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González-López TJ, Bermejo-Vega N, Cardesa-Cabrera R, Martínez-Robles V, Aguilar-Monserrate G, Pérez-Segura G, Domingo A, Luis-Navarro J, Lakhwani S, Acedo N, Lozano ML, Bernat S, Torres-Tienza A, Ruano A, Jarque I, Galán P, Benet C, Marcellini S, Jimenez-Bárcenas R, Martínez-Carballeira D, De Miguel-Llorente D, Perona-Blázquez A, Gonzalez-Gascón I, Lopez-Ansoar E, Alonso-Alonso JM, Bengochea-Casado ML, Díaz-Gálvez FJ, Moretó A, Moreno-Jiménez G, Hernández-Martin R, de Cabo E, Dávila-Valls J, Cuesta A, Pastoriza C, Hermida-Fernández GJ, García C, Pozas-Mañas MA, Aguilar C, Fernandez-Jimenez D, Navas-Elorza B, López-Santamaría Castro C, Lorenzo A, Ortín X, García M, Piernas S, Díaz-Santa J, Soto I, Provan D, García-Donas Gabaldón G. Fostamatinib effectiveness and safety for immune thrombocytopenia in clinical practice. Blood 2024; 144:646-656. [PMID: 38843478 DOI: 10.1182/blood.2024024250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/12/2024] Open
Abstract
ABSTRACT Fostamatinib, a recently approved Syk inhibitor used in adult primary immune thrombocytopenia (ITP), has been shown to be safe and effective in this disorder. However, clinical trial results may not be similarly reproduced in clinical practice. Here, 138 patients with ITP (both primary and secondary) from 42 Spanish centers who had been treated with fostamatinib were evaluated prospectively and retrospectively. The median age of our cohort (55.8% women) was 66 years (interquartile range [IQR], 56-80). The median time since ITP diagnosis at fostamatinib initiation was 51 months (IQR, 10-166). The median number of therapies before fostamatinib initiation was 4 (IQR, 2-5), including eltrombopag (76.1%), romiplostim (57.2%), and IV immunoglobulins (44.2%). Fifty-eight patients (42.0%) had signs/symptoms of bleeding in the month before treatment initiation. Seventy-nine percent of patients responded to fostamatinib with 53.6% complete responses (platelet count > 100 × 109/L). Eighty-three patients (60.1%) received fostamatinib monotherapy, achieving a high response rate (85.4%). The proportion of time in response during the 27-month period examined was 83.3%. The median time to platelet response was 11 days (IQR, 7-21). Sixty-seven patients (48.5%) experienced adverse events, mainly grade 1 to 2; the commonest of which were diarrhea (n = 28) and hypertension (n = 21). One patient had deep venous thrombosis, and one patient developed acute myocardial infarction. Fostamatinib was shown to be effective with good safety profile in patients with primary and secondary ITP across a wide age spectrum in this real-world study.
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Affiliation(s)
| | - Nuria Bermejo-Vega
- Department of Hematology, Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain
| | | | | | | | - Gloria Pérez-Segura
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Abel Domingo
- Department of Hematology, Fundació Privada Hospital Asil de Granollers, Barcelona, Spain
| | - Josefa Luis-Navarro
- Department of Hematology Hospital General de Riotinto, Minas de Riotinto, Huelva, Spain
| | - Sunil Lakhwani
- Department of Hematology, Hospital Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Natalia Acedo
- Department of Hematology, Hospital Universitario de La Princesa, Madrid, Spain
| | - María Luisa Lozano
- Department of Hematology, Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, Centro de Investigación Biomédica en Red de Enfermedades Raras- Instituto de Salud Carlos III, Murcia, Spain
| | - Silvia Bernat
- Department of Hematology, Hospital Universitario de La Plana, Villareal, Spain
| | - Ana Torres-Tienza
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | - Ana Ruano
- Department of Hematology, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Isidro Jarque
- Department of Hematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Galán
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | - Carmen Benet
- Department of Hematology, Hospital Arnau de Vilanova, Valencia, Spain
| | - Shally Marcellini
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | | | | | | | - Alvaro Perona-Blázquez
- Department of Hematology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Elsa Lopez-Ansoar
- Department of Hematology, Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | | | | | | | - Ana Moretó
- Department of Hematology, Hospital Universitario de Cruces, Barakaldo, Spain
| | | | | | - Erik de Cabo
- Department of Hematology, Complejo Hospital de El Bierzo, Ponferrada, Spain
| | | | - Amalia Cuesta
- Department of Hematology, Hospital Sierrallana, Cantabria, Spain
| | - Carmen Pastoriza
- Department of Hematology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | | | - Covadonga García
- Department of Hematology, Hospital Universitario de Burgos, Burgos, Spain
| | | | - Carlos Aguilar
- Department of Hematology, Complejo Asistencial de Soria, Soria, Spain
| | | | | | | | - Alvaro Lorenzo
- Department of Hematology, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - Xavier Ortín
- Department of Hematology, Hospital Verge de la Cinta, Tortosa, Spain
| | - Marta García
- Department of Hematology, Hospital de Terrassa, Barcelona, Spain
| | - Sonia Piernas
- Department of Hematology, Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Johana Díaz-Santa
- Department of Hematology, Hospital Universitari Doctor Josep Trueta, Girona, Spain
| | - Inmaculada Soto
- Department of Hematology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Drew Provan
- Department of Haematology, Barts and The London School of Medicine, London, United Kingdom
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Pektaş G, Uncu İA, Dere Y, Öncü Ş, Kızılkaya MB, Sadi G, Pektaş MB. Retrospective Evaluation of Survival and Prognostic Factors in Immune Thrombocytopenia: A Single-Center and Cross-Sectional Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1153. [PMID: 39064581 PMCID: PMC11279052 DOI: 10.3390/medicina60071153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/07/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Immune thrombocytopenia (ITP) is an autoimmune disease characterized by the autoantibody-mediated destruction of platelets. The treatment of ITP aims to maintain a sufficient platelet count to prevent bleeding. First-line treatment options include corticosteroids and intravenous immunoglobulin (IVIg), while second-line treatments include splenectomy, rituximab and other immunosuppressive agents, and thrombopoietin (TPO) receptor agonists. This study aims to discuss the treatment methods and results from 100 patients with ITP at the Muğla Training and Research Hospital through a pharmacological approach. Materials and Methods: Demographic characteristics, clinical findings, bone marrow aspiration and biopsy results, and treatments and treatment responses at the time of diagnosis of the 100 patients with ITP who were treated and followed up in the period 2015-2023 were evaluated retrospectively. Results: In the third month after treatment, the overall response percentage was 100% in patients who received steroids only and 88% in patients who received IVIg treatment alone or in combination with steroids (p > 0.05). The most preferred second-line treatments were splenectomy (41%), eltrombopag (26%), and rituximab (10%). Bone marrow biopsy was performed in 54% of patients, where 35.1% showed increased megakaryocytes, 44.4% adequate megakaryocytes, and 14.8% decreased megakaryocytes. It is noted that eltrombopag and rituximab, in particular, yield higher complete remission rates than immunosuppressive drugs. Conclusions: Considering the side effects of immunosuppressive medications, IVIg, splenectomy, and steroid therapy, the use of new agents such as eltrombopag, which are easily tolerated and have a lower risk of side effects, is expected to increase.
