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Gotesman M, Shear M, Raheel S, Procassini M, Panosyan EH. Pediatric Immune Thrombocytopenia. Adv Pediatr 2024; 71:229-240. [PMID: 38944486 DOI: 10.1016/j.yapd.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Pediatric immune thrombocytopenia (ITP) is a fairly common bleeding disorder PRESENTING with a decreased number of platelets. The typical clinical presentation involves mild bleeding symptoms with bruising and petechiae and occasional mucosal bleeding. ITP is thought to be an autoimmune disorder and more recently other mechanisms have been described. Most cases resolve spontaneously and can undergo watchful waiting as the platelet count improves. Initially, steroids or intravenous immunoglobulin G (IVIg) can be used to increase platelets. For those cases that do not resolve and become persistent or chronic, there are multiple treatment options, with new agents being studied in adults that will hopefully make it to clinical trials in pediatrics in the future.
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Affiliation(s)
- Moran Gotesman
- The Lundquist Institute of Biomedical Innovation, Torrance, CA, USA; Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA.
| | - Marni Shear
- Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
| | - Sahar Raheel
- Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
| | - Michael Procassini
- Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
| | - Eduard H Panosyan
- The Lundquist Institute of Biomedical Innovation, Torrance, CA, USA; Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
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Zhu H, Ruan X, Zhao K, Kuang W, Liu S, Yan W, Fu X, Cheng Z, Li R, Peng H. The miR-641-STIM1 and SATB1 axes play important roles in the regulation of the Th17/Treg balance in ITP. Sci Rep 2024; 14:11243. [PMID: 38755179 PMCID: PMC11098809 DOI: 10.1038/s41598-024-61660-9] [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: 06/28/2023] [Accepted: 05/08/2024] [Indexed: 05/18/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease caused by T-cell dysfunction. Recently, several studies have shown that a disturbed Th17/Treg balance contributes to the development of ITP. MicroRNAs (miRNAs) are small noncoding RNA moleculesthat posttranscriptionally regulate gene expression. Emerging evidences have demonstrated that miRNAs play an important role in regulating the Th17/Treg balance. In the present study, we found that miR-641 was upregulated in ITP patients. In primary T cells, overexpression of miR-641 could cause downregulation of its target genes STIM1 and SATB1, thus inducing a Th17 (upregulated)/Treg (downregulated) imbalance. Inhibition of miR-641 by a miR-641 sponge in primary T cells of ITP patients or by antagomiR-641 in an ITP murine model could cause upregulation of STIM1 and SATB1, thus restoring Th17/Treg homeostasis. These results suggested that the miR-641-STIM/SATB1 axis plays an important role in regulating the Th17/Treg balance in ITP.
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Affiliation(s)
- Hongkai Zhu
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
| | - Xueqin Ruan
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
- Department of Hematology, The People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, P.R. China, Nanning, China
| | - Kexin Zhao
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
| | - Wenyong Kuang
- Department of Hematology, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Sufang Liu
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
| | - Wenzhe Yan
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
| | - Xianming Fu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhao Cheng
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China.
| | - Ruijuan Li
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China.
| | - Hongling Peng
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
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Russo G, Parodi E, Farruggia P, Notarangelo LD, Perrotta S, Casale M, Cesaro S, Del Borrello G, Del Vecchio GC, Giona F, Gorio C, Ladogana S, Lassandro G, Marzollo A, Maslak K, Miano M, Nardi M, Palumbo G, Rossi F, Spinelli M, Tolva A, Saracco P, Ramenghi U, Giordano P. Recommendations for the management of acute immune thrombocytopenia in children. A Consensus Conference from the Italian Association of Pediatric Hematology and Oncology. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2024; 22:253-265. [PMID: 37677093 PMCID: PMC11073630 DOI: 10.2450/bloodtransfus.501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/07/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is an acquired immune-mediated bleeding disorder characterized by isolated thrombocytopenia. Its estimated yearly incidence in the pediatric population is 1.9-6.4/100,000. ITP in children is usually a self-limiting and benign disorder. The clinical management of children with ITP often remains controversial, as robust randomized trials on the management of this disorder are lacking. Treatments vary widely in clinical practice and existing guidelines from hematology societies on clinical management offer indications based largely on expert opinion rather than strong evidence. MATERIALS AND METHODS The Coagulative Disorder Working Group of the Italian Association of Pediatric Hematology and Oncology (AIEOP) developed this document to collect shared expert opinions on the management of newly diagnosed ITP, updating previous guidelines and providing recommendations to pediatricians. Each statement has been given a score expressing the strength of evidence, appropriateness and agreement among participants. RESULTS Clear-cut definitions of the clinical phases of the disease and clinical response are stated. Recommendations are given regarding the classification of bleeding symptoms, evaluation of bleeding risk, diagnosis, and prognostic factors. Specific recommendations for treatment include indications for first-line (intravenous immunoglobulins, steroids) and second-line (combined therapy, thrombopoietin receptor agonists, immunosuppressive drugs, rituximab) therapeutic agents, as well as hemorrhagic emergency and supportive treatment, including emergency splenectomy. The optimal follow-up schedule, the relation between ITP and vaccines and health-related quality-of-life issues are also discussed. DISCUSSION The panel achieved broad consensus on issues related to how to treat children with newly diagnosed ITP, providing a comprehensive review of all relevant clinical aspects.
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Affiliation(s)
- Giovanna Russo
- Pediatric Onco-hematology Unit, Azienda Policlinico Rodolico San Marco, Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - Emilia Parodi
- Pediatric and Neonatology Unit, Ordine Mauriziano Hospital, Turin, Italy
| | - Piero Farruggia
- Pediatric Hematology and Oncology Unit, ARNAS Ospedale Civico, Palermo, Italy
| | - Lucia D. Notarangelo
- Direzione Medica di Presidio, Children’s Hospital, ASST-Spedali Civili, Brescia, Italy
| | - Silverio Perrotta
- Department of Women, Children and General and Specialized Surgery, “Luigi Vanvitelli” Università degli Studi della Campania, Naples, Italy
| | - Maddalena Casale
- Department of Women, Children and General and Specialized Surgery, “Luigi Vanvitelli” Università degli Studi della Campania, Naples, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giovanni Del Borrello
- Pediatric Oncohematology, Pediatrics Department, Hospital Città Della Salute e Della Scienza, University of Turin, Turin, Italy
| | - Giovanni C. Del Vecchio
- Interdisciplinary Department of Medicine, Pediatric Section, “Aldo Moro” University of Bari, Bari, Italy
| | - Fiorina Giona
- Department of Translational and Precision Medicine, Sapienza University of Rome, AOU Policlinico Umberto I, Rome, Italy
| | - Chiara Gorio
- Pediatric Onco-hematology Unit, Children’s Hospital, ASST-Spedali Civili, Brescia, Italy
| | - Saverio Ladogana
- Pediatric Onco-hematology Unit “Casa Sollievo della Sofferenza” Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - Giuseppe Lassandro
- Interdisciplinary Department of Medicine, Pediatric Section, “Aldo Moro” University of Bari, Bari, Italy
| | - Antonio Marzollo
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Padua University Hospital, Padua, Italy
| | - Karolina Maslak
- Pediatric Onco-hematology Unit, Azienda Policlinico Rodolico San Marco, Department of Clinical and Experimental Medicine, University of Catania, Italy
| | - Maurizio Miano
- Hematology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Margherita Nardi
- Pediatric Hematology Oncology, Bone Marrow Transplant, Azienda Ospedaliero Universitaria Pisana, S. Chiara Hospital, Pisa, Italy
| | - Giuseppe Palumbo
- Department of Pediatric Hematology and Oncology Cell and Gene Therapy, Bambino Gesù Children’s Hospital, IRCCS, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Francesca Rossi
- Department of Women, Children and General and Specialized Surgery, “Luigi Vanvitelli” Università degli Studi della Campania, Naples, Italy
| | - Marco Spinelli
- Pediatric Hematology Oncology Unit, Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Alessandra Tolva
- Pediatric Hematology-Oncology, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paola Saracco
- Department of Public Health and Pediatric Sciences, Regina Margherita Children’s Hospital, University of Turin, Turin, Italy
| | - Ugo Ramenghi
- Department of Public Health and Pediatric Sciences, Regina Margherita Children’s Hospital, University of Turin, Turin, Italy
| | - Paola Giordano
- Interdisciplinary Department of Medicine, Pediatric Section, “Aldo Moro” University of Bari, Bari, Italy
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Delgado-Miguel C, Camps JI. Simultaneous Robotic-Assisted Splenectomy and Cholecystectomy in Children: Is It Safe and Effective? J Laparoendosc Adv Surg Tech A 2024; 34:438-442. [PMID: 37976218 DOI: 10.1089/lap.2023.0255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
Background: Hematologic conditions such as hereditary spherocytosis, sickle cell disease, and idiopathic thrombocytopenic purpura are frequently linked to cholelithiasis. In instances where symptoms are present, simultaneous cholecystectomy and splenectomy are commonly recommended. Our aim was to assess the outcomes of robotic-assisted procedures conducted for simultaneous surgical issues involving the spleen and gallbladder in pediatric patients. Materials and Methods: We have made a simultaneous retrospective study of children with hereditary hematological diseases who underwent combined robotic-assisted splenectomy and cholecystectomy at our institution from January 2010 to December 2021. Demographics, clinical features, intraoperative data, length of hospital stay, postoperative complications, and follow-up outcomes were analyzed. Results: A total of 11 patients (6 male; 5 female) were included, with a mean age of 13.9 ± 4.4 years (range 8-17). Hereditary spherocytosis was the most common disease (7 cases), followed by sick cell disease (4 cases), with associated symptomatic gallbladder litiasis in all of them. Both operations were carried out using the da Vinci® Surgical Si System in a single docking robotic platform (four robotic arms). Median total surgery time was 145 minutes (Q1-Q3: 115-162). Minimal intraoperative bleeding was recorded (mean 45 ± 15 mL), with no intraoperative complications or conversion. Median length of hospital stay was 3 days (Q1-Q3: 2-4). There were no cases of surgical wound infections or postoperative bleeding documented. Conclusion: Simultaneous robotic-assisted splenectomy and cholecystectomy can be considered safe and feasible interventions in children with hematological diseases that affect both the spleen and the gallbladder. However, further research is needed to enhance the existing evidence and establish a standardized approach.
