illness of adult chronic ITP in the US. Curr Med Res Opin 2009; 25:2961-9. [PMID: 19835465 DOI: 10.1185/03007990903362388] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Chronic idiopathic thrombocytopenic purpura (ITP), the predominant diagnosis in the ICD-9-CM category of primary thrombocytopenia in adults, is an autoimmune disease characterized by autoantibody-mediated platelet destruction and reduced platelet production. The objective of this study was to describe ITP patient demographics, treatment, medical care resource utilization, and costs from a real-world situation. RESEARCH DESIGN AND METHODS Managed-care administrative claims data from January 1 2000 to February 29 2004 were used in a retrospective, longitudinal cohort study to evaluate the burden of illness of chronic idiopathic primary thrombocytopenia among adults in the US, with particular emphasis on chronic ITP. RESULTS The annual prevalence of chronic, non-secondary, idiopathic thrombocytopenia in adults (out of >5.5 million patients) was 0.08% (i.e., 80 persons in 100 000). The mean age of the total cohort was 56.5 years (men, 60.2; women, 53.3); ratio of women to men was 1.1:1. The most frequently used thrombocytopenia-associated treatments were pharmacological therapy (e.g., immunoglobulins and corticosteroids) and whole blood transfusions; frequently used concomitant medications were antibiotics, antihypertensive agents, analgesics, and antidepressants. These data indicate that idiopathic thrombocytopenia-associated medical resource utilization and the corresponding expenditures for those services were substantive and constant over time. A large proportion of the overall patient care was directed to the treatment of bleeding and bruising symptoms. Although hospital and ER use was infrequent, these services accounted for the majority of ITP-attributable costs (46.1% were attributable to ITP-related hospital admissions; 45.0% were attributable to ER services for ITP). CONCLUSIONS There is a need for patient-directed care plans, fuller consideration of available treatments, and the potential reduction in patient burden of illness. Study limitations included a broadly defined cohort and possible underreporting of certain medications. Introduction of highly effective and well-tolerated medications may reduce the cost and resource burden of ITP on the healthcare system.
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Combination immunosuppressant therapy for patients with chronic refractory immune thrombocytopenic purpura. Blood 2009; 115:29-31. [PMID: 19897578 DOI: 10.1182/blood-2009-06-222448] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Treatment options for patients with chronic refractory immune thrombocytopenic purpura (ITP) are limited. Because combination immunosuppressant therapy appeared to be effective in ITP and other disorders, we used this approach in patients with particularly severe and refractory ITP. In this retrospective, observational study, we determined the response (platelet count above 30 x 10(9)/L and doubling of baseline) among 19 refractory ITP patients. Treatment consisted of azathioprine, mycophenolate mofetil, and cyclosporine. The patients had failed a median of 6 prior treatments, including splenectomy (in all except 1). Of 19 patients, 14 (73.7%) achieved a response lasting a median of 24 months, after which time 8 (57.1%) relapsed. Of the 8 relapsing patients, 6 responded to additional treatments. Of the 14 patients who achieved an initial response, 2 (14.3%) remained in remission after eventually stopping all medications. Severe adverse events did not occur. Combination immunosuppressant therapy can produce a rise in the platelet count that is sometimes sustained in refractory ITP patients.
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Rodeghiero F, Besalduch J, Michel M, Provan D, Grotzinger K, Thompson G. Treatment practices in adults with chronic immune thrombocytopenia - a European perspective. Eur J Haematol 2009; 84:160-8. [PMID: 19845743 DOI: 10.1111/j.1600-0609.2009.01361.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Immune thrombocytopenia (ITP) is characterised by platelet destruction and impaired production leading to isolated thrombocytopenia. The aim of this study, comprising a retrospective longitudinal cohort study complemented by a Delphi panel of 35 physicians, was to describe standard treatment practices and treating physician's perception and preferences for available treatment options in chronic ITP. The medical records of 610 patients were reviewed over 12 months. Mean age at the start of the observational period was 54.6 yr, median platelet count 77 x 10(9)/L with 41% of patients having symptoms of ITP. Treated patients (61%) received an average of 2.7 medications either for ITP or ITP treatment-related side effects. An array of products was used, but the most frequent were corticosteroids. Delphi panel physicians (45%) indicated the main goals for treatment were to increase platelet levels to at least 30 x 10(9)/L to prevent bleeding or haemorrhage. The majority (89%) indicated that personal experience influenced treatment choice. Most (>80%) rated splenectomy and high-dose corticosteroids as the most effective but were concerned about side effects, and many (75%) would like access to interventions with improved efficacy and safety. The study highlights the need for updated evidence-based treatment guidelines to assist physicians in patient treatment decisions and to realise improvements in patient outcomes. It also identified perceived shortcomings of existing therapies and the need to establish an evidence base for newer interventions that could potentially make lasting response to treatment with fewer adverse effects an achievable goal.
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Affiliation(s)
- Francesco Rodeghiero
- Department of Cellular Therapy and Haematology, Ospedale S, Bortolo di Vicenza, Italy.
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