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Affiliation(s)
- Gökhan Pektaş
- Division of Hematology, Faculty of Medicine, Muğla Sıtkı Koçman University, 48000 Muğla, Türkiye; (G.P.); (İ.A.U.)
| | - İbrahim Asaf Uncu
- Division of Hematology, Faculty of Medicine, Muğla Sıtkı Koçman University, 48000 Muğla, Türkiye; (G.P.); (İ.A.U.)
| | - Yelda Dere
- Department of Medical Pathology, Faculty of Medicine, Muğla Sıtkı Koçman University, 48000 Muğla, Türkiye;
| | - Şeyma Öncü
- Department of Medical Pharmacology, Faculty of Medicine, Afyonkarahisar Health Sciences University, 03200 Afyonkarahisar, Türkiye;
| | - Merve Becit Kızılkaya
- Department of Toxicology, Faculty of Pharmacy, Afyonkarahisar Health Sciences University, 03200 Afyonkarahisar, Türkiye;
| | - Gökhan Sadi
- Department of Biology, K.O. Science Faculty, Karamanoglu Mehmetbey University, 70100 Karaman, Türkiye;
| | - Mehmet Bilgehan Pektaş
- Department of Medical Pharmacology, Faculty of Medicine, Afyonkarahisar Health Sciences University, 03200 Afyonkarahisar, Türkiye;
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3
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Kosmidou A, Gavriilaki E, Tragiannidis A. The Challenge for a Correct Diagnosis of Refractory Thrombocytopenia: ITP or MDS with Isolated Thrombocytopenia? Cancers (Basel) 2024; 16:1462. [PMID: 38672544 PMCID: PMC11048195 DOI: 10.3390/cancers16081462] [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: 02/29/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by isolated thrombocytopenia. It is diagnosed in patients with a platelet count below 100,000 per cubic millimeter in whom other causes of thrombocytopenia have been ruled out, and its diagnosis is generally one of exclusion. Clinical manifestations of patients may vary from asymptomatic disease to mild mucocutaneous or life-threatening bleeding. Glucocorticoids are used as first-line treatment for ITP, while other second-line medications, mainly thrombopoietin-receptor agonists (TPO-RA) and rituximab, are given to patients in whom ITP does not remit, or relapses soon after glucocorticoid treatment. Refractoriness of ITP strongly questions its diagnosis and necessitates a thorough clinical and laboratory work-up to decide whether that is the case of refractory ITP or a misdiagnosis. The aim of this review is to summarize the conditions associated with isolated thrombocytopenia and highlight the characteristics of confusing cases. Even though the case of a myelodysplastic syndrome presented with isolated thrombocytopenia (MDS-IT) is relatively rare and not well-established in the literature, it constitutes one of the most predominant misdiagnoses of refractory ITP. MDS-IT patients are thought to present with multilineage dysplasia, normal karyotype and low risk prognostic score, based on IPSS-R. It has been shown that a significant proportion of MDS-IT patients are misdiagnosed as having the more common ITP. Therefore, it is crucial that in confusing cases of persistent thrombocytopenia a detailed diagnostic work-up is applied-including evaluation of peripheral-blood smear, bone marrow examination and cytogenetic testing-to avoid unnecessary therapy delay.
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Affiliation(s)
- Aikaterini Kosmidou
- 2nd Department of Internal Medicine, General Hospital of Kavala, 65500 Kavala, Greece
| | - Eleni Gavriilaki
- 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
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4
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Mazzucconi MG, Rodeghiero F, Avvisati G, De Stefano V, Gugliotta L, Ruggeri M, Vianelli N, Fazi P, Paoloni F, Sargentini V, Baldacci E, Ferretti A, Martino B, Vincelli ID, Carli G, Fortuna S, Di Ianni M, Ranalli P, Palandri F, Polverelli N, Lugli E, Rivolti E, Patriarca A, Rago A, D'Adda M, Gentile M, Siragusa S, Sibilla S, Carella AM, Rossi E, Battistini R, Zaja F, Bocchia M, Di Renzo N, Musto P, Crugnola M, Giuffrida AC, Krampera M, Tafuri A, Santoro C. Prednisone vs high-dose dexamethasone in newly diagnosed adult primary immune thrombocytopenia: a randomized trial. Blood Adv 2024; 8:1529-1540. [PMID: 38231017 DOI: 10.1182/bloodadvances.2023010975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 01/18/2024] Open
Abstract
ABSTRACT A debate exists regarding which type of corticosteroids (standard-dose prednisone [PDN] or high-dose dexamethasone [HD-DXM]) is the best first-line treatment for adult patients with newly diagnosed untreated primary immune thrombocytopenia (pITP). An ad hoc study compared PDN with HD-DXM in newly diagnosed untreated patients with pITP (aged ≥18 but ≤80 years, platelet count of ≤20 or >20 but <50 × 109/L, and bleeding score of ≥8). Patients were randomised to receive PDN 1 mg/kg per day from days 0 to 28 (Arm A) or HD-DXM 40 mg per day for 4 days, every 14 days, for 3 consecutive courses (Arm B). Fifty-nine of 113 patients (52.2%) were randomized to Arm A and 54 of 113 (47.8%) to Arm B. In evaluable patients, total initial responses (complete response [CR], partial response [PR], minimal response [MR]) were 44 of 56 (78.57%) in Arm A and 46 of 49 (93.88%) in Arm B at days 42 and 46, respectively (P = 0.0284). Total final responses (at day 180 from initial response) were 26 of 43 (60.47%) in Arm A and 23 of 39 (58.97%) in Arm B (P = 0.8907). Total persistent responses (at 12 months from initial response) were 25 of 31 (80.65%) in Arm A and 20 of 36 (55.56%) in Arm B (P = 0.0292). Seven relapses occurred. Median follow-up was 44.4 months. Overall survival was 100% at 48 months, overall disease-free survival was 81.11% at 48 months from day 180. PDN and pulsed HD-DXM were well tolerated; HD-DXM allows effective initial responses but less long lasting than PDN. This trial was registered at www.clinicaltrials.gov as #NCT00657410.