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Affiliation(s)
- Carlos Delgado-Miguel
- Department of Pediatric Surgery, Prisma Health Children's Hospital, Columbia, South Carolina, USA
- Institute for Health Research (IdiPaz), La Paz University Hospital, Madrid, Spain
| | - Juan I Camps
- Department of Pediatric Surgery, Prisma Health Children's Hospital, Columbia, South Carolina, USA
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Delgado-Miguel C, Camps JI. Robotic-assisted versus laparoscopic splenectomy in children: a costeffectiveness study. J Robot Surg 2024; 18:51. [PMID: 38280120 DOI: 10.1007/s11701-023-01783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/13/2023] [Indexed: 01/29/2024]
Abstract
Laparoscopic elective splenectomy is considered as a safe surgical treatment of spleen non-traumatic blood disorders. However, robotic assisted splenectomy is becoming a promising alternative, although there are scarce studies in pediatric patients. Our aim is to compare the effectiveness and associated costs of both procedures in children. A single-institution retrospective study was performed among consecutive children undergoing splenectomy between 2004 and 2021, who were divided according to the surgical approach: LAS group (laparoscopic splenectomy) and RAS group (robotic assisted splenectomy). Demographics, clinical features, intraoperative blood loss, surgery time, length of hospital stay (LOS), postoperative complications, need for postoperative blood transfusion, readmission rate and economic data were compared. A total of 84 patients were included (23 LAS group; 61 RAS group), without demographic or clinical differences between them. RAS patients presented lower intraoperative blood loss (42 ± 15 vs. 158 ± 39 ml; p < 0.021) and shorter surgery time (135 ± 39 vs. 182 ± 68 min; p = 0.043), with no differences in median LOS (3 days in both groups). No intraoperative complications or conversion was reported. Five postoperative complications were observed: 4 in LAS patients (17.4%) versus only one in RAS (1.6%; p = 0.021). One reintervention was required in LAS group due to hemoperitoneum 12 h after splenectomy. RAS patients had lower postoperative blood transfusion requirements (1.6% vs. 13.0%; p = 0.025) and lower readmission rate (3.3 vs. 17.4%; p = 0.042). No differences were observed when comparing the median economic costs ($25,645 LAS vs. $28,135 RAS; p = 0.215). Robotic assisted splenectomy may be considered as a safe and feasible option in children compared to the traditional laparoscopic approach. Level of evidence: III.
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Affiliation(s)
- Carlos Delgado-Miguel
- Department of Pediatric Surgery, Prisma Health Children's Hospital, 9 Richland Medical Park Dr, Columbia, SC, 29203, USA.
- Department of Pediatric Surgery, La Paz Children's University Hospital, Madrid, Spain.
| | - Juan I Camps
- Department of Pediatric Surgery, Prisma Health Children's Hospital, 9 Richland Medical Park Dr, Columbia, SC, 29203, USA
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Su J, Xu M, Dong Z, Wang Q, Ma L, Xiao P, Chen X. Efficacy and safety of azathioprine plus prednisone versus prednisone alone as first-line treatment for antinuclear antibody-positive immune thrombocytopenia: a retrospective cohort study. Hematology 2023; 28:2196864. [PMID: 37014744 DOI: 10.1080/16078454.2023.2196864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/26/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE Antinuclear antibody (ANA)-positive immune thrombocytopenia (ITP) patients have an unsatisfactory prognosis due to the more severe conditions of these patients and poor response to first-line glucocorticoids (GCs). The current study intended to compare the efficacy and safety of AZA plus prednisone and prednisone alone as first-line treatment in ANA-positive ITP patients. METHODS Fifteen ANA-positive ITP patients receiving AZA plus prednisone (AZA + GC group) and eighteen ANA-positive ITP patients receiving prednisone alone (GC group) as first-line treatment were retrospectively enrolled. RESULTS The complete response (CR) rate (60.0% versus 22.2%) (P = 0.038) was increased in the AZA + GC group versus the GC group, while the overall response rate (86.7% versus 55.6%) (P = 0.070) only showed an increasing trend that did not achieve statistical significance. In addition, multivariate analysis revealed that AZA + GC (versus GC) (odds ratio = 31.331, P = 0.018) was independently associated with a higher possibility of achieving CR. Additionally, accumulating relapse-free duration was prolonged in the AZA + GC group versus the GC group (median: 7.8 months versus 3.4 months) (P = 0.038). Additionally, the multivariate analysis suggested that AZA + GC (versus GC) (hazard ratio = 0.306, P = 0.007) was independently correlated with longer accumulating relapse-free duration. The incidence of adverse events did not differ between the two groups (all P > 0.05), and the common adverse events in the AZA + GC group were pneumonia (13.3%), anemia (13.3%), cough (13.3%), nausea (6.7%), and granulocytopenia (6.7%), which were all tolerable and manageable. CONCLUSION First-line AZA plus prednisone realizes a better hematological response and relapse-free duration with acceptable adverse events compared to prednisone alone in ANA-positive ITP patients.
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Affiliation(s)
- Junnan Su
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Meihong Xu
- Department of Physical Examination, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Zhigao Dong
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Qingqing Wang
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Lili Ma
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Pingping Xiao
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Xuyan Chen
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
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Goyal VD, Pahade A, Misra G, Kaira V. Mitral valve replacement in patients of rheumatic heart disease associated with immune thrombocytopenia. Indian J Thorac Cardiovasc Surg 2023; 39:516-521. [PMID: 37609607 PMCID: PMC10441999 DOI: 10.1007/s12055-023-01517-4] [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: 12/06/2022] [Revised: 04/02/2023] [Accepted: 04/05/2023] [Indexed: 08/24/2023] Open
Abstract
Immune thrombocytopenia in association with rheumatic heart disease is not commonly seen. Surgical management of rheumatic heart disease becomes more challenging in the presence of immune thrombocytopenia. The risk of complications increases manifold and judicious medical management before, during, and after surgery is imperative. We discuss two such cases, the complications we faced and the problems we anticipated before, and their prevention. Both patients were managed without using immunoglobulins or doing splenectomy. The literature on valve replacement in patients of immune thrombocytopenia and the implications of immune thrombocytopenia in the management of patients with rheumatic heart disease is also reviewed.
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Affiliation(s)
| | - Akhilesh Pahade
- Department of Anaesthesia, SRMS, IMS, Bareilly, UP 243202 India
| | - Gaurav Misra
- Department of Anaesthesia, SRMS, IMS, Bareilly, UP 243202 India
| | - Vaanika Kaira
- Department of Pathology, SRMS, IMS, Bareilly, UP 243202 India
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Giordano P, Lassandro G, Barone A, Cesaro S, Fotzi I, Giona F, Gorio C, Maggio A, Miano M, Marzollo A, Nardi M, Pession A, Ruggiero A, Russo G, Saracco P, Spinelli M, Tolva A, Tornesello A, Palladino V, Del Vecchio GC. Long term use of eltrombopag in children with chronic immune thrombocytopenia: extended real life retrospective multicenter experience of the Italian Association of Pediatric Hematology and Oncology. Front Med (Lausanne) 2023; 10:1214308. [PMID: 37521342 PMCID: PMC10375288 DOI: 10.3389/fmed.2023.1214308] [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: 04/29/2023] [Accepted: 06/02/2023] [Indexed: 08/01/2023] Open
Abstract
Background The present multicenter retrospective study on eltrombopag administration in Italian children with chronic ITP aims to extend follow-up of our previous study. Materials and methods This retrospective multicenter study was conducted in 17 centers affiliated to the Italian Association of Pediatric Hematology and Oncology (AIEOP). Patients were classified into three subgroups: group 1 included patients who discontinued treatment due to a stable platelet count; group 2 included patients who discontinued treatment due to ineffectiveness; group 3 included patients who did not permanently discontinue treatment. Results 56 patients were eligible for analysis. The median duration of eltrombopag treatment was 40 months (7-71 months). Twenty patients (36%) discontinued permanently eltrombopag. The reasons of permanent discontinuation were adverse effects (n = 1), inefficacy (n = 10), stable platelet count (n = 9). All patients of group 1 maintained a durable response without additional treatments after eltrombopag discontinuation. We found that patients of group 2 were on treatment for less time (median treatment time: 13.5 months, min: 6.0 - max: 56.0) than patients of group 1 (median treatment time: 34 months, min: 16.0 - max: 62.0) (p < 0.05). Patients of group 2 mostly did not achieve a stable platelet count in the first 6 months of treatment and underwent concomitant therapies during follow-up respect of group 1 and group 3 (p < 0.01). Conclusion Our study found that the benefits of eltrombopag treatment, in terms of platelet count improvement and use of additional therapies, are identifiable from the first 6 months of treatment.
