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Elsayed A, Elsayed B, Elmarasi M, Elsabagh AA, Elsayed E, Elmakaty I, Yassin M. Thrombopoietin Receptor Agonists in Post-Hematopoietic Cell Transplantation Complicated by Prolonged Thrombocytopenia: A Comprehensive Review. Immunotargets Ther 2024; 13:461-486. [PMID: 39290805 PMCID: PMC11407319 DOI: 10.2147/itt.s463384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 08/08/2024] [Indexed: 09/19/2024] Open
Abstract
Hematopoietic cell transplantation (HCT) is a well-established procedure that has become a therapeutic mainstay for various hematological conditions. Prolonged thrombocytopenia following HCT is associated with a significant risk of morbidity and mortality, yet no universally recognized treatment protocol exists for such a complication. First-generation thrombopoietin receptor (TpoR) agonists as well as second-generation agents are known for their role in enhancing platelet production, and their use is expanding across various thrombocytopenic conditions. Therefore, we conducted this comprehensive review of the literature to provide an updated evaluation of the use of TpoR agonists and explore their efficacy and safety in the treatment of extended post-HCT thrombocytopenia. The literature search was conducted using PubMed database from 1996 through December 2023, using a predefined strategy with medical subject headings terms. We identified 64 reports on the utility of TpoR agonists, five of them were randomized controlled trials and the rest were retrospective observational studies and case series, with a total number of 1730 patients. Second-generation TpoR agonists appear more convenient than subcutaneous recombinant human thrombopoietin (rhTpo) as they can be orally administered and exhibit similar efficacy in platelet recovery, as indicated by recent trial results. Among these agents, avatrombopag, unlike eltrombopag, does not require any dietary restrictions, which could be more favorable for patients. However, eltrombopag remains the most extensively studied agent. TpoR agonists had promising effects in the treatment of post-HCT thrombocytopenia with a good safety profile so far, highlighting the potential benefit of their use.
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Affiliation(s)
| | - Basant Elsayed
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Elmarasi
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | | | - Engy Elsayed
- College of Medicine, Qatar University, Doha, Qatar
| | - Ibrahim Elmakaty
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Yassin
- College of Medicine, Qatar University, Doha, Qatar
- Hematology Section, National Center for Cancer Care and Research (NCCCR), Doha, Qatar
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2
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Yu J, Miao P, Qian S. Application of recombinant human thrombopoietin in pregnant women with immune thrombocytopenia: a single-center experience of four patients and literature review. J Int Med Res 2023; 51:3000605231187950. [PMID: 37548331 PMCID: PMC10408329 DOI: 10.1177/03000605231187950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023] Open
Abstract
The management of pregnant women with immune thrombocytopenia who fail to respond to corticosteroids and intravenous immunoglobulin is an intractable clinical challenge because of the limited availability of evidence-based information. Recombinant human thrombopoietin (rhTPO) is recommended for refractory immune thrombocytopenia (ITP). To date, however, few studies have investigated rhTPO treatment during pregnancy. We retrospectively reviewed four cases who were diagnosed with ITP and treated with rhTPO during pregnancy in our center from January 2015 to June 2020. Of the four cases, two (50%) responded to rhTPO treatment. No adverse events were noted in the newborns. Our findings indicate that rhTPO treatment is safe for patients with refractory gestational ITP, and that subcutaneous injection is a convenient delivery method that does not lead to adverse events. Thus, rhTPO may be a viable alternative treatment option for patients with refractory gestational ITP who do not respond to first-line therapies.
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Affiliation(s)
- Jingdi Yu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Peiwen Miao
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang Chinese Medical University, Hangzhou, China
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3
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Doberne JW, Maisonave Y, DeVore A, Guinn N, Schroder JN. Bloodless HeartMate 3 explantation and orthotopic heart transplant in a heart failure patient refusing blood products. J Heart Lung Transplant 2022; 41:1859-1860. [PMID: 36115786 DOI: 10.1016/j.healun.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Julie W Doberne
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Yasmin Maisonave
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Adam DeVore
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Nicole Guinn
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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4
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van Dijk WEM, van Es RJJ, Correa MEP, Schutgens REG, van Galen KPM. Dentoalveolar Procedures in Immune Thrombocytopenia; Systematic Review and an Institutional Guideline. TH OPEN 2021; 5:e489-e502. [PMID: 34805736 PMCID: PMC8595053 DOI: 10.1055/a-1641-7770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background
Dentoalveolar procedures in immune thrombocytopenia (ITP) pose a risk of bleeding due to thrombocytopenia and infection due to immunosuppressive treatments. We aimed to systematically review the safety and management of dentoalveolar procedures in ITP patients to create practical recommendations.