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Affiliation(s)
- Maria Gabriella Mazzucconi
- Hematology, Dipartimento Medicina Traslazionale e di Precisione, Università degli Studi Sapienza, Rome, Italy
| | - Francesco Rodeghiero
- Hematology Project Foundation, Vicenza Affiliated to the Department of Hematology, San Bortolo Hospital, Vicenza, Italy
| | | | - Valerio De Stefano
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Luigi Gugliotta
- Unità Operativa Complessa di Ematologia, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Marco Ruggeri
- Unità Operativa Complessa (UOC) Ematologia, Azienda Unità Locale Socio Sanitaria 8 Berica-Ospedale di Vicenza, Vicenza, Italy
| | - Nicola Vianelli
- Istituto di Ematologia Seràgnoli, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy
| | - Paola Fazi
- Gruppo Italiano Malattie EMatologiche Adulto Foundation, Franco Mandelli Onlus, Rome, Italy
| | - Francesca Paoloni
- Gruppo Italiano Malattie EMatologiche Adulto Foundation, Franco Mandelli Onlus, Rome, Italy
| | - Valeria Sargentini
- Gruppo Italiano Malattie EMatologiche Adulto Foundation, Franco Mandelli Onlus, Rome, Italy
| | - Erminia Baldacci
- UOC Ematologia, Azienda Ospedaliero Universitaria Policlinico Umberto I, Rome, Italy
| | - Antonietta Ferretti
- Hematology, Dipartimento Medicina Traslazionale e di Precisione, Università degli Studi Sapienza, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Bruno Martino
- Dipartimento Emato-Oncologia, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | | | - Giuseppe Carli
- Hematology Project Foundation, Vicenza Affiliated to the Department of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Stefania Fortuna
- Hematology Project Foundation, Vicenza Affiliated to the Department of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Mauro Di Ianni
- UOC Ematologia Clinica, Azienda Sanitaria Locale (ASL) Pescara PO Santo Spirito, Pescara, Italy
| | - Paola Ranalli
- UOC Ematologia Clinica, Azienda Sanitaria Locale (ASL) Pescara PO Santo Spirito, Pescara, Italy
| | - Francesca Palandri
- Istituto di Ematologia Seràgnoli, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy
| | - Nicola Polverelli
- Struttura Semplice a Valenza Dipartimentale Centro Trapianti Midollo per Adulti, Azienda Socio Sanitaria Territoriale (ASST) degli Spedali civili di Brescia, Brescia, Italy
| | - Elisabetta Lugli
- Ematology, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy
| | - Elena Rivolti
- Ematology, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy
| | - Andrea Patriarca
- Struttura Complessa a Direzione Universitaria Ematologia, Azienda Ospedlaiero Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Angela Rago
- UOC Ematologia, ASL Latina-Ospedale S.M. Goretti, Latina, Italy
| | - Mariella D'Adda
- Unità Operativa (UO) Ematologia, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera of Cosenza, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Sergio Siragusa
- UOC di Ematologia, Azienda Ospedaliera Universitaria Policlinico di Palermo, Palermo, Italy
| | - Silvia Sibilla
- UO Ematologia, Ente Ecclesiastico Cardinale G. Panico, Tricase, Italy
| | - Angelo Michele Carella
- UOC Ematologia e Centro Trapianti Cellule Staminali Emopoietiche, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Elena Rossi
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Roberta Battistini
- UOC Ematologia e Centro Trapianti CSE, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Francesco Zaja
- Dipartimento Scienze Mediche, Università degli Studi di Trieste Unità Complessa Operativa Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Monica Bocchia
- UOC Ematologia e Trapianti, Azienda Ospedlaiero Universitaria Senese Policlinico Le Scotte, Siena, Italy
| | - Nicola Di Renzo
- UOC di Ematologia e Trapianto di Cellule Staminali, Ospedale Vito Fazzi ASL Lecce, Lecce, Italy
| | - Pellegrino Musto
- Department of Precision and Regenerative Medicine and Ionian Area, Aldo Moro University School of Medicine and Unit of Hematology and Stem Cell Transplantation, Azienda Ospedaliero Universitaria Consorziale Policlinico, Bari, Italy
| | - Monica Crugnola
- Hematology Unit and Bone Marrow Transplantation Center, Azienda Ospedaliera Universitaria, Parma, Italy
| | - Anna Chiara Giuffrida
- UOC Medicina Trasfusionale, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Mauro Krampera
- UOC di Ematologia e Centro Trapianto di Midollo Osseo, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Agostino Tafuri
- Hematology, University Hospital Sant'Andrea, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristina Santoro
- UOC Ematologia, Azienda Ospedaliero Universitaria Policlinico Umberto I, Rome, Italy
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5
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Rottenstreich A, Bussel JB. Treatment of immune thrombocytopenia during pregnancy with thrombopoietin receptor agonists. Br J Haematol 2023; 203:872-885. [PMID: 37830251 DOI: 10.1111/bjh.19161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 09/30/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
The introduction of thrombopoietin receptor agonists (TPO-RAs) led to a paradigm shift in the management of immune thrombocytopenia (ITP). However, TPO-RAs are not approved for use during pregnancy due to the absence of evidence and concerns for possible effects on the fetus due to their expected transplacental transfer. This comprehensive review examines the safety and efficacy of TPO-RA in 45 pregnancies of women with ITP (romiplostim n = 22; eltrombopag n = 21; both in the same pregnancy n = 2). Mothers experienced failure of the median of three treatment lines during pregnancy prior to TPO-RA administration. A platelet response (>30 × 109 /L) was seen in 86.7% of cases (including a complete response >100 × 109 /L in 66.7%) and was similar between eltrombopag and romiplostim (87.0% and 83.3%, p = 0.99). The maternal safety profile was favourable, with no thromboembolic events encountered. Neonatal thrombocytopenia was noted in one third of cases, with one case of ICH grade 3, and neonatal thrombocytosis was observed in three cases. No other neonatal adverse events attributable to TPO-RAs were seen. This review suggests that the use of TPO-RA during pregnancy is associated with a high response rate and appears safe. Nevertheless, TPO-RA should not be routinely used in pregnancy and should be avoided in the first trimester until further evidence is accumulated.
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Affiliation(s)
- Amihai Rottenstreich
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
- Laboratory of Blood and Vascular Biology, Rockefeller University, New York, New York, USA
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
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6
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González-López TJ, Schifferli A. Early immunomodulation in immune thrombocytopenia-A report of the ICIS meeting in Lenzerheide, Switzerland 2022. Br J Haematol 2023; 203:101-111. [PMID: 37735547 DOI: 10.1111/bjh.19082] [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: 05/28/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
The only way to prevent immune thrombocytopenia (ITP) from becoming refractory would be to restore tolerance to platelets at an early phase of the disease. Numerous immune alterations probably accumulate in chronic ITP; thus, the chances of cure decrease significantly with time. Currently, sustained remission off treatment (SROT) is a clinical definition describing patients who can discontinue their ITP treatment without risk and maintain a state of remission. Different treatment strategies are presently being evaluated with the goal of attaining SROT, mostly combining drugs targeting the innate and/or the adaptive immune system, the inflammation state, so as increasing the platelet load. In this sense, thrombopoietin receptor agonists (TPO-RAs) have shown promising results if used as upfront treatment. TPO-RAs seem to exhibit immunomodulation and immune tolerance properties, increasing not only the platelet antigen mass but also increasing the transforming growth factor-β concentration, and stimulating regulatory T and B lymphocytes. However, more immunological studies are needed to establish accurate molecular alterations in ITP that are potentially reversed with treatments.
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Affiliation(s)
| | - Alexandra Schifferli
- Department of Haematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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7
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Low-dose decitabine modulates myeloid-derived suppressor cell fitness via LKB1 in immune thrombocytopenia. Blood 2022; 140:2818-2834. [PMID: 36037415 DOI: 10.1182/blood.2022016029] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 01/05/2023] Open
Abstract
Myeloid-derived suppressor cells (MDSCs) are heterogeneous immature cells and natural inhibitors of adaptive immunity. Metabolic fitness of MDSCs is fundamental for its suppressive activity toward effector T cells. Our previous studies showed that the number and inhibitory function of MDSCs were impaired in patients with immune thrombocytopenia (ITP) compared with healthy controls. In this study, we analyzed the effects of decitabine on MDSCs from patients with ITP, both in vitro and in vivo. We found that low-dose decitabine promoted the generation of MDSCs and enhanced their aerobic metabolism and immunosuppressive functions. Lower expression of liver kinase 1 (LKB1) was found in MDSCs from patients with ITP, which was corrected by decitabine therapy. LKB1 short hairpin RNA (shRNA) transfection effectively blocked the function of MDSCs and almost offset the enhanced effect of decitabine on impaired MDSCs. Subsequently, anti-CD61 immune-sensitized splenocytes were transferred into severe combined immunodeficient (SCID) mice to induce ITP in murine models. Passive transfer of decitabine-modulated MDSCs significantly raised platelet counts compared with that of phosphate buffered saline-modulated MDSCs. However, when LKB1 shRNA-transfected MDSCs were transferred into SCID mice, the therapeutic effect of decitabine in alleviating thrombocytopenia was quenched. In conclusion, our study suggests that the impaired aerobic metabolism of MDSCs is involved in the pathogenesis of ITP, and the modulatory effect of decitabine on MDSC metabolism contributes to the improvement of its immunosuppressive function. This provides a possible mechanism for sustained remission elicited by low-dose decitabine in patients with ITP.