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Affiliation(s)
- Paola Giordano
- Interdisciplinary Department of Medicine, Pediatric Unit “B. Trambusti”, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Lassandro
- Interdisciplinary Department of Medicine, Pediatric Unit “B. Trambusti”, University of Bari Aldo Moro, Bari, Italy
| | - Angelica Barone
- Department of Pediatric Onco-Hematology, University Hospital of Parma, Parma, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Ilaria Fotzi
- Department Pediatric Hematology Oncology, Azienda Ospedaliero Universitaria A. Meyer Children Hospital, Florence, Italy
| | - Fiorina Giona
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Gorio
- Hemato-Oncology Unit, Children Hospital, Spedali Civili, Brescia, Italy
| | - Angela Maggio
- Department of Hematology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Maurizio Miano
- Clinical and Experimental Hematology Unit, “G. Gaslini” Children's Hospital, Genoa, Italy
| | - Antonio Marzollo
- Pediatric Hematology-Oncology Unit, Department of Women's and Children's Health, Azienda Ospedaliera-University of Padova, Padua, Italy
| | - Margherita Nardi
- Pediatric Hematology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Andrea Pession
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giovanna Russo
- Pediatric Hemato-Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Paola Saracco
- Pediatric Hematology, Department of Pediatrics, University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Marco Spinelli
- Clinica Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alessandra Tolva
- Pediatric Hematology/Oncology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Assunta Tornesello
- Pediatric Hematology Oncology, Presidio Ospedaliero Vito Fazzi, Lecce, Italy
| | - Valentina Palladino
- Interdisciplinary Department of Medicine, Pediatric Unit “B. Trambusti”, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Carlo Del Vecchio
- Interdisciplinary Department of Medicine, Pediatric Unit “B. Trambusti”, University of Bari Aldo Moro, Bari, Italy
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Use of thrombopoietin receptor agonists in adults with immune thrombocytopenia: a systematic review and Central European expert consensus. Ann Hematol 2023; 102:715-727. [PMID: 36826482 PMCID: PMC9951167 DOI: 10.1007/s00277-023-05114-8] [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: 11/07/2022] [Accepted: 01/26/2023] [Indexed: 02/25/2023]
Abstract
There are currently three thrombopoietin receptor agonists (TPO-RAs) approved in Europe for treating patients with immune thrombocytopenia (ITP): romiplostim (Nplate®), eltrombopag (Revolade®), and avatrombopag (Doptelet®). However, comparative clinical data between these TPO-RAs are limited. Therefore, the purpose of this study was to perform a literature review and seek expert opinion on the relevance and strength of the evidence concerning the use of TPO-RAs in adults with ITP. A systematic search was conducted in PubMed and Embase within the last 10 years and until June 20, 2022. A total of 478 unique articles were retrieved and reviewed for relevance. The expert consensus panel comprised ITP senior hematologists from eight countries across Central Europe. The modified Delphi method, consisting of two survey rounds, a teleconference and email correspondence, was used to reach consensus. Forty articles met the relevancy criteria and are included as supporting evidence, including five meta-analyses analyzing all three European-licensed TPO-RAs and comprising a total of 31 unique randomized controlled trials (RCTs). Consensus was reached on seven statements for the second-line use of TPO-RAs in the management of adult ITP patients. In addition, the expert panel discussed TPO-RA treatment in chronic ITP patients with mild/moderate COVID-19 and ITP patients in the first-line setting but failed to reach consensus. This work will facilitate informed decision-making for healthcare providers treating adult ITP patients with TPO-RAs. However, further studies are needed on the use of TPO-RAs in the first-line setting and specific patient populations.
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Rosenberg A, Cashion C, Ali F, Haran H, Biswas RK, Chen V, Crowther H, Curnow J, Deakin E, Tan CW, Tan YL, Vanlint A, Ward CM, Bird R, Rabbolini DJ. Treatment of immune thrombocytopenia in Australian adults: A multicenter retrospective observational study. Res Pract Thromb Haemost 2022; 6:e12792. [PMID: 36186101 PMCID: PMC9483174 DOI: 10.1002/rth2.12792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background In Australia, prescribing restrictions limit access to internationally recommended second‐line therapies such as rituximab and thrombopoietin agonists (TPO‐A) (eltrombopag and romiplostim). Subsequent lines of therapy include an array of immunosuppressive and immune‐modulating agents directed by drug availability and physician and patient preference. Objectives The objective of the study was to describe the use of first and subsequent lines of treatment for adult immune thrombocytopenia (ITP) in Australia and to assess their effectiveness and tolerability. Patients/Methods A retrospective review of medical records was conducted of 322 patients treated for ITP at eight participating centers in Australia between 2013 and 2020. Data were analyzed by descriptive statistics and frequency distribution using pivot tables, and comparisons between centers were assessed using paired t tests. Results Mean age at diagnosis of ITP was 48.8 years (standard deviation [SD], 22.6) and 58.3% were women. Primary ITP was observed in 72% and secondary ITP in 28% of the patients; 95% of patients received first‐line treatment with prednisolone (76%), dexamethasone (15%), or intravenous immunoglobulin (48%) alone or in combination. Individuals with secondary ITP were less steroid dependent (72% vs. 76%) and required less treatment with a second‐line agent (47% vs. 58%) in the study sample. Over half (56%) of the cohort received treatment with one or more second‐line agents. The mean number of second‐line agents used for each patient was 1.9 (SD, 1.2). The most used second‐line therapy was rituximab, followed by etrombopag and splenectomy. These also generated the highest rates of complete response (60.3%, 72.1%, and 71.8% respectively). The most unfavorable side effect profiles were seen in long‐term corticosteroids and splenectomy. Conclusion A wide range of “second‐line” agents were used across centers with variable response rates and side effect profiles. Findings suggest greater effectiveness of rituximab and TPO‐A, supporting their use earlier in the treatment course of patients with ITP across Australia.
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Affiliation(s)
| | - Catelyn Cashion
- The Royal North Shore Hospital Sydney New South Wales Australia
| | - Fariya Ali
- Westmead Hospital Westmead New South Wales Australia
| | - Harini Haran
- Westmead Hospital Westmead New South Wales Australia
| | - Raaj K Biswas
- Sydney Local Health District Clinical Research Centre Camperdown New South Wales Australia
| | - Vivien Chen
- The Concord & Repatriation Hospital Concord West New South Wales Australia.,ANZAC Research Institute and Concord Repatriation Hospital Concord New South Wales Australia
| | - Helen Crowther
- Blacktown & Mount Druitt Hospital Blacktown New South Wales Australia
| | | | | | - Chee-Wee Tan
- The Royal Adelaide Hospital Adelaide South Australia Australia
| | - Yi Ling Tan
- Nepean Hospital Kingswood New South Wales Australia
| | - Andrew Vanlint
- The Royal Adelaide Hospital Adelaide South Australia Australia
| | - Christopher M Ward
- The Royal North Shore Hospital Sydney New South Wales Australia.,Northern Blood Research Centre, Kolling Institute, University of Sydney Sydney New South Wales Australia
| | - Robert Bird
- The Princess Alexandra Hospital Woollongabba Queensland Australia
| | - David J Rabbolini
- Lismore Base Hospital Lismore New South Wales Australia.,Northern Clinical School and the Rural Clinical School (Northern Rivers), University of Sydney Sydney New South Wales Australia
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11
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Ding B, Liu L, Dai Y, Li M, Xia A, Song X, Liu J, Wang X, Song Y, Zhou H. Identification and verification of differentially expressed key genes in peripheral blood-derived T cells between chronic immune thrombocytopenia patients and healthy controls. Bioengineered 2022; 13:13587-13595. [PMID: 35796625 PMCID: PMC9450975 DOI: 10.1080/21655979.2022.2080422] [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] [Indexed: 11/23/2022] Open
Abstract
Immune thrombocytopenia (ITP), characterized by decreased platelet counts, is a complex immune-mediated disorder with unelucidated pathogenesis. Accumulating evidence shows that T cell-mediated platelet destruction is one crucial process during the progression of ITP. Here, we attempted to identify core genes in peripheral blood-derived T-cells of chronic ITP through the analysis of microarray data (GSE43179) and clinical verification, with the aim to further understand the pathogenesis and progression of ITP. Compared with healthy controls, 97 differentially expressed genes (DEGs), including 63 up-regulated and 34 down-regulated were identified in ITP patients. Functional enrichment analysis showed that the DEGs were mainly enriched in innate immune response, inflammatory response, and IL-17 signaling pathway. Among the DEGs, top 15 hub genes ranked by degree score were identified via protein-protein interaction (PPI) network and were further confirmed by quantitative reverse transcription PCR (qRT-PCR). Among top 15 hub genes, the expression levels of 14 DEGs like TLR4, S100A8, S100A9, and S100A12 were significantly up-regulated, while one DEG IFNG was down-regulated in ITP patients. Noticeably, TLR4 exhibited the highest degree score, and S100A8 had the largest fold change in qRT-PCR analysis. Altogether, our results suggested that the pathogenesis and progression of ITP are related with multiple immune-related pathways, and that TLR4 and S100A8 are likely to play crucial roles.
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Affiliation(s)
- Bingjie Ding
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Liu Liu
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yingtong Dai
- Department of Blood Component Preparation, Henan Province Red Cross Blood Center, Zhengzhou, Henan, China
| | - Mengjuan Li
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Ao Xia
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Xuewen Song
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Jianping Liu
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Xiaoran Wang
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Yongping Song
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
| | - Hu Zhou
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, Henan, China
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12
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Janssens A, Selleslag D, Depaus J, Beguin Y, Lambert C. Primary immune thrombocytopenia in adults: Belgian recommendations for diagnosis and treatment anno 2021 made by the Belgian Hematology Society. Acta Clin Belg 2022; 77:470-483. [PMID: 33635747 DOI: 10.1080/17843286.2021.1876310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The Belgian Hematology Society (BHS) updated the 2013 guidelines for diagnosis and treatment of primary immune thrombocytopenia (ITP) [1]. As knowledge about ITP pathophysiology is increasing, the mode of action of old therapies is better understood and novel drugs are introduced to target more specific pathways.Corticosteroids with or without intravenous immunoglobulins (IgIV) remain the first-line treatment. According to the updated international guidelines a short course of corticosteroids rather than a prolonged treatment has to be recommended. The same guidelines stress that consequent therapies as thrombopoietic agents (TPO-RAs) and rituximab should be available independent of duration of ITP.Although the majority of recommendations is based on very low-quality evidence, it is strongly advised to individualize the ITP management taking patient values. and preferences in account. The main treatment goal in all ITP patients must be to maintain a safe platelet count to prevent or stop bleeding with a minimum of toxicity and not to normalize the platelet count.