Methods
PubMed, Embase, Cochrane, and Cinahl were searched for original studies on dentoalveolar procedures in primary ITP patients. We recorded bleeding- and infection-related outcomes and therapeutic strategies. Clinically relevant bleeding was defined as needing medical attention.
Results
Seventeen articles were included, of which 12 case reports/series. Overall, the quality of the available evidence was poor. Outcomes and administered therapies (including hemostatic therapies and prophylactic antibiotics) were not systematically reported. At least 73 dentoalveolar procedures in 49 ITP patients were described. The range of the preoperative platelet count was 2 to 412 × 10
9
/L. Two clinically relevant bleedings (2%) were reported in the same patient of which one was life-threatening. Strategies used to minimize the risk of bleeding were heterogeneous and included therapies to increase platelet count, antifibrinolytics, local measures, and minimally invasive techniques. Reports on the occurrence of bleedings due to anesthetics or infection were lacking.
Conclusion
Based on alarmingly limited data, clinically relevant bleedings and infections after dentoalveolar procedures in ITP patients seem rare. Awaiting prospective and controlled studies to further evaluate these risks and the efficacy of therapeutic interventions, we provided our institutional guideline to guide the management of dentoalveolar procedures in ITP patients.
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Affiliation(s)
- Wobke E M van Dijk
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert J J van Es
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria E P Correa
- Oral Medicine Ambulatory, Hematology and Hemotherapy Center, University of Campinas, Campinas, Sao Paulo, Brazil
| | - Roger E G Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karin P M van Galen
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
PURPOSE OF REVIEW In this review, we discuss recent developments and trends in the perioperative management of thrombocytopenia. RECENT FINDINGS Large contemporary data base studies show that preoperative thrombocytopenia is present in about 8% of asymptomatic patients, and is associated with increased risks for bleeding and 30-day mortality. Traditionally specific threshold platelet counts were recommended for specific procedures. However, the risk of bleeding may not correlate well with platelet counts and varies with platelet function depending on the underlying etiology. Evidence to support prophylactic platelet transfusion is limited and refractoriness to platelet transfusion is common. A number of options exist to optimize platelet counts prior to procedures, which include steroids, intravenous immunoglobulin, thrombopoietin receptor agonists, and monoclonal antibodies. In addition, intraoperative alternatives and adjuncts to transfusion should be considered. It appears reasonable to use prophylactic desmopressin and antifibrinolytic agents, whereas activated recombinant factor VII could be considered in severe bleeding. Other options include enhancing thrombin generation with prothrombin complex concentrate or increasing fibrinogen levels with fibrinogen concentrate or cryoprecipitate. SUMMARY Given the lack of good quality evidence, much research remains to be done. However, with a multidisciplinary multimodal perioperative strategy, the risk of bleeding can be decreased effectively.