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8
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Elsayh KI, Saad K, Osman NS, Mahmoud KH, Ahmad FA, Khalaf SM, Sayed NG, Zahran ZAM, Ghandour AMA, Elhoufey AA, Bedir T, Zahran A. Regulatory T-lymphocyte subsets in children with chronic immune thrombocytopenia after high-dose of dexamethasone. Pediatr Res 2022; 92:1432-1436. [PMID: 35173302 PMCID: PMC9700518 DOI: 10.1038/s41390-022-01978-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 01/19/2022] [Accepted: 01/23/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is an acquired autoimmune disease. This study's objective was to estimate the variations in the population of CD4+CD25+High FoxP3+ cells (CD4+ regulatory T-lymphocytes; Tregs) in previously untreated children with chronic ITP managed in Assiut University Hospitals, as well as to evaluate the efficacy of high-dose dexamethasone (HD-DXM) in these patients. METHODS In this study, we investigated the frequencies of T-lymphocyte subsets in 27 untreated children with chronic ITP. RESULTS Prior to treatment, the percentages of CD4+CD25High cells and Tregs were significantly lower in the chronic ITP group compared to the control group (p = 0.018 and p < 0.0001, respectively). After treatment with HD-DXM, Tregs and platelets were significantly increased in these patients (p < 0.0001 for both). CONCLUSIONS Our results suggest that Tregs are deficient in children with chronic ITP and that HD-DXM immunosuppressive therapy can restore the levels of these cells. IMPACT CD4+CD25High cells and Tregs were significantly lower in children chronic ITP compared to healthy control. HD-DXM treatment led to significantly increased Tregs and platelets in these patients. Our results suggest that Tregs are deficient in children with chronic ITP and that HD-DXM immunosuppressive therapy can restore the levels of these cells.
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Affiliation(s)
| | - Khaled Saad
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Naglaa Samy Osman
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Faisal A Ahmad
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Shaimaa M Khalaf
- Department of Pediatrics, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Noha G Sayed
- Department of clinical pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Aliaa M A Ghandour
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Amira A Elhoufey
- Department of Community Health Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt
- Department of Community Health Nursing, Alddrab University College, Jazan University, Jazan, Saudi Arabia
| | - Tamer Bedir
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Asmaa Zahran
- Department of Clinical Pathology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
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9
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AYDIN K, GÜRKAN E. İmmün trombositopenili erişkin hastalarda birinci basamak tedavide yüksek doz metilprednizolonun etkinliği. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1085840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Purpose: We aimed to compare the efficacy of high-dose methylprednisolone (HDP) with intravenous immunoglobulin (IVIG) and conventional prednisolone (CDP) as a first-line therapy in adult patients with immune thrombocytopenia (ITP).
Materials and Methods: This retrospective study included 140 adult patients with either previously untreated newly diagnosed ITP (n=51) or persistent or chronic ITP (n=22/n=67)) with episodes. Patients with a platelet count
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Affiliation(s)
- Kaniye AYDIN
- ÇUKUROVA ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, İÇ HASTALIKLARI ANABİLİM DALI, İÇ HASTALIKLARI YOĞUN BAKIM BİLİM DALI
| | - Emel GÜRKAN
- ÇUKUROVA ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, İÇ HASTALIKLARI ANABİLİM DALI, HEMATOLOJİ BİLİM DALI
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10
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Lebowa W, Zdziarska J, Sacha T. Immune Thrombocytopenia: Characteristics of the Population and Treatment Methods-One-Center Experience. Hamostaseologie 2022; 43:132-141. [PMID: 35654406 DOI: 10.1055/a-1767-0304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a disease with variable clinical presentation, requiring different treatment lines. AIM The study aimed to characterize a group of ITP patients in terms of clinical picture and disease treatment, as well as to present the current standard of care of ITP in Poland, in the context of local and international guidelines. MATERIALS AND METHODS The study included adult patients diagnosed with ITP, treated at the Department of Haematology of the Jagiellonian University Hospital in Krakow from January 2006 to January 2021. Patient characteristics, clinical manifestation of ITP, and treatment methods were analyzed. RESULTS A total of 245 ITP patients were included. 57.1% of them were asymptomatic at diagnosis. Most common symptoms were thrombocytopenic purpura (68.2%), followed by epistaxis (34.7%) and gum bleeds (19.2%). Life-threatening bleedings were noted in three cases (1.2%). 23.2% of patients did not require treatment. Prednisone was the most commonly used first-line therapy (75.5% of patients). Treatment with eltrombopag and romiplostim was used in 40.4 and 8.5% of patients requiring second-line therapy, respectively. 14.3% of all patients ultimately underwent splenectomy, including 51.5% of those who needed second-line treatment. The initial response rate was 74.3%; however, post-splenectomy relapses occurred in 22.9% of patients. CONCLUSIONS ITP is a disease of mild clinical course, often asymptomatic. Chronic disease often requires multiple treatment lines and balancing between bleeding risk and treatment toxicity, based on individual risk-benefit assessment. Local access restrictions to thrombopoietin receptor agonists determined the treatment strategy.
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Affiliation(s)
- Weronika Lebowa
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Joanna Zdziarska
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Tomasz Sacha
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland.,Department of Haematology, Jagiellonian University Medical College, Cracow, Poland
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11
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Feng R, Liu Y, Zhu XL, Zhai WY, He Y, Fu HX, Jiang Q, Jiang H, Lu J, Liu H, Wang JW, Wang H, Xie YD, Ma H, Huang XJ, Zhang XH. Recombinant human thrombopoietin increases platelet count in severe thrombocytopenic patients with hepatitis B-related cirrhosis: Multicentre real-world observational study. J Viral Hepat 2022; 29:306-316. [PMID: 35152507 DOI: 10.1111/jvh.13655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 11/25/2021] [Accepted: 02/03/2022] [Indexed: 12/23/2022]
Abstract
Patients with hepatitis B-related cirrhosis complicated with thrombocytopenia have a higher risk of bleeding, which may lead to higher mortality. We aimed to explore the efficacy and safety of recombinant human thrombopoietin (rhTPO) in the treatment of hepatitis B-related cirrhosis complicated with severe thrombocytopenia. Patients with hepatitis B-related compensated liver cirrhosis complicated with severe thrombocytopenia were divided into four groups according to the treatment method for thrombocytopenia. Platelet counts, the appearance of bleeding symptoms and adverse events were evaluated during the observation period. Also during the observational period, the platelet counts in the prednisone group, rhTPO group and prednisone plus rhTPO group were higher than those in the no treatment group. Patients without splenomegaly reacted better to rhTPO. Fewer bleeding events of grade 2 or worse were observed in the three treatment groups compared to the no treatment group. The platelet counts at baseline and treatment with rhTPO and/or prednisone were factors associated with bleeding events of grade 2 or worse in multivariate analysis. There could be a potential advantage for the use of rhTPO plus prednisone based on higher platelet counts and fewer bleeding events. Treatment with rhTPO was more effective in patients without splenomegaly.
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Affiliation(s)
- Ru Feng
- Department of Hematology, National Center of Gerontology, Beijing Hospital, Beijing, China.,Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Liu
- Department of Hematology, the Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Xiao-Lu Zhu
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Wan-Yi Zhai
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Yun He
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Hai-Xia Fu
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Qian Jiang
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Hao Jiang
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Jin Lu
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Hui Liu
- Department of Hematology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Beijing, China
| | - Hao Wang
- Institute of Hepatic Diseases, Peking University People's Hospital, Beijing, China
| | - Yan-Di Xie
- Institute of Hepatic Diseases, Peking University People's Hospital, Beijing, China
| | - Hui Ma
- Institute of Hepatic Diseases, Peking University People's Hospital, Beijing, China
| | - Xiao-Jun Huang
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Xiao-Hui Zhang
- Institute of Hematology, Peking University People's Hospital, Beijing, China
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12
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Gonzalez-Porras JR, Palomino D, Vaquero-Roncero LM, Bastida JM. Bleeding complications associated with pregnancy with primary immune thrombocytopenia: a meta-analysis. TH OPEN 2022; 6:e230-e237. [PMID: 36046200 PMCID: PMC9423940 DOI: 10.1055/a-1837-7581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 04/21/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction
Immune thrombocytopenia (ITP) during pregnancy has received little attention from researchers. Reliable information about the outcome of mothers and newborns is required to properly counsel women who are pregnant or planning to become pregnant. Our primary outcomes were the frequency and severity of maternal and neonatal bleeding events in the setting of ITP in pregnancy. Mode of delivery, neonatal thrombocytopenia, and maternal/infant mortality were secondary outcomes.