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Affiliation(s)
- A. Janssens
- Department of Hematology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - D. Selleslag
- Department of Hematology, AZ Sint-Jan Brugge, Brugge, Belgium
| | - J. Depaus
- Department of Hematology, CHU UCL Namur, Yvoir, Belgium
| | - Y. Beguin
- Department of Hematology, Centre Hospitalier Universitaire Liège, Liège, Belgium
| | - C. Lambert
- Department of Hematology, Cliniques Universitaire St Luc, Bruxelles, Belgium
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13
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Mei H, Liu X, Li Y, Zhou H, Feng Y, Gao G, Cheng P, Huang R, Yang L, Hu J, Hou M, Yao Y, Liu L, Wang Y, Wu D, Zhang L, Zheng C, Shen X, Hu Q, Liu J, Jin J, Luo J, Zeng Y, Gao S, Zhang X, Zhou X, Shi Q, Xia R, Xie X, Jiang Z, Gao L, Bai Y, Li Y, Xiong J, Li R, Zou J, Niu T, Yang R, Hu Y. Dose tapering to withdrawal stage and long-term efficacy and safety of hetrombopag for the treatment of immune thrombocytopenia: Results from an open-label extension study. J Thromb Haemost 2022; 20:716-728. [PMID: 34821020 DOI: 10.1111/jth.15602] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/18/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The efficacy of hetrombopag in Chinese patients with immune thrombocytopenia (ITP) has been demonstrated in a randomized, double-blind, placebo-controlled, multicenter, phase III trial (NCT03222843). OBJECTIVE This study aimed to report comprehensive data on a ≤6-week dose tapering to withdrawal (Stage 3) and an additional 24-week long-term extension period (Stage 4) in this phase III trial. PATIENTS/METHODS Patients who fulfilled the screening criteria were eligible to enter Stage 3 or 4. During Stage 3, hetrombopag was gradually tapered to withdrawal. During Stage 4, hetrombopag treatment was initiated at 2.5, 3.75, 5, or 7.5 mg once daily. The efficacy endpoints during Stage 3 or 4 and the safety profile during the entire treatment period were reported. RESULTS Among 194 patients who entered Stage 3, 171 (88.1%) relapsed. The median time to the first relapse since the start of Stage 3 was 15.0 days (95% CI, 14.0-16.0). In Stage 4, 144 (42.5%) patients responded at ≥75% of their assessments and 254 (74.9%) patients achieved platelet count ≥30 × 109 /L at least once, which was at least twice their baseline platelet count in the hetrombopag group (n = 339). The most common adverse events were upper respiratory tract infection (53.1%), thrombocytopenia (27.1%), and urinary tract infection (21.2%) in the hetrombopag group. CONCLUSION The majority of patients who experienced dose tapering to withdrawal experienced a relapse. Long-term treatment with hetrombopag was effective in increasing and maintaining platelet count within the desired range in Chinese adults with ITP. Hetrombopag was well tolerated.
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Affiliation(s)
- Heng Mei
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Liu
- Thrombosis and Hemostasis Center, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Hematological Disorders, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yan Li
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Hu Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Feng
- Department of Hematopathology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guangxun Gao
- The Blood Internal Medicine, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Peng Cheng
- Hematology Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ruibin Huang
- Hematology Department, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linhua Yang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Jianda Hu
- Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yazhou Yao
- Hematology Department, Baoji Central Hospital, Baoji, China
| | - Li Liu
- Department of Hematopathology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Yi Wang
- Department of Hematopathology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Depei Wu
- Hematology Department, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liansheng Zhang
- Hematology Department, Lanzhou University Second Hospital, Lanzhou, China
| | - Changcheng Zheng
- Hematology Department, The First Affiliated Hospital of USTC, Hefei, China
| | - Xuliang Shen
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Qi Hu
- Department of Hematology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Jing Liu
- Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Jianmin Luo
- Department of Hematology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yun Zeng
- Department of Hematology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Sujun Gao
- Hematology, The First Hospital of Jilin University, Changchun, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Beijing, China
| | - Xin Zhou
- Hematology Department, Wuxi People's Hospital, Wuxi, China
| | - Qingzhi Shi
- Hematology Department, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ruixiang Xia
- Hematology Department, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaobao Xie
- Hematology Department, The First People's Hospital of Changzhou, Changzhou, China
| | - Zhongxing Jiang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Gao
- Department of Hematology, The Second Affiliated Hospital of Military Medical University PLA, Chongqing, China
| | - Yuansong Bai
- Hematology & Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yan Li
- Hematology Department, The First Hospital of China Medical University, Shenyang, China
| | - Junye Xiong
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Runzi Li
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Jianjun Zou
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Ting Niu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Renchi Yang
- Thrombosis and Hemostasis Center, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Hematological Disorders, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yu Hu
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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14
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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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15
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Carpenedo M, Baldacci E, Baratè C, Borchiellini A, Buccisano F, Calvaruso G, Chiurazzi F, Fattizzo B, Giuffrida G, Rossi E, Palandri F, Scalzulli PR, Siragusa SM, Vitucci A, Zaja F. Second-line administration of thrombopoietin receptor agonists in immune thrombocytopenia: Italian Delphi-based consensus recommendations. Ther Adv Hematol 2021; 12:20406207211048361. [PMID: 34646432 PMCID: PMC8504223 DOI: 10.1177/20406207211048361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction: In patients with primary immune thrombocytopenia (ITP), a short course of steroids is routinely given as first-line therapy. However, the response is often transient and additional therapy is usually needed. Thrombopoietin receptor agonists (TPO-RAs) are frequently used as second-line therapy, although there is little clinical guidance on the timing of their administration and on tapering/discontinuation of the drug. To provide clinical recommendations, we used the Delphi technique to obtain consensus for statements regarding administration and on tapering/discontinuation of second-line TPO-RAs among a group of Italian clinicians with expertise in management of ITP. Methods: The Delphi process was used to obtain agreement on five statements regarding initiation and on tapering/discontinuation of second-line TPO-RAs. Agreement was considered when 75% of participants approved the statement. Eleven experts participated in the voting. Results: Full consensus was reached for three of the five statements. The experts held that an early switch from corticosteroids to a TPO-RA has the dual advantage of sparing patients from corticosteroid abuse and improve long-term clinical outcomes. All felt that dose reduction of TPO-RAs can be considered in patients with a stable response and platelet count >100 × 109/L that is maintained for at least 6 months in the absence of concomitant treatments, although there was less agreement in patients with a platelet count >50 × 109/L. Near consensus was reached regarding the statement that early treatment with a TPO-RA is associated with an increase in clinically significant partial or complete response. The experts also agreed that optimization of tapering and discontinuation of TPO-RA therapy in selected patients can improve the quality of life. Conclusion: The present consensus can help to provide guidance on use of TPO-RAs in daily practice in patients with ITP. Plain language summary Second-line administration of thrombopoietin receptor agonists in immune thrombocytopenia
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Affiliation(s)
- Monica Carpenedo
- Hematology and Transplantation Unit, ASST San Gerardo Hospital, Via G. B. Pergolesi, 33, 20900 Monza MB, Italy
| | - Erminia Baldacci
- Department of Hematology, Policlinico Umberto I University Hospital, Rome, Italy
| | - Claudia Baratè
- Hematology and Bone Marrow Transplant Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandra Borchiellini
- Regional Reference Center of Haemostasis and Thrombosis Haematology Unit, Città della Salute e della Scienza, Turin, Italy
| | - Francesco Buccisano
- Hematology, Department of BioMedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Giuseppina Calvaruso
- Campus of Hematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo, Italy
| | - Federico Chiurazzi
- Department of Clinical Medicine, University "Federico II" of Naples, Naples, Italy
| | - Bruno Fattizzo
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gaetano Giuffrida
- Division of Haematology, A.O.U. Policlinico Vittorio Emanuele, Catania, Italy
| | - Elena Rossi
- Department of Radiological and Hematological Sciences, Universita Cattolica del Sacro Cuore and Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Potito Rosario Scalzulli
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | | | - Angelantonio Vitucci
- Haematology with Transplant Unit, Az. Universitario-Ospedaliera Consorziale Policlinico, Bari, Italy
| | - Francesco Zaja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
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16
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Nam CH, Byun JM, Shin DY, Hong J, Kim I, Yoon SS, Koh Y. Romiplostim plus danazol as salvage treatment for eltrombopag refractory immune thrombocytopenia: a retrospective pilot study. Blood Res 2021; 56:202-204. [PMID: 34462405 PMCID: PMC8478612 DOI: 10.5045/br.2021.2021067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/11/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Chang Hyun Nam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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17
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Yuan B, Yin C, Ye X, Bai Z, Lu Z, Li X, Al-Azab M, Mu L, Li W. Differential effects of Huaier aqueous extract on human CD4 +T lymphocytes from patients with primary immune thrombocytopenia. Exp Hematol 2021; 101-102:58-67. [PMID: 34450221 DOI: 10.1016/j.exphem.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 08/05/2021] [Accepted: 08/11/2021] [Indexed: 02/07/2023]
Abstract
Huaier, a traditional Chinese medicine, is currently used to treat certain types of cancer in the clinic and is also regarded as an immune-modulating and immune-enhancing agent that regulates immune cells. Emerging evidence indicates that an imbalance of immune cells, such as CD4+ T helper (Th) lymphocytes, contributes to the progression of immune thrombocytopenia (ITP), but the effects of Huaier on the regulation of CD4+ T cells are not yet fully elucidated. In the present study, Jurkat cells and peripheral blood mononuclear cells (PBMCs) from patients with ITP and healthy volunteers were treated with Huaier aqueous extract (HR). The CCK-8 assay revealed that HR suppressed the proliferation of Jurkat cells in a dose-dependent manner, whereas 3 mg/mL could decrease cell viability by 50%. At the latter concentration, the activation of CD4+ T cells from patients with ITP was partially attenuated. In addition, HR could correct the unbalanced Th1/Th2 polarization and inhibit the secretion of pro-inflammatory factors interleukin (IL)-2, tumor necrosis factor-α, and interferon-γ. It also suppressed Treg and facilitated Th17 differentiation, but did not change the levels of IL-10 and transforming growth factor-β. Thus, this study provides more information on how Huaier regulates cellular immunity and improves our understanding of the use of Huaier in ITP.
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Affiliation(s)
- Bo Yuan
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Chunlai Yin
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Xiaokang Ye
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Ziran Bai
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Zhimin Lu
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Xia Li
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Mahmoud Al-Azab
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Lijun Mu
- Department of Hematology, Second Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Weiping Li
- Department of Hematology, Second Hospital of Dalian Medical University, Dalian, Liaoning, China; Department of Immunology, Dalian Medical University, Dalian, Liaoning, China.
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Salous AK, Zalatimo O. A Novel Intraoperative Transient Variant of Immune Thrombocytopenia. Cureus 2021; 13:e15370. [PMID: 34239798 PMCID: PMC8248282 DOI: 10.7759/cureus.15370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 11/21/2022] Open
Abstract
Immune thrombocytopenia, also known as immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by a very low number of platelets and associated excessive bleeding. Primary ITP is a diagnosis of exclusion and secondary causes of ITP including lymphoproliferative disorders, medications, and certain infections must be ruled out during workup. This is the first report to highlight intraoperative ITP or an ITP-like novel variant in the perioperative setting leading to increased bleeding. The patient's extensive workup failed to reveal any secondary causative factors. The clinical presentation of ITP was transient. She received tranexamic acid (TXA), intravenous steroids, and intravenous immunoglobulins (IVIG) and recovered without complication. This case report explores a potentially underreported cause for intraoperative and postoperative hemorrhage in surgical patients.