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6
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Bussel JB, Soff G, Balduzzi A, Cooper N, Lawrence T, Semple JW. A Review of Romiplostim Mechanism of Action and Clinical Applicability. Drug Des Devel Ther 2021; 15:2243-2268. [PMID: 34079225 PMCID: PMC8165097 DOI: 10.2147/dddt.s299591] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Thrombocytopenia results from a variety of conditions, including radiation, chemotherapy, autoimmune disease, bone marrow disorders, pathologic conditions associated with surgical procedures, hematopoietic stem cell transplant (HSCT), and hematologic disorders associated with severe aplastic anemia. Immune thrombocytopenia (ITP) is caused by immune reactions that accelerate destruction and reduce production of platelets. Thrombopoietin (TPO) is a critical component of platelet production pathways, and TPO receptor agonists (TPO-RAs) are important for the management of ITP by increasing platelet production and reducing the need for other treatments. Romiplostim is a TPO-RA approved for use in patients with ITP in the United States, European Union, Australia, and several countries in Africa and Asia, as well as for use in patients with refractory aplastic anemia in Japan and Korea. Romiplostim binds to and activates the TPO receptor on megakaryocyte precursors, thus promoting cell proliferation and viability, resulting in increased platelet production. Through this mechanism, romiplostim reduces the need for other treatments and decreases bleeding events in patients with thrombocytopenia. In addition to its efficacy in ITP, studies have shown that romiplostim is effective in improving platelet counts in various settings, thereby highlighting the versatility of romiplostim. The efficacy of romiplostim in such disorders is currently under investigation. Here, we review the structure, mechanism, pharmacokinetics, and pharmacodynamics of romiplostim. We also summarize the clinical evidence supporting its use in ITP and other disorders that involve thrombocytopenia, including chemotherapy-induced thrombocytopenia, aplastic anemia, acute radiation syndrome, perisurgical thrombocytopenia, post-HSCT thrombocytopenia, and liver disease.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Gerald Soff
- Department of Medicine, Hematology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | | | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
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Kuter DJ, Tarantino MD, Lawrence T. Clinical overview and practical considerations for optimizing romiplostim therapy in patients with immune thrombocytopenia. Blood Rev 2021; 49:100811. [PMID: 33781612 DOI: 10.1016/j.blre.2021.100811] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/23/2020] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
The fundamental treatment goal for patients with immune thrombocytopenia (ITP) is reduced or ameliorated bleeding. Although various treatment options exist for the management of ITP, recent advances have led to the approval of three thrombopoietin receptor agonists (TPO-RAs; romiplostim, eltrombopag, and avatrombopag) in the United States and European Union. Current treatment guidelines for ITP indicate that medical therapy is preferred over surgical therapy and support the use of TPO-RAs as early as 3 months after disease onset. More recent data are available on the use of romiplostim in patients who have had ITP for <1 year, and romiplostim is now indicated for the treatment of adults who have not responded adequately to initial treatment, as well as children aged ≥1 year who have had ITP for ≥6 months. Here we review the role of romiplostim in the management of ITP, with a focus on efficacy and safety data, emerging data on early use (beginning within 3 months of disease onset) and treatment-free remission, and practical considerations for optimal management of ITP.
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Affiliation(s)
- David J Kuter
- Hematology Division, Massachusetts General Hospital, Suite 118, Room 110, Zero Emerson Place, Boston, MA 02114, USA.
| | - Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, 9128 North Lindbergh Drive, Peoria, IL 61615, USA.
| | - Tatiana Lawrence
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 91320, USA.
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8
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Arnold DM, Heddle NM, Cook RJ, Hsia C, Blostein M, Jamula E, Sholzberg M, Lin Y, Kassis J, Larratt L, Tinmouth A, Amini S, Schipperus M, Lim W, Vishnu P, Warner M, Carruthers J, Li N, Lane S, Kelton JG. Perioperative oral eltrombopag versus intravenous immunoglobulin in patients with immune thrombocytopenia: a non-inferiority, multicentre, randomised trial. LANCET HAEMATOLOGY 2020; 7:e640-e648. [PMID: 32853584 DOI: 10.1016/s2352-3026(20)30227-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Patients with immune thrombocytopenia are at risk of bleeding during surgery, and intravenous immunoglobulin is commonly used to increase the platelet count. We aimed to establish whether perioperative eltrombopag was non-inferior to intravenous immunoglobulin. METHODS We did a randomised, open-label trial in eight academic hospitals in Canada. Patients were aged at least 18 years, with primary or secondary immune thrombocytopenia and platelet counts less than 100 × 109 cells per L before major surgery or less than 50 × 109 cells per L before minor surgery. Previous intravenous immunoglobulin within 2 weeks or thrombopoietin receptor agonists within 4 weeks before randomisation were not permitted. Patients were randomly assigned to receive oral daily eltrombopag 50 mg from 21 days preoperatively to postoperative day 7 or intravenous immunoglobulin 1 g/kg or 2 g/kg 7 days before surgery. Eltrombopag dose adjustments were allowed weekly based on platelet counts. The randomisation sequence was generated by a computerised random number generator, concealed and stratified