Material and Methods
We comprehensively reviewed the prospective studies that enrolled ≥20 pregnant women with primary ITP. Two reviewers, blinded to each other, searched Medline and Embase up to February 2021. Meta-analyses of the maternal and newborn outcomes were performed. Weighted proportions were estimated by a random-effects model.
Results
From an initial screening of 163 articles, 15 were included, encompassing 1,043 pregnancies. The weighted event rate for bleeding during pregnancy was 0.181 (95% confidence interval [CI], 0.048–0.494). Most of these were nonsevere cases. The weighted event rates were 0.053 (95% CI, 0.020–0.134) for severe postpartum hemorrhage, 0.014 (95% CI, 0.008–0.025) for intracerebral hemorrhage, and 0.122 (0.095–0.157) for severe thrombocytopenia events in neonates (platelet count <50,000/μL). There were no reliable predictors of severe neonatal thrombocytopenia. The incidence of neonatal mortality was 1.06%. There were no maternal deaths.
Conclusion
Primary ITP in pregnant women is rarely associated with poor outcomes.
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13
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Wang ZJ, Chen HB, Zhou F, Yu H, Wu XY, Shen YQ, Qiu YN, Jin RM. A New Immunosuppressive Therapy for Very Severe Aplastic Anemia in Children with Autoantibodies. Curr Med Sci 2022; 42:379-386. [PMID: 35258748 DOI: 10.1007/s11596-022-2519-2] [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: 01/30/2021] [Accepted: 10/11/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE At present, a number of very severe aplastic anemia (VSAA) patients cannot receive hematopoietic stem cell transplantation (HSCT) or standard immunosuppressive therapy (IST) due to the high cost of therapy, shortage of sibling donors, and lack of resources to support the HSCT. In addition, some VSAA patients with autoantibodies have no life-threatening infections or bleeding at the time of initial diagnosis. Considering the disease condition, economics and other factors, the present study designed a new and relatively mild treatment strategy: cyclosporine A plus pulsed high-dose prednisone (CsA+HDP). METHODS The present study retrospectively analyzed 11 VSAA patients, who were treated with CsA+HDP in our hospital from August 2017 to August 2019. RESULTS The median follow-up time for these patients was 24.9 months. The overall response rate was 54.5% (6/11) at six months after the initiation of IST and 81.8% (9/11) at deadline. Five patients achieved complete remission and four patients met the criteria for partial response at the last follow-up. The median time to response for responders was 110 days. Three patients underwent HSCT due to the poor effect of CsA+HDP or to find a suitable transplant donor. Recurrence and clonal evolution were not found in any of these patients. The estimated 3-year overall survival rate and 3-year failure-free survival rate were 100.0% and 72.7%, respectively. In addition, the results revealed that the cyclosporine-prednisone-associated toxicity was mild and well-tolerated by most patients. CONCLUSION The novel CsA+HDP regimen has good therapeutic effect and safety for VSAA patients with autoantibodies, who have no serious life-threatening infections or bleeding at the time of initial diagnosis.
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Affiliation(s)
- Zhong-Jian Wang
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Hong-Bo Chen
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Fen Zhou
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Hui Yu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiao-Yan Wu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ya-Qing Shen
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yi-Ning Qiu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Run-Ming Jin
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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14
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Li C, Sun M, Li R, Wang S, Shao L, Xu M, Yao M, Wang L, Hou M, Feng Q, Peng J. Association of metformin treatment and outcome in adult patients with ITP and pre-existing T2DM. Br J Haematol 2022; 197:367-372. [PMID: 35288929 DOI: 10.1111/bjh.18121] [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: 10/12/2021] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 12/15/2022]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune haemorrhagic disease that could manifest with comorbid type 2 diabetes mellitus (T2DM). However, the exact impact of T2DM in patients with ITP remains uncertain. In this study, we performed a retrospective cohort study of 458 participants with ITP. The prevalence of T2DM was 7.6% in this population (35 patients), which was slightly lower than the Chinese nationwide prevalence of T2DM, calculated to be approximately 10.9%. The participants with pre-existing T2DM displayed a significantly higher response to therapy than those without T2DM (71% vs. 53%). Furthermore, in the T2DM cohort, the response rate reached 88% when metformin was included in the treatment regimen. This clinical evidence suggests that metformin therapy might improve the clinical outcomes of ITP.
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Affiliation(s)
- Chaoyang Li
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Meng Sun
- Jinan Vocational College of Nursing, Jinan, China.,Department of Pharmaceutics, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ranran Li
- Department of Radiology, Ningjin County People's Hospital, Dezhou, China
| | - Shuwen Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Linlin Shao
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Miao Xu
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medcine, Shandong University, Jinan, China
| | - Meiyue Yao
- Medical College, Qilu Institute of Technology, Jinan, China
| | - Lin Wang
- 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.,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medcine, Shandong University, Jinan, China
| | - Qi Feng
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medcine, Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, China
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15
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Wu YJ, Liu H, Zeng QZ, Liu Y, Wang JW, Wang WS, Jia-Feng, Zhou HB, Huang QS, He Y, Fu HX, Zhu XL, Jiang Q, Jiang H, Chang YJ, Xu LP, Huang XJ, Zhang XH. All- trans retinoic acid plus low-dose rituximab vs low-dose rituximab in corticosteroid-resistant or relapsed ITP. Blood 2022; 139:333-342. [DOI: i:10.1182/blood.2021013393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Abstract
The study aimed to compare the efficacy and safety of all-trans retinoic acid (ATRA) plus low-dose rituximab (LD-RTX) with LD-RTX monotherapy in corticosteroid-resistant or relapsed immune thrombocytopenia (ITP) patients. Recruited patients were randomized at a ratio of 2:1 into 2 groups: 112 patients received LD-RTX plus ATRA, and 56 patients received LD-RTX monotherapy. Overall response (OR), defined as achieving a platelet count of ≥30 × 109/L confirmed on ≥2 separate occasions (≥7 days apart), at least a doubling of the baseline platelet count without any other ITP-specific treatment, and the absence of bleeding within 1 year after enrollment, was observed in more patients in the LD-RTX plus ATRA group (80%) than in the LD-RTX monotherapy group (59%) (between-group difference, 0.22; 95% CI, 0.07-0.36). Sustained response (SR), defined as maintenance of a platelet count >30 × 109/L, an absence of bleeding, and no requirement for any other ITP-specific treatment for 6 consecutive months after achievement of OR during 1 year following enrollment, was achieved by 68 (61%) patients in the combination group and 23 (41%) patients in the monotherapy group (between-group difference, 0.20; 95% CI, 0.04-0.35). The 2 most common adverse events (AEs) for the combination group were dry skin and headache or dizziness. Our findings demonstrated that ATRA plus LD-RTX significantly increased the overall and sustained response, indicating a promising treatment option for corticosteroid-resistant or relapsed adult ITP. This study is registered at www.clinicaltrials.gov as #NCT03304288.