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Affiliation(s)
| | - Omar Zalatimo
- Neurological Surgery, Sinai Hospital of Baltimore, Baltimore, USA
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Sandal R, Mishra K, Jandial A, Sahu KK, Siddiqui AD. Update on diagnosis and treatment of immune thrombocytopenia. Expert Rev Clin Pharmacol 2021; 14:553-568. [PMID: 33724124 DOI: 10.1080/17512433.2021.1903315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a heterogeneous acquired disorder characterized by isolated thrombocytopenia whose exact pathogenesis is not yet clear. Depending upon the presence or absence of an underlying treatable cause, ITP can be categorized as primary or secondary. Primary ITP is a diagnosis of exclusion and there is no gold standard test for its confirmation. Recent drug intake, infections, lymphoproliferative disorders, and connective tissue disorders should be ruled out before labeling a patient as primary ITP. AREA COVERED This review summarizes a comprehensive update on the diagnostic and therapeutic modalities for ITP. We reviewed the literature using GOOGLE SCHOLAR, PUBMED and ClinicalTrial.gov databases as needed to support the evidence. We searched the literature using the following keywords: 'immune thrombocytopenia,' 'idiopathic thrombocytopenic purpura,' 'thrombocytopenia,' 'immune thrombocytopenic purpura,' and 'isolated thrombocytopenia'. EXPERT OPINION We believe that more detailed studies are required to understand the exact pathophysiology behind ITP. The first-line drugs like corticosteroids have both short-term and long-term adverse effects. This brings the need to explore effective alternative medications and to reconsider their role in ITP treatment algorithm if guidelines can be modified based on new studies.
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Affiliation(s)
- Rajeev Sandal
- Dept of Clinical Hematology, IGMC, Shimla, Himachal Pradesh, India
| | - Kundan Mishra
- Department of Internal Medicine (Adult Clinical Hematology Division), Postgraduate Institute of Medical Education and Research, Chandigarh (Union Territory), India
| | - Aditya Jandial
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), Delhi, India
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
| | - Ahmad Daniyal Siddiqui
- Division of Hematology and Oncology, Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
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20
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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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21
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Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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22
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Risk factors and predictors of treatment responses and complications in immune thrombocytopenia. Ann Hematol 2021; 100:645-651. [PMID: 33515047 DOI: 10.1007/s00277-021-04424-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 01/11/2021] [Indexed: 01/22/2023]
Abstract
Management of adult patients with immune thrombocytopenia (ITP) is often unsatisfactory, due to variable efficacy of treatment, risk of life-threatening bleeding if disease control is poor, and side effects associated with treatment. Lack of data on the platelet count threshold associated with bleeding and infection risk associated with ITP treatment limits risk/benefit clinical decision making. We reviewed medical records of all ITP patients who were admitted to our hospital between 2012 and 2017 to evaluate the platelet count threshold for bleeding, infection burden associated with treatment, and real-world efficacy of second-line treatment. We demonstrated fair discrimination between platelet count and occurrence of bleeding, with 15 × 109/L being the optimal cut-off for predicting any bleeding while 20 × 109/L had the highest negative predictive value for severe bleeding. In multivariable analyses, patients who were treated with corticosteroids for at least 2 months were 5.3 times as likely to have an infection. In addition, rituximab response was strongly associated with response to frontline corticosteroids and infection was associated with older age ≥ 65 years and corticosteroid dependence. If corticosteroids are initiated, physicians should aim for the shortest duration of treatment before switching to effective second-line agents for hemostatic platelet counts.
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23
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Fu S, Wang T, Xu F. Delayed immune thrombocytopenia after discontinuation of nivolumab therapy: A case report and literature review. J Oncol Pharm Pract 2021; 27:1548-1552. [PMID: 33435825 DOI: 10.1177/1078155220981155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Nivolumab, a programmed death-1(PD-1) inhibitor antibody, have demonstrated anti-tumor activity for multiple malignancies. Such immune checkpoint inhibitors induce novel and distinctive adverse effects, which are collectively named immune-related adverse events. Immune-related adverse events can theoretically occur at any part of the body, including the haemopoietic system. Most immune-related adverse events developed within 10 weeks of receiving immunotherapy. Thus far, there is no report of immune thrombocytopenia as an immune-related adverse event developed after discontinuation of immunotherapy. CASE REPORT We describe a 62-year-old male with metastatic non-small cell lung cancer developed immune thrombocytopenia nearly two months after discontinuation of nivolumab. When thrombocytopenia was detected, the patient was undergoing radiotherapy of supraclavicular lymph nodes. After complex diagnosis-by-exclusion process, nivolumab-induced immune thrombocytopenia was diagnosed. MANAGEMENT AND OUTCOME Intravenous immunoglobulins 20 g daily for 5 days, intravenous methylprednisolone 40 mg daily for 14 days followed by oral prednisone, intermittent platelet transfusion and oral thrombopoietin receptor (eltrombopag 25 mg daily) were administered. After 30 days, his platelet count had achieved a level of adequate hemostasis and continued to improvement during the tapering period. DISCUSSION Most immune-related developed 6 months of immunotherapy. Clinicians need to be aware of a clinical diagnostic complex, developing months to years after discontinuation of immunotherapy, which recently is termed delayed immune-related events. This case is the first report of immune checkpoint inhibitors-induced thrombocytopenia that developed nearly 2 months after discontinuation of treatment with nivolumab for metastatic NSCLC. In future clinical practice, patients who have received immune checkpoint inhibitors develop new or unexplained symptom, irrespective of interval post-immunotherapy, immune-related adverse events should be considered.
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Affiliation(s)
- Shengya Fu
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Ting Wang
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Xu
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Wang S, Zhang X, Leng S, Xu Q, Sheng Z, Zhang Y, Yu J, Feng Q, Hou M, Peng J, Hu X. Immune Checkpoint-Related Gene Polymorphisms Are Associated With Primary Immune Thrombocytopenia. Front Immunol 2021; 11:615941. [PMID: 33584705 PMCID: PMC7874092 DOI: 10.3389/fimmu.2020.615941] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/24/2020] [Indexed: 12/22/2022] Open
Abstract
Cancer immunotherapy by immune checkpoint blockade has been effective in the treatment of certain tumors. However, the association between immune checkpoints and autoimmune diseases remains elusive and requires urgent investigation. Primary immune thrombocytopenia (ITP), characterized by reduced platelet count and a consequent increased risk of bleeding, is an autoimmune disorder with a hyper-activated T cell response. Here, we investigated the contribution of immune checkpoint-related single-nucleotide polymorphisms (SNPs), including CD28, ICOS, PD1, TNFSF4, DNAM1, TIM3, CTLA4, and LAG3 to the susceptibility and therapeutic effects of ITP. In this case-control study, 307 ITP patients and 295 age-matched healthy participants were recruited. We used the MassARRAY system for genotyping immune checkpoint-related SNPs. Our results revealed that rs1980422 in CD28 was associated with an increased risk of ITP after false discovery rate correction (codominant, CT vs. TT, OR = 1.788, 95% CI = 1.178-2.713, p = 0.006). In addition, CD28 expression at both the mRNA and protein levels was significantly higher in patients with CT than in those with the TT genotype (p = 0.028 and p = 0.001, respectively). Furthermore, the T allele of PD1 rs36084323 was a risk factor for ITP severity and the T allele of DNAM1 rs763361 for corticosteroid-resistance. In contrast, the T allele of LAG3 rs870849 was a protective factor for ITP severity, and the T allele of ICOS rs6726035 was protective against corticosteroid-resistance. The TT/CT genotypes of PD1 rs36084323 also showed an 8.889-fold increase in the risk of developing refractory ITP. This study indicates that immune checkpoint-related SNPs, especially CD28 rs1980422, may be genetic factors associated with the development and treatment of ITP patients. Our results shed new light on prognosis prediction, disease severity, and discovering new therapeutic targets.
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Affiliation(s)
- Shuwen Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyu Zhang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shaoqiu Leng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qirui Xu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zi Sheng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yanqi Zhang
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jie Yu
- Department of Hematology, Weihai Municipal Hospital, Weihai, China
| | - Qi Feng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiang Hu
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Newland A, McDonald V. Fostamatinib: a review of its clinical efficacy and safety in the management of chronic adult immune thrombocytopenia. Immunotherapy 2020; 12:1325-1340. [DOI: 10.2217/imt-2020-0215] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Management of chronic immune thrombocytopenia (ITP) is going through a transition, with the main driving forces being a better understanding of the disease, recognition that platelet count is less important than bleeding symptoms, and the availability of new therapies. The heterogeneity of chronic ITP makes treatment challenging, and highlights the need for a personalized approach. A key aspect of tailored treatment is the availability of agents to target specific underlying pathophysiological mechanisms. In this review, we examine the evidence for orally bioavailable fostamatinib and its active moiety, tamatinib (R406), which has been approved for the treatment of chronic adult ITP. Fostamatinib inhibits FcR-triggered, Syk-dependent cytoskeletal rearrangement during phagocytosis and, as such, represents an active therapy targeting a previously unexplored mechanism of ITP pathogenesis.
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Affiliation(s)
- Adrian Newland
- Academic Haematology Unit, Blizard Institute, Barts & The London School of Medicine & Dentistry, Queen Mary Institute of London, London, UK
| | - Vickie McDonald
- Department of Haematology, The Royal London Hospital, Barts Health NHS Trust, London, UK
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26
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Spontaneous Epidural Hematomas due to Cerebral Venous Thrombosis in a Patient with Immune Thrombocytopenic Purpura. J Stroke Cerebrovasc Dis 2020; 29:105244. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 11/17/2022] Open
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Abstract
BACKGROUND Severe immune thrombocytopenia complicating pregnancy may require treatment beyond first-line medications (intravenous immunoglobulins or corticosteroids), but there is a paucity of literature on the use of such second-line agents in pregnancy. CASE The patient is a 29-year-old woman with early-onset severe immune thrombocytopenia at 13 weeks of gestation. Maternal platelet counts reached a nadir of less than 5×10/L. The thrombocytopenia persisted despite first-line medications. Romiplostim, rituximab, and azathioprine were added to the therapeutic regimen. Platelet counts eventually stabilized at greater than 150×10/L before delivery. After delivery at term, the neonate had transient B-cell suppression, which was presumed to be secondary to rituximab, but was otherwise doing well and meeting all milestones at 7 months of age. CONCLUSION The addition of second-line agents was associated with sustained elevation in maternal platelet counts and may have obviated the need for splenectomy.