by centre and surgery type (major or minor). The central study statistician was masked to treatment allocation. The primary outcome was achievement of perioperative platelet count targets (90 × 109 cells per L before major surgery or 45 × 109 cells per L before minor surgery) without rescue treatment. We did intention-to-treat and per-protocol analyses using an absolute non-inferiority margin of -10%. This trial is registered with ClinicalTrials.gov, NCT01621204. FINDINGS Between June 5, 2013, and March 7, 2019, 92 patients with immune thrombocytopenia were screened, of whom 74 (80%) were randomly assigned: 38 to eltrombopag and 36 to intravenous immunoglobulin. Median follow-up was 50 days (IQR 49-55). By intention-to-treat analysis, perioperative platelet targets were achieved for 30 (79%) of 38 patients assigned to eltrombopag and 22 (61%) of 36 patients assigned to intravenous immunoglobulin (absolute risk difference 17·8%, one-sided lower limit of the 95% CI 0·4%; pnon-inferiority=0·005). In the per-protocol analysis, perioperative platelet targets were achieved for 29 (78%) of 37 patients in the eltrombopag group and 20 (63%) of 32 in the intravenous immunoglobulin group (absolute risk difference 15·9%, one-sided lower limit of the 95% CI -2·1%; pnon-inferiority=0·009). Two serious adverse events occurred in the eltrombopag group: one treatment-related pulmonary embolism and one vertigo. Five serious adverse events occurred in the intravenous immunoglobulin group (atrial fibrillation, pancreatitis, vulvar pain, chest tube malfunction and conversion to open splenectomy); all were related to complications of surgery. No treatment-related deaths occurred. INTERPRETATION Eltrombopag is an effective alternative to intravenous immunoglobulin for perioperative treatment of immune thrombocytopenia. However, treatment with eltrombopag might increase risk of thrombosis. The decision to choose one treatment over the other will depend on patient preference, resource limitations, cost, and individual risk profiles. FUNDING GlaxoSmithKline and Novartis.
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Affiliation(s)
- Donald M Arnold
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada; Canadian Blood Services, Ancaster, ON, Canada.
| | - Nancy M Heddle
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard J Cook
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON, Canada
| | - Cyrus Hsia
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
| | - Mark Blostein
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Erin Jamula
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jeannine Kassis
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Loree Larratt
- Division of Hematology, University of Alberta, Edmonton, AB, Canada
| | - Alan Tinmouth
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sufia Amini
- Department of Hematology, HagaZiekenhuis, The Hague, Netherlands
| | - Martin Schipperus
- Department of Hematology, HagaZiekenhuis, The Hague, Netherlands; Department of Hematology, University Medical Centre Groningen, Groningen, Netherlands
| | - Wendy Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Prakash Vishnu
- Division of Hematology, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | | | - Julie Carruthers
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Na Li
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon Lane
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John G Kelton
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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9
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Bussel JB, Kuter D. Preparing patients with immune thrombocytopenia for surgery: what are the options? LANCET HAEMATOLOGY 2020; 7:e626-e627. [PMID: 32853578 DOI: 10.1016/s2352-3026(20)30253-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Affiliation(s)
| | - David Kuter
- Section of Hematology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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10
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Qureshi K, Bonder A. Thrombopoietin-receptor agonists in perioperative treatment of patients with chronic liver disease. World J Meta-Anal 2020; 8:220-232. [DOI: 10.13105/wjma.v8.i3.220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/20/2020] [Accepted: 06/10/2020] [Indexed: 02/06/2023] Open
Abstract
Thrombocytopenia is a multifactorial disorder that is common in patients with chronic liver disease (CLD), leading to challenging perioperative planning. As thrombocytopenia in CLD is associated with thrombopoietin (TPO) deficiency, the use of TPO-receptor agonists (TPO-RAs) to increase platelet counts is a promising approach. This has led to the development of various TPO-RAs, including romiplostim, eltrombopag, avatrombopag, and lusutrombopag. Of these, only avatrombopag and lusutrombopag are approved by the United States Food and Drug Administration for the perioperative treatment of thrombocytopenia in patients with CLD. Platelet transfusion is commonly used for the clinical management of thrombocytopenia in patients with CLD undergoing invasive procedures. However, the limitations and possible risks of transfusion, including short duration of efficacy, development of antiplatelet antibodies, risk of infections and such complications as transfusion-related acute lung injury or circulatory overload, and possibility of refractoriness, limit its use. Moreover, there is no consensus among guidelines as to the platelet count at which transfusions are indicated. Results from studies using TPO-RAs perioperatively in patients with thrombocytopenia and CLD are promising and provide an alternative to platelet transfusions in the pre- and post-operative setting. These TPO-RAs are the subject of this review, with focus on their use in the perioperative setting in patients with thrombocytopenia, associated supporting clinical trials, efficacy and safety data, and their use with respect to platelet transfusions.