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Affiliation(s)
- Ye-Jun Wu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hui Liu
- Department of Hematology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Qiao-Zhu Zeng
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yi Liu
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wen-Sheng Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Jia-Feng
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China; and
| | - He-Bing Zhou
- Department of Hematology, The Affiliated Beijing Luhe Hospital of Capital Medical University, Beijing, China
| | - Qiu-Sha Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yun He
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hai-Xia Fu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Lu Zhu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qian Jiang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hao Jiang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ying-Jun Chang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lan-Ping Xu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Jun Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
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16
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Bobircă A, Bobircă F, Ancuța I, Florescu A, Bojincă M, Muscă A, Florescu DN, Florescu LM, Sima RM, Florescu A, Mușetescu AE. COVID-19-A Trigger Factor for Severe Immune-Mediated Thrombocytopenia in Active Rheumatoid Arthritis. LIFE (BASEL, SWITZERLAND) 2022; 12:life12010077. [PMID: 35054471 PMCID: PMC8780601 DOI: 10.3390/life12010077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 01/04/2022] [Indexed: 12/13/2022]
Abstract
Thrombocytopenia is defined as a platelet count below 150,000/mm3 for adults. There is still controversy about whether individuals with platelet counts of 100,000/mm3 to 150,000/mm3 should be classified as having genuine thrombocytopenia or borderline thrombocytopenia. Thrombocytopenia is considered mild when the platelet count is between 70,000 and 150,000/mm3 and severe if the count is less than 20,000/mm3. Thrombocytopenia in rheumatoid arthritis is a rare complication, with an incidence estimated between 3 and 10%. The main etiological aspects include drug-induced thrombocytopenia and immune thrombocytopenic purpura. The most common hematological abnormalities in SARS-CoV-2 infection are lymphopenia and thrombocytopenia. It has been observed that the severity of thrombocytopenia correlates with the severity of the infection, being a poor prognosis indicator and a risk factor for mortality. COVID-19 can stimulate the immune system to destroy platelets by increasing the production of autoantibodies and immune complexes. Autoimmunity induced by viral infections can be related to molecular mimicry, cryptic antigen expression and also spreading of the epitope. During the COVID-19 pandemic, it is of great importance to include the SARS-CoV-2 infection in differential diagnoses, due to the increased variability in forms of presentation of this pathology. In this review, our aim is to present one of the most recently discovered causes of thrombocytopenia, which is the SARS-CoV-2 infection and the therapeutic challenges it poses in association with an autoimmune disease such as rheumatoid arthritis.
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Affiliation(s)
- Anca Bobircă
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Florin Bobircă
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Dr I. Cantacuzino Clinical Hospital, 050474 Bucharest, Romania;
| | - Ioan Ancuța
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Anca Florescu
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Mihai Bojincă
- Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (A.B.); (I.A.); (M.B.)
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Alice Muscă
- Department of Internal Medicine and Rheumatology, Dr I. Cantacuzino Clinical Hospital, 011437 Bucharest, Romania; (A.F.); (A.M.)
| | - Dan Nicolae Florescu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Lucian Mihai Florescu
- Department of Radiology and Medical Imaging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Romina Marina Sima
- Department of Obstetrics and Gynecology, “Bucur” Maternity, “Saint John” Clinical Emergency Hospital, 077160 Bucharest, Romania;
| | - Alesandra Florescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
- Correspondence:
| | - Anca Emanuela Mușetescu
- Department of Rheumatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
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Abdallah GEM, Abbas WA, Elbeih EAS, Abdelmenam E, Mohammed Saleh MF. Systemic corticosteroids in the treatment of warm autoimmune hemolytic anemia: A clinical setting perspective. Blood Cells Mol Dis 2021; 92:102621. [PMID: 34808491 DOI: 10.1016/j.bcmd.2021.102621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/14/2021] [Accepted: 10/16/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION There are unmet answers about the effect of the different forms of corticosteroids in the treatment of the warm autoimmune hemolytic anemia (WAIHA). We aimed to describe the initial response rate and the safety profile of different regimens and forms of parenteral corticosteroids versus the solo oral prednisolone as first-line strategies for newly diagnosed adult WAIHA. METHODS We recruited 156 patients who treated with either oral prednisolone 1 mg/kg daily for 3 weeks or intravenous corticosteroids like dexamethasone 40 mg daily for 4 days, Methylprednisolone 1 g/day for 3 days, or Methylprednisolone 1 g/day for 5 days then followed by oral prednisolone 1 mg/kg/day for 3 weeks. Full clinical and laboratory evaluations were done every 3 days for 3 weeks. RESULTS The primary outcome was the rate of response at the end of the third-week post treatment. The rate of response was more in the group started the treatment intravenously (81.6% versus 41.7% and p = 0.0001). Multivariate cox regression analysis proved the predictivity of intravenous corticosteroid therapy for initial response. CONCLUSION The safety profile of the different forms and regimens of corticosteroids were comparable. Therefore, parenteral regimens can be used as a rescue treatment in severe cases of WAIHA.
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Affiliation(s)
- Ghada E M Abdallah
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Wael A Abbas
- Department of Internal Medicine, Faculty of Medicine, Assiut University Assiut, Egypt
| | - Esam A S Elbeih
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ehab Abdelmenam
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mostafa F Mohammed Saleh
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
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18
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Ishiyama M, Shiseki M, Yoshinaga K, Ryuzaki M, Izuka Y, Watanabe A, Tanaka N, Shinohara A, Hagiwara S, Tanaka J. Very Early Increased Platelet Count within a Week after Initiation of High-Dose Dexamethasone Treatment Is Associated with Long-Term Response in Newly Diagnosed Immune Thrombocytopenia Patients. Acta Haematol 2021; 145:193-200. [PMID: 34818223 DOI: 10.1159/000518744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/28/2021] [Indexed: 11/19/2022]
Abstract
To evaluate the long-term efficacy of high-dose dexamethasone (HD-DXM) treatment for immune thrombocytopenia (ITP), we retrospectively analysed 36 newly diagnosed ITP patients treated with HD-DXM as a first-line treatment. An initial response was obtained in 23 (63.9%) patients, including 11 with a complete response (CR) and 12 with a partial response (PR). Six months after HD-DXM treatment, 26 of 33 (78.8%) evaluable patients achieved objective responses, including 18 CR and 8 PR. Among 13 patients without initial response, very early increased platelet count within a week (VEIP) was observed in 7 patients, 5 (71.4%) of whom achieved a response at 6 months. In 29 patients who had available platelet count within a week, patients showing VEIP revealed longer survival than those who did not (p = 0.026). HD-DXM was an effective treatment for newly diagnosed ITP patients. VEIP after HD-DXM treatment initiation was associated with a long-term objective response in newly diagnosed ITP patients.
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Affiliation(s)
- Midori Ishiyama
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan,
| | - Masayuki Shiseki
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kentaro Yoshinaga
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Michiko Ryuzaki
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuki Izuka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Aya Watanabe
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Norina Tanaka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Akihito Shinohara
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shotaro Hagiwara
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junji Tanaka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
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All-trans retinoic acid plus low-dose rituximab vs low-dose rituximab in corticosteroid-resistant or relapsed ITP. Blood 2021; 139:333-342. [PMID: 34665865 DOI: 10.1182/blood.2021013393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
The study aimed to compare the efficacy and safety of all-trans retinoic acid (ATRA) plus low-dose rituximab (LD-RTX) with LD-RTX monotherapy in corticosteroid-resistant or relapsed immune thrombocytopenia (ITP) patients. Recruited patients were randomized at a ratio of 2:1 into 2 groups: 112 patients received LD-RTX plus ATRA and 56 patients received LD-RTX monotherapy. Overall response (OR), defined as achieving a platelet count of ≥ 30 × 109/L confirmed on at least two separate occasions (at least 7 days apart), at least a doubling of the baseline platelet count without any other ITP-specific treatment and the absence of bleeding within 1 year after enrollment, was observed in more patients in the LD-RTX plus ATRA group (80%) than in the LD-RTX monotherapy group (59%) (between-group difference, 0.22; 95% CI, 0.07 to 0.36). Sustained response (SR), defined as maintenance of a platelet count > 30 x 109/L, an absence of bleeding, and no requirement for any other ITP-specific treatment for 6 consecutive months after achievement of OR during 1 year following enrollment, was achieved by 68 (61%) patients in the combination group and 23 (41%) patients in the monotherapy group (between-group difference, 0.20; 95% CI, 0.04 to 0.35). The 2 most common AEs for the combination group were dry skin and headache or dizziness. Our findings demonstrated that ATRA plus LD-RTX significantly increased the overall and sustained response, indicating a promising treatment option for corticosteroid-resistant or relapsed adult ITP. This study is registered at www.clinicaltrials.gov as #NCT03304288.