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28
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Ciobanu AM, Dumitru AE, Gica N, Botezatu R, Peltecu G, Panaitescu AM. Benefits and Risks of IgG Transplacental Transfer. Diagnostics (Basel) 2020; 10:E583. [PMID: 32806663 PMCID: PMC7459488 DOI: 10.3390/diagnostics10080583] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/13/2022] Open
Abstract
Maternal passage of immunoglobulin G (IgG) is an important passive mechanism for protecting the infant while the neonatal immune system is still immature and ineffective. IgG is the only antibody class capable of crossing the histological layers of the placenta by attaching to the neonatal Fc receptor expressed at the level of syncytiotrophoblasts, and it offers protection against neonatal infectious pathogens. In pregnant women with autoimmune or alloimmune disorders, or in those requiring certain types of biological therapy, transplacental passage of abnormal antibodies may cause fetal or neonatal harm. In this review, we will discuss the physiological mechanisms and benefits of transplacental transfer of maternal antibodies as well as pathological maternal situations where this system is hijacked, potentially leading to adverse neonatal outcomes.
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Affiliation(s)
- Anca Marina Ciobanu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | | | - Nicolae Gica
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Radu Botezatu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Gheorghe Peltecu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
| | - Anca Maria Panaitescu
- Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania; (A.M.C.); (N.G.); (R.B.); (G.P.)
- Filantropia Clinical Hospital, Bucharest 11171, Romania;
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29
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Hayden A, Vyas-Lahar A, Rella V, Rudinskaya A. Severe refractory thrombocytopenia in a woman positive for coronavirus disease 2019 with lupus and antiphospholipid syndrome. Lupus 2020; 29:1472-1474. [DOI: 10.1177/0961203320940389] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has created new challenges that necessitate prompt responses in unexpected clinical situations. Multiple extrapulmonary manifestations and complications of COVID-19 have already been described, but only scattered data are present on immunologic manifestations. We present a case of severe refractory thrombocytopenia in a 51-year-old woman with a history of long-standing systemic lupus erythematosus and antiphospholipid syndrome who presented with hemoptysis in the setting of COVID-19 infection. The patient failed to respond to initial treatment with intravenous immunoglobulin, high-dose steroids, and platelet transfusion, but responded to eltrombopag, with prompt improvement of a platelet count. The current case report provides clinical data of relevance to the largely unexplored question of the immunologic complications of COVID-19 in patients with a pre-existing inflammatory state.
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Affiliation(s)
- Alina Hayden
- Department of Medicine, Norwalk Hospital, Western Connecticut Health Network, Norwalk, USA
| | - Aishwarya Vyas-Lahar
- Department of Medicine, Norwalk Hospital, Western Connecticut Health Network, Norwalk, USA
| | - Vincent Rella
- Department of Hematology and Oncology, Danbury Hospital, Western Connecticut Health Network, Norwalk, USA
| | - Alla Rudinskaya
- Section of Rheumatology, Western Connecticut Health Network, Danbury, USA
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30
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Retrospective analysis of different regimens for Chinese adults with severe newly diagnosed immune thrombocytopenia. Clin Exp Med 2020; 20:381-385. [PMID: 32458092 DOI: 10.1007/s10238-020-00630-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/10/2020] [Indexed: 10/24/2022]
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31
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McGrath LJ, Kilpatrick K, Overman RA, Reams D, Sharma A, Altomare I, Wasser J, Brookhart MA. Treatment Patterns Among Adults with Primary Immune Thrombocytopenia Diagnosed in Hematology Clinics in the United States. Clin Epidemiol 2020; 12:435-445. [PMID: 32440222 PMCID: PMC7211324 DOI: 10.2147/clep.s229266] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 04/16/2020] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Patients with immune thrombocytopenia (ITP) have low platelet counts and an increased risk of bleeding. We described treatment patterns and clinical outcomes in routine practice in the United States (US). PATIENTS AND METHODS Using electronic health record data from hematology/oncology clinics linked to administrative claims in the US, we studied 447 adults newly diagnosed with primary ITP from 2011 to 2016. Patients with a secondary cause of thrombocytopenia were excluded. The incidence of ITP treatment initiation, bleeding events, and rescue therapy use were estimated using competing risk models. RESULTS At 1-year post-ITP diagnosis, 50% of patients were prescribed an oral corticosteroid, with the majority being prescribed immediately following diagnosis. Of the more common second-line options, rituximab use was the most frequent (1-year cumulative incidence: 16% [95% confidence interval: 12, 19]), followed by romiplostim (9% [7, 12] and eltrombopag (5% [3, 8]). Use of these drugs was similar at 2 years post-diagnosis. At 6 months post-ITP treatment initiation, the cumulative incidence of bleeding was similar among eltrombopag and romiplostim initiators (17% [6, 33] and 19% [9, 31], respectively) and was slightly lower in rituximab users (12% [6, 20]). However, during this same timeframe, rituximab users had a higher incidence of rescue therapy use (48% [36, 58] versus 29% [14, 46] in eltrombopag and 26% [14, 39] in romiplostim users). Although splenectomy was rare, at 6 months post-surgery nearly 20% had experienced a bleed and nearly 20% had required rescue. CONCLUSION This study describes the health trajectory of adults with ITP who are managed in hematology clinics in the US and could inform the design of non-interventional studies of comparative effectiveness among treatments.
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Affiliation(s)
| | | | | | | | | | | | | | - M Alan Brookhart
- NoviSci, Inc., Durham, NC, USA
- Department of Population Health Sciences, Duke University, Durham, NC, USA
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32
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Al-Samkari H, Grace RF, Kuter DJ. The role of romiplostim for pediatric patients with immune thrombocytopenia. Ther Adv Hematol 2020; 11:2040620720912992. [PMID: 32523658 PMCID: PMC7236573 DOI: 10.1177/2040620720912992] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/18/2020] [Indexed: 01/19/2023] Open
Abstract
The thrombopoietin receptor agonists (TPO-RAs) are a class of platelet growth factors used to treat immune thrombocytopenia (ITP) in children and adults. Romiplostim is a peptide TPO-RA approved for over a decade to treat adults with ITP but was just recently US Food and Drug Administration approved to manage ITP in children 1 year of age and older who have had an inadequate response to corticosteroids, intravenous immunoglobulin, or splenectomy. Like the small molecule TPO-RA eltrombopag, romiplostim offers a high clinical response rate in pediatric patients with ITP, but requires use over an extended, and possibly indefinite, duration. This review is a critical appraisal of the role of romiplostim in pediatric ITP, discussing the safety and efficacy of this agent in clinical trials of children and adults and defining the patients most likely to benefit from romiplostim treatment. The treating hematologist is additionally provided guidance with treatment goals, dosing strategies, toxicity management, and indications for discontinuation.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical chool, Suite 118, Room 112, Zero Emerson Place, Boston, MA 02114, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - David J Kuter
- Division of Hematology, Harvard Medical School, Boston, MA, USA
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33
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Kim TO, Flanagan JM, Habibi A, Arulselvan A, Lambert MP, Grace RF, Despotovic JM. Genetic variants in toll-like receptor 4 are associated with lack of steroid-responsiveness in pediatric ITP patients. Am J Hematol 2020; 95:395-400. [PMID: 31903617 DOI: 10.1002/ajh.25716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 12/20/2019] [Accepted: 12/27/2019] [Indexed: 01/19/2023]
Abstract
Although the most common front-line therapies for immune thrombocytopenia (ITP) have been in use for decades, it is still not possible to predict an individual patient's clinical course and response to therapy. Patients are managed with a trial-and-error approach and often suffer side effects of therapies which could have been avoided if response prediction were possible. Corticosteroids are the most frequently used upfront therapy for adults and children with ITP. Our group performed whole exome sequencing on a cohort of pediatric ITP patients, and identified two missense single nucleotide variants (SNV) in Toll-like receptor 4 (TLR4). These coding variants in TLR4 had an increased frequency in Caucasian patients with poor response to upfront steroid therapy. Both TLR4 (D299G; rs4986790) and TLR4 (T399I; rs4986791) had a minor allele frequency (MAF) of 20.7% in those patients unresponsive to steroids, but were present at lower allele frequencies of 2.3% and 3.4% in responders respectively (P < .001). These findings were consistent with the trend identified in an independent cohort of pediatric ITP patients treated with corticosteroids who underwent direct genotyping for both SNVs. This study identified two candidate genetic variants in two unique cohorts of ITP patients which may contribute to steroid response and have prognostic implications for treatment response in ITP.