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Affiliation(s)
- Kamran Qureshi
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, MO 63104, United States
| | - Alan Bonder
- Division of Gastroenterology/Liver Center, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
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11
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Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, Ghanima W, Godeau B, González-López TJ, Grainger J, Hou M, Kruse C, McDonald V, Michel M, Newland AC, Pavord S, Rodeghiero F, Scully M, Tomiyama Y, Wong RS, Zaja F, Kuter DJ. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv 2019; 3:3780-3817. [PMID: 31770441 PMCID: PMC6880896 DOI: 10.1182/bloodadvances.2019000812] [Citation(s) in RCA: 572] [Impact Index Per Article: 114.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/18/2019] [Indexed: 01/19/2023] Open
Abstract
Over the last decade, there have been numerous developments and changes in treatment practices for the management of patients with immune thrombocytopenia (ITP). This article is an update of the International Consensus Report published in 2010. A critical review was performed to identify all relevant articles published between 2009 and 2018. An expert panel screened, reviewed, and graded the studies and formulated the updated consensus recommendations based on the new data. The final document provides consensus recommendations on the diagnosis and management of ITP in adults, during pregnancy, and in children, as well as quality-of-life considerations.
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Affiliation(s)
- Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University and Canadian Blood Services, Hamilton, ON, Canada
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Beng H Chong
- St. George Hospital, NSW Health Pathology, University of New South Wales, Sydney, NSW, Australia
| | - Nichola Cooper
- Department of Haematology, Hammersmith Hospital, London, United Kingdom
| | | | - Waleed Ghanima
- Departments of Research, Medicine and Oncology, Østfold Hospital Trust, Grålum, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Bertrand Godeau
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | | | - John Grainger
- Department of Haematology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Ming Hou
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, China
| | | | - Vickie McDonald
- Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Marc Michel
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Adrian C Newland
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sue Pavord
- Haematology Theme Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, United Kingdom
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Osaka, Japan
| | - Raymond S Wong
- Sir YK Pao Centre for Cancer and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy; and
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Abstract
Abstract
Transfusion-related acute lung injury is a leading cause of death associated with the use of blood products. Transfusion-related acute lung injury is a diagnosis of exclusion which can be difficult to identify during surgery amid the various physiologic and pathophysiologic changes associated with the perioperative period. As anesthesiologists supervise delivery of a large portion of inpatient prescribed blood products, and since the incidence of transfusion-related acute lung injury in the perioperative patient is higher than in nonsurgical patients, anesthesiologists need to consider transfusion-related acute lung injury in the perioperative setting, identify at-risk patients, recognize early signs of transfusion-related acute lung injury, and have established strategies for its prevention and treatment.
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13
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Vourc'h M, Senage T, Lepoivre T, Volteau C, Fortuit C, Pattier S, Guimbretiere G, Roussel JC, Rozec B. Romiplostim as a transfusion saving strategy in 20 patients after heart or lung transplantation: a single centre before-after pilot study. Perfusion 2019; 35:121-130. [PMID: 31359829 DOI: 10.1177/0267659119864814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Thrombocytopenia is a common disorder after heart or lung transplantation. Platelet transfusion is often required to maintain haemostasis but represents a specific cause of morbidity and mortality in this setting including alloimmunisation and graft rejection. STUDY DESIGN AND METHODS As part of a health-care quality improvement project, in a single-centre before-after pilot study, the relevance of a platelet transfusion saving strategy based on romiplostim administration after transplantation was assessed in patients with platelet count <100 × 109/L. Transfusions on days 28 and 90 were compared using propensity matched score for adjustment of demographic characteristics at baseline. The primary outcome was platelet transfusion until day 28 after transplantation. RESULTS Ninety-three patients were analysed (73 before vs. 20 after). The median [interquartile range] number of platelet concentrate was 1 [0;4.0] before versus 0.5 [0;2.0] in the after period, mean difference 0.5 confidence interval 95% [-0.7 to 1.7], p = 0.39. On day 28, median [interquartile range] red blood cell transfusion was significantly higher in the before versus the after period, 7 [2.0;13.5] versus 6 [1.5;8.5], mean difference 3.2 CI 95% [0.4-6.0], p = 0.02. At 6 months, the rate of patients with de novo anti-human leukocyte antigen alloimmunisation was 45% before versus 53% in the after period (p = 0.56). Deep venous thrombosis was detected in nine patients (12%) before versus seven patients (35%) in the after period (p = 0.04). CONCLUSION Romiplostim did not significantly reduce platelet transfusion after heart or lung transplantation. Its relevance and safety in a global transfusion strategy remains to be studied in this setting in a large randomised study.