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20
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The Efficacy and Safety of Different Dosages of Rituximab for Adults with Immune Thrombocytopenia: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9992086. [PMID: 34660807 PMCID: PMC8514896 DOI: 10.1155/2021/9992086] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 07/17/2021] [Accepted: 08/25/2021] [Indexed: 01/19/2023]
Abstract
Background Rituximab has been frequently used as a second-line treatment for patients with immune thrombocytopenia (ITP). The optimal dose and course of rituximab are uncertain. Methods A comprehensive search for randomized controlled trials reporting the use of low-dose (100 mg) or standard-dose (375 mg/m2) rituximab in ITP treatment was conducted. Meta-analyses were performed on CRR (complete response rate), ORR (overall response rate), PRR (partial response rate), SRR (sustained response rate), infection rate, SB (significant bleeding) rate, and SAE (serious adverse event) rate. Results A total of 12 studies were included, comprising 869 patients. Compared to the control group, rituximab treatment resulted in an obvious increase in CRR (P < 0.00001), ORR (P < 0.0001), and SRR at month 6 and 12 (P = 0.0007, P = 0.0003), without increasing the infection rate (P = 0.12) and SAE rate (P = 0.11). No significant differences in CRR (RR 1.61 vs. 1.42, P = 0.45), ORR (RR 1.26 vs. 1.49, P = 0.28), PRR (RR 1.25 vs. 1.00, P = 0.11), SRR at month 12 (RR 2.00 vs. RR 1.64, P = 0.54), infection rate (RR 0.85 vs. 1.46, P = 0.36), and SB rate (RR 0.14 vs. 1.19, P = 0.17) were found in subgroups of low dose and standard dose. Conclusion Rituximab was effective and safe for adult patients with ITP. A low-dose rituximab regimen might be an effective alternative to the standard-dose regimen in ITP, as it showed similar CRR, ORR, and SRR at month 12 and was relatively safer with a lower cost.
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21
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Al-Samkari H, Cronin A, Arnold DM, Rodeghiero F, Grace RF. Extensive variability in platelet, bleeding, and QOL outcome measures in adult and pediatric ITP: Communication from the ISTH SSC subcommittee on platelet immunology. J Thromb Haemost 2021; 19:2348-2354. [PMID: 33974336 DOI: 10.1111/jth.15366] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Despite publication of standardization recommendations by the immune thrombocytopenia (ITP) International Working Group (IWG) in 2009, there remains inconsistent outcomes definitions across ITP studies. To understand current practices and inform future standardization efforts, we characterized how outcomes have been measured following publication of IWG recommendations. METHODS PubMed/MEDLINE-indexed manuscripts published from January 2010 through December 2019 describing platelet, bleeding, and/or health-related quality of life (HRQoL) outcome measures in adult and pediatric ITP were comprehensively reviewed. This project was endorsed by the Platelet Immunology SSC of the ISTH. RESULTS The PubMed/MEDLINE search revealed 1562 manuscripts; following review, 168 met inclusion criteria. Platelet response outcomes were reported in 141 studies, of which 57% did not use IWG definitions (using 21 distinct alternative platelet response schemes). Most randomized trials did not use IWG definitions, instead favoring platelet ≥50 × 109 /L to define response. Platelet ≥100 × 109 /L sustained for ≥6 months in the absence of therapy was the most common ITP remission definition. Bleeding outcomes were reported systematically in 41% of studies, which used 21 distinct reporting schemes. A plurality of adult studies used the World Health Organization Bleeding Scale and a plurality of pediatric studies used the Buchanan and Adix Score. HRQoL outcomes were reported in few studies (9%), which used a total of eight different HRQoL instruments. CONCLUSIONS Despite prior attempts to standardize ITP outcome evaluation, wide variability in platelet, bleeding, and HRQoL outcomes remain. Most ITP studies did not systematically evaluate bleeding or HRQoL outcomes. Further standardization of outcome measurement in both pediatric and adult ITP is greatly needed.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandria Cronin
- Medical Library, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Francesco Rodeghiero
- Hematology Project Foundation, affiliated to the Department of Hematology, S. Bortolo Hospital, Vicenza, Italy
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
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22
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Sirotich E, Guyatt G, Gabe C, Ye Z, Beck CE, Breakey V, Cooper N, Cuker A, Charness J, de Wit K, DiRaimo J, Fein SG, Grace RF, Hassan Z, Jamula E, Kang M, Manski CF, O'Connor C, Pai M, Paynter D, Porter SC, Pruitt B, Strachan G, Webert KE, Yan JW, Kelton JG, Bakchoul T, Arnold DM. Definition of a critical bleed in patients with immune thrombocytopenia: Communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost 2021; 19:2082-2088. [PMID: 34327824 DOI: 10.1111/jth.15368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/12/2021] [Accepted: 04/28/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is an autoimmune disease characterized by low platelet counts and increased risk of bleeding. In preparation for an upcoming guideline, the ITP Emergency Management Guideline Panel, including clinical experts in hematology, emergency medicine, research methodology, and patient representatives, identified the need for a standardized definition of a critical ITP bleed. The goal of the definition was to distinguish critical bleeds from bleeds that may not require urgent treatment, typically in the context of severe thrombocytopenia. METHODS The panel met in person and virtually to achieve consensus on the criteria for critical bleeding events among patients with ITP. Existing ITP bleeding scores and published definitions of major bleeds in patients receiving anticoagulation informed the definition of a critical ITP bleed. The Platelet Immunology Scientific Standardization Committee (SSC) of the International Society on Thrombosis and Haemostasis endorsed the definition. RESULTS A critical ITP bleed was defined as: (a) a bleed in a critical anatomical site including intracranial, intraspinal, intraocular, retroperitoneal, pericardial, or intramuscular with compartment syndrome; or (2) an ongoing bleed that results in hemodynamic instability or respiratory compromise. CONCLUSION The definition of a critical ITP bleed was developed by the ITP Emergency Management Guideline Panel and endorsed by the Platelet Immunology SSC. It incorporates both anatomic and physiologic risk and pertains to patients with confirmed or suspected ITP who typically have severe thrombocytopenia (platelet count below 20 × 109 /L).