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Affiliation(s)
- Taylor Olmsted Kim
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Jonathan M. Flanagan
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
| | - Ali Habibi
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
| | - Abinaya Arulselvan
- Children's Hospital of Philadelphia, Division of Hematology Philadelphia Pennsylvania
| | - Michele P. Lambert
- Children's Hospital of Philadelphia, Division of Hematology Philadelphia Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Department of Pediatrics Philadelphia Pennsylvania
| | - Rachael F. Grace
- Harvard Medical School Boston Massachusetts
- Boston Children's Hospital Dana Farber/Boston Children's Cancer and Blood Disorders Center Boston Massachusetts
| | - Jenny M. Despotovic
- Baylor College of Medicine, Department of Pediatrics Division of Hematology/Oncology Houston Texas
- Texas Children's Hematology Centers Houston Texas
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Schizas D, Katsaros I, Karatza E, Kykalos S, Spartalis E, Tsourouflis G, Dimitroulis D, Nikiteas N. Concomitant Laparoscopic Splenectomy and Cholecystectomy: A Systematic Review of the Literature. J Laparoendosc Adv Surg Tech A 2020; 30:730-736. [PMID: 32202962 DOI: 10.1089/lap.2020.0004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Concomitant laparoscopic splenectomy and cholecystectomy (CLSC) is performed for concurrent pathologies of the spleen and gallbladder. This systematic review aimed to evaluate the available evidence on its indications, operative technique, and outcomes. Materials and Methods: The PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: December 6, 2019) for studies reporting on CLSC. The National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool was utilized for the evaluation of eligible articles. Results: Eight studies met inclusion criteria and concerned collectively 108 patients (53 males and 55 females) with a mean age of 27.02 ± 20.48 years (mean, SD). The most common surgery indications were hereditary spherocytosis (38.9%) and sickle cell disease or β-thalassemia (32.4%). Laparoscopic cholecystectomy preceded splenectomy in the majority of cases (75%). A five-trocar approach was most frequently (89.8%) utilized. The mean operation duration was 170.18 ± 53.07 minutes (mean, SD). Resected spleen weight was 601.82 ± 386.02 g (mean, SD) and had a length of 18.74 ± 5.3 cm (mean, SD). The conversion rate was 2.7%, while 20.4% of included cases experienced postoperative complications. Most frequent ones included pulmonary infection (6.5%) and portal/splenic vein thrombosis (4.6%). No postoperative death was recorded. Mean hospitalization period was 5.43 ± 3.18 days (mean, SD). Conclusions: CLSC is a safe and feasible operation for simultaneous diseases of the spleen and gallbladder that require elective procedures. High-quality clinical trials are essential to further elucidate clinical evidence and standardize operative technique.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery and National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Ioannis Katsaros
- First Department of Surgery and National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Elli Karatza
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Stylianos Kykalos
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Eleftherios Spartalis
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Gerasimos Tsourouflis
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Dimitroulis
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Nikolaos Nikiteas
- Second Propaedeutic Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Gudbrandsdottir S, Leven E, Imahiyerobo A, Lee CS, Bussel J. Combination of thrombopoietin receptor agonists, immunosuppressants and intravenous immunoglobulin as treatment of severe refractory immune thrombocytopenia in adults and children. Br J Haematol 2020; 189:e37-e40. [PMID: 32096213 DOI: 10.1111/bjh.16426] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/20/2019] [Indexed: 01/06/2023]
Affiliation(s)
- Sif Gudbrandsdottir
- Department of Pediatric Oncology/Hematology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA.,Department of Hematology, Copenhagen University Hospital Roskilde, Roskilde, Denmark.,Institute for Inflammation Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Emily Leven
- Department of Pediatric Oncology/Hematology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA.,Icahn School of Medicine, Mount Sinai, NY, USA
| | - Allison Imahiyerobo
- Department of Pediatric Oncology/Hematology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA.,Department of Medicin, Columbia University Medical Centre, New York, NY, USA
| | - Christina Soo Lee
- Department of Pediatric Oncology/Hematology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA.,New York Medical College, New York, NY, USA
| | - James Bussel
- Department of Pediatric Oncology/Hematology, New York Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
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36
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Autoimmune Complications in Chronic Lymphocytic Leukemia in the Era of Targeted Drugs. Cancers (Basel) 2020; 12:cancers12020282. [PMID: 31979293 PMCID: PMC7072470 DOI: 10.3390/cancers12020282] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/19/2020] [Accepted: 01/21/2020] [Indexed: 12/21/2022] Open
Abstract
Autoimmune phenomena are frequently observed in patients with chronic lymphocytic leukemia (CLL) and are mainly attributable to underlying dysfunctions of the immune system. Autoimmune cytopenias (AIC) affect 4-7% of patients with CLL and mainly consist of autoimmune hemolytic anemia and immune thrombocytopenia. Although less common, non-hematological autoimmune manifestations have also been reported. Treatment of CLL associated AIC should be primarily directed against the autoimmune phenomenon, and CLL specific therapy should be reserved to refractory cases or patients with additional signs of disease progression. New targeted drugs (ibrutinib, idelalisib and venetoclax) recently entered the therapeutic armamentarium of CLL, showing excellent results in terms of efficacy and became an alternative option to standard chemo-immunotherapy for the management of CLL associated AIC. However, the possible role of these drugs in inducing or exacerbating autoimmune phenomena still needs to be elucidated. In this article, we review currently available data concerning autoimmune phenomena in patients with CLL, particularly focusing on patients treated with ibrutinib, idelalisib, or venetoclax, and we discuss the possible role of these agents in the management of AIC.
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Rodeghiero F, Marranconi E. Management of immune thrombocytopenia in women: current standards and special considerations. Expert Rev Hematol 2020; 13:175-185. [PMID: 31903814 DOI: 10.1080/17474086.2020.1711729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Immune thrombocytopenia (ITP) is an acquired autoimmune disorder, with an incidence rate of 20-40/million adults/year and an estimated prevalence in women of childbearing age of 24.5/million.Areas covered: Authors discuss management of ITP in pregnancy, treatment-related toxicity, delivery, neonatal thrombocytopenia and breastfeeding, and other women's specific issues. The search of papers published between January 1990 and December 2019 was done on PubMed using combinations of the keywords below. The distinction between ITP and other thrombocytopenias in pregnancy is of paramount importance. The current belief (at variance with the past) that ITP is a relatively benign disease pregnancy is emphasized.Expert opinion: The lack of randomized, prospective, controlled studies hampers evidence-based statements. Remarkably, ITP diagnosis is still one of exclusion, there are no clinical or laboratory criteria for prognosis and we still need more solid data on the risks related to neonatal thrombocytopenia. Corticosteroids and IVIG remain the mainstay of treatment, since rituximab, thrombopoietin-receptor agonists, fostamatinib may be toxic in pregnancy. Safety and efficacy of recombinant-human-thrombopoietin, available in China, require confirmation studies. Quality of life and women-related toxicity of treatments in young girls, adults, and elders are still an orphan area of investigation.
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Affiliation(s)
- Francesco Rodeghiero
- Hematology Project Foundation and Department of Hematology, S. Bortolo Hospital, Vicenza, Italy
| | - Ettore Marranconi
- Hematology Project Foundation and Department of Hematology, S. Bortolo Hospital, Vicenza, Italy.,Graduate School in Hospital Pharmacy, Pisa University, Pisa, Italy
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38
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Management of elderly patients with immune thrombocytopenia: Real-world evidence from 451 patients older than 60 years. Thromb Res 2020; 185:88-95. [DOI: 10.1016/j.thromres.2019.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 09/26/2019] [Accepted: 11/19/2019] [Indexed: 12/26/2022]
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39
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Kumar P. The General Pediatrician's Guide to Isolated Thrombocytopenia. Pediatr Ann 2020; 49:e27-e35. [PMID: 31930420 DOI: 10.3928/19382359-20191212-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Platelets are an essential component of the hemostatic pathway; therefore, it is important to identify and diagnose patients with low platelet counts. This can be challenging, however, because thrombocytopenia can be relatively common and the differential diagnosis can be broad. Furthermore, because platelets can be affected both in form and function in a variety of medical conditions, platelet abnormalities can be the principal driver in some disorders but only a consequence in others. Critical factors in identifying the etiology of the thrombocytopenia include the severity and acuity of the patient's initial presentation along with the history, physical examination, and laboratory findings, all of which can provide important clues. The accurate diagnosis of thrombocytopenia is crucial for determining the appropriate management. This review highlights the key diagnostic considerations and recommended treatment when isolated thrombocytopenia is encountered in clinical practice. [Pediatr Ann. 2020;49(1):e27-e35.].
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40
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Primary Immune Thrombocytopenia: A Translational Research Model for Autoimmune Diseases. J Clin Med 2019; 8:jcm8111971. [PMID: 31739462 PMCID: PMC6912248 DOI: 10.3390/jcm8111971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 11/10/2019] [Indexed: 12/18/2022] Open
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41
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Cooper N, Cines DB. The child with immune thrombocytopenia: to treat or not to treat, is that still the question? Haematologica 2019; 104:2132-2134. [PMID: 31666343 DOI: 10.3324/haematol.2019.229179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Nichola Cooper
- Centre for Haematology, Department of Medicine, Imperial College, Hammersmith Hospital, London, UK
| | - Douglas B Cines
- Departments of Pathology and Laboratory Medicine and Medicine, University of Pennsylvania-Perelman School of Medicine, Philadelphia, PA, USA
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42
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43
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Hellmich B, Löffler C. [What are the indications for rescue procedures? : Systemic rheumatic diseases in the intensive care unit]. Z Rheumatol 2019; 78:955-966. [PMID: 31485728 PMCID: PMC7101899 DOI: 10.1007/s00393-019-00687-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Schwere, organ- oder lebensbedrohliche Manifestationen entzündlicher rheumatischer Erkrankungen, wie z. B. eine diffuse alveoläre Hämorrhagie im Rahmen einer Kleingefäßvaskulitis, sprechen nicht immer ausreichend oder mit zeitlicher Verzögerung auf eine immunsuppressive Therapie an. Bei einem drohenden oder bereits eingetretenen Organversagen besteht dann nicht selten die Notwendigkeit, die immunsuppressive Therapie auf der Intensivstation um rasch wirksame Rescue-Therapieverfahren zu ergänzen. Aufgrund der Seltenheit vieler rheumatischer Erkrankungen ist die Evidenz zum Einsatz von Rescue-Therapieverfahren wie der Plasmapherese, der extrakorporalen Membranoxygenierung (ECMO) oder der Gabe von intravenösen Immunglobulinen (IVIG) für viele Indikationen eher gering. Der Einsatz der Plasmapherese wird bei einer akuten Anti-GBM(glomeruläre Basalmembran)-Erkrankung (Goodpasture Syndrom) oder einem katastrophalen Antiphospholipidantikörpersyndrom (CAPS) als sinnvoll angesehen. Eine ECMO-Therapie kann bei persistierender respiratorischer Insuffizienz trotz mechanischer Beatmung als Folge einer diffusen alveolären Hämorrhagie oder eines Acute-Respiratory-Distress-Syndroms (ARDS) anderer Ursache erwogen werden. Eine Gabe von IVIG ist bei einer akuten kardialen Beteiligung im Rahmen einer Kawasaki-Erkrankung indiziert und kann beim CAPS sowie bei therapierefraktären Myositiden erwogen werden.