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Affiliation(s)
- Mickael Vourc'h
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, Nantes University Hospital, Nantes, France.,School of Medicine, UPRES EA 3826, Thérapeutiques Cliniques et Expérimentales des Infections, IRS2 Nantes Biotech, France
| | - Thomas Senage
- Department of Thoracic and Cardiovascular Surgery, Nantes University Hospital, Nantes, France
| | - Thierry Lepoivre
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, Nantes University Hospital, Nantes, France
| | - Christelle Volteau
- Biometry Platform, Research Promotion Department, Nantes University Hospital, Nantes, France
| | - Camille Fortuit
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, Nantes University Hospital, Nantes, France
| | - Sabine Pattier
- Department of Cardiology, Hôpital Nord Laennec, Nantes University Hospital, Nantes, France
| | - Guillaume Guimbretiere
- Department of Thoracic and Cardiovascular Surgery, Nantes University Hospital, Nantes, France
| | - Jean-Christian Roussel
- Department of Thoracic and Cardiovascular Surgery, Nantes University Hospital, Nantes, France
| | - Bertrand Rozec
- Intensive Care Unit of Cardiothoracic Surgery, Anesthesia and Critical Care Department, Hôpital Nord Laennec, Nantes University Hospital, Nantes, France
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14
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Considerations for Medications Commonly Utilized in the Oncology Population in the Intensive Care Unit. ONCOLOGIC CRITICAL CARE 2019. [PMCID: PMC7189427 DOI: 10.1007/978-3-319-74588-6_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
An increasing number of oncologic patients are presenting to the intensive care unit with complications from both their chronic disease states and cancer therapies due to improved survival rates. The management of these patients is complex due to immunosuppression (from the malignancy and/or treatment), metabolic complications, and diverse medication regimens with the potential for significant drug-drug interactions and overlapping adverse effects. This chapter will provide clinicians with an overview of non-chemotherapy medications frequently encountered in the critically ill oncologic patient, with a focus on practical considerations.
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15
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A single-institution experience of performing bloodless transplant in Jehovah's Witness patients. Hematol Oncol Stem Cell Ther 2019; 12:44-49. [DOI: 10.1016/j.hemonc.2018.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/17/2018] [Accepted: 11/15/2018] [Indexed: 11/18/2022] Open
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16
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Appropriate Clinical Application of Thrombocytes Concentrate. Fam Med 2019. [DOI: 10.30841/2307-5112.1.2019.172190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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17
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Thrombopoietin Receptor Agonists. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00061-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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18
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Al-Samkari H, Marshall AL, Goodarzi K, Kuter DJ. Romiplostim for the management of perioperative thrombocytopenia. Br J Haematol 2018; 182:106-113. [DOI: 10.1111/bjh.15280] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/26/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Hanny Al-Samkari
- Center for Hematology; Massachusetts General Hospital Cancer Center; Harvard Medical School; Boston MA USA
| | | | - Katayoon Goodarzi
- Center for Hematology; Massachusetts General Hospital Cancer Center; Harvard Medical School; Boston MA USA
| | - David J. Kuter
- Center for Hematology; Massachusetts General Hospital Cancer Center; Harvard Medical School; Boston MA USA
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19
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Spina P, Impera S, Todaro AM, Salerno M, Floridia PM, Castagna F, Consoli U. “On-demand” treatment with Thrombopoietin mimetics as “bridge to recovery” from chemotherapy in chronic immune thrombocytopenia patients with cancer. A single centre experience in nine patients. Br J Haematol 2018; 181:400-403. [DOI: 10.1111/bjh.14605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paolo Spina
- UOC di Ematologia; Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi; Catania Italy
| | - Stefana Impera
- UOC di Ematologia; Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi; Catania Italy
| | - Anna Maria Todaro
- UOC di Ematologia; Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi; Catania Italy
| | - Marilena Salerno
- UOC di Ematologia; Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi; Catania Italy
| | - Pietro Michele Floridia
- UOC di Ematologia; Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi; Catania Italy
| | - Fabrizio Castagna
- UOC di Ematologia; Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi; Catania Italy
| | - Ugo Consoli
- UOC di Ematologia; Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi; Catania Italy
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20
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Zaja F, Barcellini W, Cantoni S, Carpenedo M, Caparrotti G, Carrai V, Di Renzo N, Santoro C, Di Nicola M, Veneri D, Simonetti F, Liberati AM, Ferla V, Paoloni F, Crea E, Volpetti S, Tuniz E, Fanin R. Thrombopoietin receptor agonists for preparing adult patients with immune thrombocytopenia to splenectomy: results of a retrospective, observational GIMEMA study. Am J Hematol 2016; 91:E293-5. [PMID: 26910388 DOI: 10.1002/ajh.24341] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/12/2016] [Accepted: 02/16/2016] [Indexed: 01/09/2023]
Abstract
In patients with immune thrombocytopenia (ITP) refractory to corticosteroids and intravenous immunoglobulins (IVIG), splenectomy may result at higher risk of peri-operative complications and, for this reason, potentially contraindicated. The thrombopoietin receptor agonists (TPO-RAs) romiplostim and eltrombopag have shown high therapeutic activity in primary ITP, but data of efficacy and safety regarding their use in preparation for splenectomy are missing. Thirty-one adult patients, median age 50 years, with corticosteroids and/or IVIG refractory persistent and chronic ITP who were treated with TPO-RAs (romiplostim= 24; eltrombopag= 7) with the aim to increase platelet count and allow a safer execution of splenectomy were retrospectively evaluated. Twenty-four patients (77%) responded to the use of TPO-RAs with a median platelet count that increased from 11 × 10(9) /L before starting TPO-RAs to 114 × 10(9) /L pre-splenectomy, but a concomitant treatment with corticosteroids and/or IVIG was required in 19 patients. Twenty-nine patients underwent splenectomy while two patients who responded to TPO-RAs subsequently refused surgery. Post-splenectomy complications were characterized by two Grade 3 thrombotic events (1 portal vein thrombosis in the patient with previous history of HCV hepatitis and 1 pulmonary embolism), with a platelet count at the time of thrombosis of 260 and 167 × 10(9) /L, respectively and one Grade 3 infectious event. TPO-RAs may represent a therapeutic option to improve platelet count and reduce the risk of peri-operative complications in ITP candidates to splenectomy. An increased risk of post-splenectomy thromboembolic events cannot be ruled out and thromboprophylaxis with low-molecular weight heparin is generally recommended.
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Affiliation(s)
- Francesco Zaja
- Clinica Ematologica, DISM, a O U S. M. Misericordia; Udine Italy
| | - Wilma Barcellini
- UOC Oncoematologia, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Milano Italy
| | - Silvia Cantoni
- S.C. Di Ematologia Ospedale Nigurda Ca' Granda; Milano Italy
| | - Monica Carpenedo
- U.O Ematologia E Trapianto, a.O San Gerardo Di Monza E Università Di Milano Bicocca; Italy
| | | | | | - Nicola Di Renzo
- U.O. Di Ematologia E Trapianto Cellule Staminali; Lecce Italy
| | - Cristina Santoro
- Dipartimento Di Biotecnologie Cellulari Ed Ematologia; , “Sapienza” Università Di Roma; Roma Italy
| | - Massimo Di Nicola
- Unità Di Immunoterapia Clinica E Terapie Innovative, Fondazione IRCCS Istituto Nazionale Tumori; Milano Italy
| | - Dino Veneri
- Clinica Ematologica, Dipartimento Di Medicina; Sezione Di Ematologia, Azienda Ospedaliera Universitaria Integrata Di Verona; Verona Italy
| | | | | | - Valeria Ferla
- UOC Oncoematologia, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Milano Italy
| | | | | | - Stefano Volpetti
- Clinica Ematologica, DISM, a O U S. M. Misericordia; Udine Italy
| | - Enrica Tuniz
- Clinica Ematologica, DISM, a O U S. M. Misericordia; Udine Italy
| | - Renato Fanin
- Clinica Ematologica, DISM, a O U S. M. Misericordia; Udine Italy
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