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Affiliation(s)
- B Hellmich
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland.
| | - C Löffler
- Vaskulitiszentrum Süd, Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken - Akademisches Lehrkrankenhaus, Universität Tübingen, Eugenstr. 3, 73230, Kirchheim u. Teck, Deutschland
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44
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Affiliation(s)
- Nichola Cooper
- From the Department of Medicine, Hammersmith Hospital, Imperial College, London (N.C.); and the Departments of Medicine, Hematology-Oncology, and Research, Østfold Hospital Trust, Kalnes, and the Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo (W.G.) - both in Norway
| | - Waleed Ghanima
- From the Department of Medicine, Hammersmith Hospital, Imperial College, London (N.C.); and the Departments of Medicine, Hematology-Oncology, and Research, Østfold Hospital Trust, Kalnes, and the Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo (W.G.) - both in Norway
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45
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Affiliation(s)
- Renee Eslick
- Clinical and Laboratory Haematologist, Haematology Department, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Claire McLintock
- Clinical and Laboratory Haematologist, Obstetric Physician, National Women’s Health, Auckland City Hospital, Auckland, New Zealand
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46
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Iba T, Watanabe E, Umemura Y, Wada T, Hayashida K, Kushimoto S, Wada H. Sepsis-associated disseminated intravascular coagulation and its differential diagnoses. J Intensive Care 2019; 7:32. [PMID: 31139417 PMCID: PMC6528221 DOI: 10.1186/s40560-019-0387-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/02/2019] [Indexed: 12/19/2022] Open
Abstract
Disseminated intravascular coagulation (DIC) is a common complication in sepsis. Since DIC not only promotes organ dysfunction but also is a strong prognostic factor, its diagnosis at the earliest possible timing is important. Thrombocytopenia is often present in patients with DIC but can also occur in a number of other critical conditions. Of note, many of the rare thrombocytopenic diseases require prompt diagnoses and specific treatments. To differentiate these diseases correctly, the phenotypic expressions must be considered and the different disease pathophysiologies must be understood. There are three major players in the background characteristics of thrombocytopenia: platelets, the coagulation system, and vascular endothelial cells. For example, the activation of coagulation is at the core of the pathogenesis of sepsis-associated DIC, while platelet aggregation is the essential mechanism in thrombotic thrombocytopenic purpura and endothelial damage is the hallmark of hemolytic uremic syndrome. Though each of the three players is important in all thrombocytopenic diseases, one of the three dominant players typically establishes the individual features of each disease. In this review, we introduce the pathogeneses, symptoms, diagnostic measures, and recent therapeutic advances for the major diseases that should be immediately differentiated from DIC in sepsis.
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Affiliation(s)
- Toshiaki Iba
- 1Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Eizo Watanabe
- 2Department of General Medical Science Graduate School of Medicine Chiba University, Chiba, Japan.,Department of Emergency and Critical Care Medicine Eastern Chiba Medical Center, Chiba, Japan
| | - Yutaka Umemura
- 4Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeshi Wada
- 5Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kei Hayashida
- 6Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Shigeki Kushimoto
- 7Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Hideo Wada
- 8Department of Molecular and Laboratory Medicine, Mie University School of Medicine, Tsu, Japan
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47
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Lacombe V, Lozac'h P, Orvain C, Lavigne C, Miot C, Pellier I, Urbanski G. [Treatment of ITP and AIHA in CVID: A systematic literature review]. Rev Med Interne 2019; 40:491-500. [PMID: 31101329 DOI: 10.1016/j.revmed.2019.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/11/2019] [Accepted: 02/24/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Ten to 15% of common variable immunodeficiencies (CVID) develop auto-immune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP). Treatment is based on immunosuppressants, which produce blocking effects in the CVID. Our objective was to assess their risk-benefit ratio in these immunocompromised patients. METHODS We identified 17 articles detailing the treatment of AIHA and/or ITP in patients suffering from CVID through a systematic review of the MEDLINE database. RESULTS The increased infectious risk with corticosteroids does not call into question their place in the first line of treatment of ITP and AIHA in CVID. High-doses immunoglobulin therapy remain reserved for ITP with a high risk of bleeding. In second-line treatment, rituximab appears to be effective, with a lower infectious risk than the splenectomy. Immunosuppressants (azathioprine, methotrexate, mycophenolate, cyclophosphamide, vincristine, ciclosporine) are moderately effective and often lead to severe infections, meaning that their use is justified only in resistant cases and steroid-sparing. Dapsone, danazol and anti-D immunoglobulins have an unfavorable risk-benefit ratio. The place of TPO receptor agonists is still to be defined. The establishment of immunoglobulin replacement in the place of immunosuppressants (except for short-term corticotherapy) or splenectomy appears to be essential to limit the risk of infections, including in the absence of previous infections. CONCLUSION The presence of CVID does not mean that it is necessary to give up on corticosteroids as a first-line treatment and rituximab as a second-line treatment for AIHA and ITP, but it should be in addition to immunoglobulin replacement. A splenectomy should be reserved as a third-line treatment.
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Affiliation(s)
- V Lacombe
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - P Lozac'h
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - C Orvain
- Service des maladies du sang, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - C Lavigne
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France; Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France
| | - C Miot
- Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France; Service d'immunologie-hématologie et oncologie pédiatriques, CHU d'Angers, 4, rue Larrey, 49000 Angers, France; Laboratoire d'immunologie et allergologie, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - I Pellier
- Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France; Service d'immunologie-hématologie et oncologie pédiatriques, CHU d'Angers, 4, rue Larrey, 49000 Angers, France
| | - G Urbanski
- Service de médecine interne et maladies vasculaires, CHU d'Angers, 4, rue Larrey, 49000 Angers, France; Centre de référence des déficits immunitaires primitifs CEREDIH, CHU d'Angers, site constitutif Angers, 4, rue Larrey, 49000 Angers, France.
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48
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De Giglio L, Grimaldi AE, Fubelli F, Marinelli F, Pozzilli C. Advances in preventing adverse events during monoclonal antibody management of multiple sclerosis. Expert Rev Neurother 2019; 19:417-429. [PMID: 31094239 DOI: 10.1080/14737175.2019.1610393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Decades of pharmacological research in Multiple Sclerosis (MS) led to the development of therapeutic Monoclonal Antibodies (MAbs) with many different mechanisms of action (MoA), potentially able to improve disability outcome but also determining a more complex management of patients. Areas covered: When clinicians select MS treatments, they should consider adverse events (AEs) on individual basis to minimize patients' risks. Some AEs are common and can be easily handled, but rare complications should also be taken into account. The aim of this review is to summarize existing evidence and provide practical recommendations for the management of therapeutic MAbs in MS. Expert opinion: The introduction of MAbs revolutionized MS treatment with an improvement in effectiveness. Unfortunately, this has been coupled with a more complex array of AEs needing a tighter surveillance strategy. A close interaction between general practitioners, neurologists, and other specialists is the key for a safer use of such effective drugs.
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Affiliation(s)
- Laura De Giglio
- a MS Center Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy.,b Department of Human Neuroscience , Sapienza University of Rome , Rome , Italy
| | | | - Federica Fubelli
- a MS Center Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy
| | | | - Carlo Pozzilli
- a MS Center Sant'Andrea Hospital, Sapienza University of Rome , Rome , Italy.,b Department of Human Neuroscience , Sapienza University of Rome , Rome , Italy
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49
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Pecoraro A, Crescenzi L, Galdiero MR, Marone G, Rivellese F, Rossi FW, de Paulis A, Genovese A, Spadaro G. Immunosuppressive therapy with rituximab in common variable immunodeficiency. Clin Mol Allergy 2019; 17:9. [PMID: 31080365 PMCID: PMC6501382 DOI: 10.1186/s12948-019-0113-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/11/2019] [Indexed: 12/23/2022] Open
Abstract
Common variable immunodeficiency (CVID) is the most frequent symptomatic primary antibody deficiency in adulthood and is characterized by the marked reduction of IgG and IgA serum levels. Thanks to the successful use of polyvalent immunoglobulin replacement therapy to treat and prevent recurrent infections, non-infectious complications, including autoimmunity, polyclonal lymphoproliferation and malignancies, have progressively become the major cause of morbidity and mortality in CVID patients. The management of these complications is particularly challenging, often requiring multiple lines of immunosuppressive treatments. Over the last 5–10 years, the anti-CD20 monoclonal antibody (i.e., rituximab) has been increasingly used for the treatment of both autoimmune and non-malignant lymphoproliferative manifestations associated with CVID. This review illustrates the evidence on the use of rituximab in CVID. For this purpose, first we discuss the mechanisms proposed for the rituximab mediated B-cell depletion; then, we analyze the literature data regarding the CVID-related complications for which rituximab has been used, focusing on autoimmune cytopenias, granulomatous lymphocytic interstitial lung disease (GLILD) and non-malignant lymphoproliferative syndromes. The cumulative data suggest that in the vast majority of the studies, rituximab has proven to be an effective and relatively safe therapeutic option. However, there are currently no data on the long-term efficacy and side effects of rituximab and other second-line therapeutic options. Further randomized controlled trials are needed to optimize the management strategies of non-infectious complications of CVID.
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Affiliation(s)
- Antonio Pecoraro
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Ludovica Crescenzi
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Maria Rosaria Galdiero
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Giancarlo Marone
- 2Department of Public Health, University of Naples Federico II, Naples, Italy.,3Monaldi Hospital Pharmacy, Naples, Italy
| | - Felice Rivellese
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy.,4Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Francesca Wanda Rossi
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Amato de Paulis
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Arturo Genovese
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Giuseppe Spadaro
- 1Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), World Allergy Organization (WAO) Center of Excellence, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy
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50
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Noor A, Rehan A, Desai A, Iorgoveanu C, Lee JC. Secondary Immune Thrombocytopenic Purpura in Renal Cell Cancer: A Paraneoplastic Syndrome. Cureus 2019; 11:e4398. [PMID: 31245188 PMCID: PMC6559687 DOI: 10.7759/cureus.4398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Secondary immune thrombocytopenic purpura (ITP) as a paraneoplastic syndrome has been reported in literature. It is commonly associated with chronic lymphocytic leukemia (CLL) and hodgkins lymphoma. Its association with solid malignancies, especially renal cell cancer is rare, with only a few documented case reports. Treatment usually consisted of targeting the underlying malignancy or utilization of steroid and intravenous immunoglobulin (IVIG) to improve thrombocytopenia. Here, we describe a case of a 75-year-old man with renal cell cancer (RCC), who presented with secondary thrombocytopenia treated with steroid and IVIG. It is important to keep RCC in differential diagnosis for causes for secondary ITP as this impacts treatment.
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Affiliation(s)
- Arish Noor
- Internal Medicine, University of Connecitcut, Hartford, USA
| | - Anam Rehan
- Internal Medicine, University of Connecticut, Hartford, USA
| | - Aakash Desai
- Internal Medicine, University of Connecticut, Hartford, USA
| | | | - Jim C Lee
- Pathology, Hartford Hospital, Hartford, USA
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