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Affiliation(s)
- Emily Sirotich
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Caroline Gabe
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Zhikang Ye
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Carolyn E Beck
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vicky Breakey
- Division of Pediatric Hemaology/Oncology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Nichola Cooper
- Department of Immunology and Inflammation, Department of Medicine, Imperial college, London, UK
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Rachael F Grace
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Ziauddin Hassan
- Department of Emergency Medicine, Dr FH Wigmore Regional Hosiptal, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Erin Jamula
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Matthew Kang
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Joseph Brant Hospital, Burlington, ON, Canada
| | - Charles F Manski
- Department of Economics and Institute for Policy Research, Northwestern University, Evanston, IL, USA
| | - Clare O'Connor
- Hamilton Health Sciences and McMaster School of Nursing, Hamilton, ON, Canada
| | - Menaka Pai
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, ON, Canada
| | - Dale Paynter
- Platelet Disorder Support Association (PDSA), Cleveland, OH, USA
| | - Stephen C Porter
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Barbara Pruitt
- Platelet Disorder Support Association, Cincinnati, OH, USA
| | - Gail Strachan
- Platelet Disorder Support Association, Cincinnati, OH, USA
| | - Kathryn E Webert
- Canadian Blood Services, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - John G Kelton
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Donald M Arnold
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
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Patwardhan P, Proudman D, Allen J, Lucas S, Nellesen D. Cost-minimization analysis comparing eltrombopag vs romiplostim for adults with chronic immune thrombocytopenia. J Manag Care Spec Pharm 2021; 27:1447-1456. [PMID: 34278835 PMCID: PMC10394751 DOI: 10.18553/jmcp.2021.21080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Promacta (eltrombopag; EPAG) and Nplate (romiplostim; ROMI) have not been compared in head-to-head trials for treatment of chronic immune thrombocytopenia (cITP); however, indirect treatment comparisons have indicated similar efficacy and safety outcomes, and the drugs are generally accepted as therapeutic alternatives. OBJECTIVE: To determine which of the 2 therapies would result in the lowest overall cost from a US health plan perspective, under the assumption of equivalent clinical efficacy and safety. METHODS: A cost-minimization model was developed in Microsoft Excel. The model incorporated only costs that differ between the treatments, including drug acquisition, administration, and monitoring costs, over a 52-week horizon. Average dosing for EPAG and ROMI was taken from the long-term EXTEND trial and from a published metaanalysis of 14 clinical trials, respectively. ROMI is injectable and EPAG is oral, so only ROMI had administration costs. The model assumed patients used 25 mg EPAG tablets and the 250 μg vial size of ROMI. ROMI wastage was included in drug acquisition costs by rounding up average dose to the nearest whole vial. Monitoring requirements were determined from US prescribing information, with platelet monitoring assumed equal, and hepatic panel testing every 4 weeks for EPAG. The model was adjustable to commercial, Medicare, and Medicaid plan perspectives, with optional inclusion of drug wastage, monitoring, or administration costs. RESULTS: The base case used a commercial plan perspective, with average dosing of 51.5 mg/day for EPAG and 4.20 μg/kg/week for ROMI. The analysis found a cost difference per treated patient of $64,770 in favor of EPAG on an annual basis. Breakdown by unique costs for EPAG included drug-acquisition cost of $123,135 and monitoring cost of $705. Breakdown by unique costs for ROMI included drug-acquisition cost of $183,234, with wastage of $63,179 and administration cost of $5,377. Based on a hypothetical commercial plan with 1 million members and an estimated 11 patients with cITP receiving ROMI, potential annual savings for switching all patients from ROMI to EPAG is $712,473 or $0.06 per member per month. EPAG remained the less costly option for all plan types and assumptions. A sensitivity analysis found that the result was most sensitive to drug pricing and wastage inputs. CONCLUSIONS: Because of lower drug-acquisition costs (including drug wastage) and administration costs, treatment of cITP with EPAG is associated with a lower net cost per patient than ROMI. DISCLOSURES This study was funded by Novartis Pharmaceuticals Corporation. Proudman, Lucas, and Nellesen are employees of Analysis Group, Inc., which received funding from Novartis Pharmaceuticals Corporation to conduct this study. Patwardhan was employed by Novartis Pharmaceuticals Corporation at the time of this study; Allen is an employee of Novartis. This research was presented as an e-poster at the AMCP 2020 Virtual, April 2020.
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Wang S, Zhang X, Leng S, Zhang Y, Li J, Peng J, Zhou Z, Feng Q, Hu X. SIRT1 single-nucleotide polymorphisms are associated with corticosteroid sensitivity in primary immune thrombocytopenia patients. Ann Hematol 2021; 100:2453-2462. [PMID: 34269838 DOI: 10.1007/s00277-021-04583-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/22/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by decreased platelet count. While corticosteroids are a useful first-line therapy for ITP patients, their long-term effectiveness is limited, and the determinants of corticosteroid sensitivity in ITP patients remain largely unknown. Sirtuin 1 (SIRT1), a member of the mammalian sirtuin family, is related to the anti-inflammatory effects of corticosteroids. Here, we investigate the contribution of the SIRT1 single-nucleotide polymorphisms (SNPs) rs12778366 and rs4746720 to ITP susceptibility. METHODS We recruited 330 ITP patients and 309 healthy controls from Han population, and performed genotyping of SIRT1 rs12778366 and rs4746720 using a MassARRAY system. The results were validated in another 55 ITP patients from ethnic minorities. RESULTS Using clinical data of patients and controls from Han polulation, including corticosteroid sensitivity, susceptibility, refractoriness, and severity, our results revealed that the CC/TC genotypes of SIRT1 rs12778366 were associated with a 2.034-fold increased risk of corticosteroid resistance compared to the homozygous major TT genotype (dominant, CC/TC vs. TT, OR = 2.034, 95% CI = 1.039-3.984, p = 0.038). In contrast, the CC/CT genotype of SIRT1 rs4746720 showed a 0.560-fold decreased risk of corticosteroid resistance (dominant, 95% CI = 0.321-0.976, OR = 0.560, p = 0.041). The C allele substitute in SIRT1 rs12778366 was significantly associated with the corticosteroid sensitivity of ITP patients (p = 0.021). The similar results were obtained in minority ITP patients. CONCLUSION This study indicates that SIRT1 rs12778366 and rs4746720 may be genetic factors related to corticosteroid sensitivity in ITP patients.
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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
| | - Yanqi Zhang
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ju Li
- Shandong Provincial Key Laboratory of Immunohematology, 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
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Zeping Zhou
- Department of Hematology, the Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
| | - Qi Feng
- 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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25
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Yu Y, Wang M, Hou Y, Qin P, Zeng Q, Yu W, Guo X, Wang J, Wang X, Liu G, Chu X, Yang L, Feng Y, Zhou F, Sun Z, Zhang M, Wang X, Wang Z, Ran X, Zhao H, Wang L, Zhang H, Bi K, Li D, Yuan C, Xu R, Wang Y, Zhou Y, Peng J, Liu X, Hou M. High-dose dexamethasone plus recombinant human thrombopoietin vs high-dose dexamethasone alone as frontline treatment for newly diagnosed adult primary immune thrombocytopenia: A prospective, multicenter, randomized trial. Am J Hematol 2020; 95:1542-1552. [PMID: 32871029 DOI: 10.1002/ajh.25989] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 08/19/2020] [Accepted: 08/29/2020] [Indexed: 12/24/2022]
Abstract
We conducted a prospective, multicenter, randomized, controlled clinical trial to compare the efficacy and safety of high-dose dexamethasone (HD-DXM) plus recombinant human thrombopoietin (rhTPO), vs HD-DXM alone in newly diagnosed adult immune thrombocytopenia (ITP) patients. Enrolled patients were randomly assigned to receive DXM plus rhTPO or DXM monotherapy. Another 4-day course of DXM was repeated if response was not achieved by day 10 in both arms. One hundred patients in the HD-DXM plus rhTPO arm and 96 patients in the HD-DXM monotherapy arm were included in the full analysis set. So, HD-DXM plus rhTPO resulted in a higher incidence of initial response (89.0% vs 66.7%, P < .001) and complete response (CR, 75.0% vs 42.7%, P < .001) compared with HD-DXM monotherapy. Response rate at 6 months was also higher in the HD-DXM plus rhTPO arm than that in the HD-DXM monotherapy arm (51.0% vs 36.5%, P = .02; sustained CR: 46.0% vs 32.3%, P = .043). Throughout the follow-up period, the overall duration of response was greater in the HD-DXM plus rhTPO arm compared to the HD-DXM monotherapy arm (P = .04), as estimated by the Kaplan-Meier analysis. The study drugs were generally well tolerated. In conclusion, the combination of HD-DXM with rhTPO significantly improved the initial response and yielded favorable SR in newly diagnosed ITP patients, thus could be further validated as a frontline treatment for ITP. This study is registered as clinicaltrials.gov identifier: NCT01734044.
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Affiliation(s)
- Yafei Yu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Miaomiao Wang
- Department of Pediatrics The Second Hospital, Cheeloo College of Medicine, Shandong University Jinan China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Ping Qin
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Qingshu Zeng
- Department of Hematology The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Wenzheng Yu
- Department of Hematology Binzhou Medical University Hospital Binzhou China
| | - Xinhong Guo
- Department of Hematology The First Affiliated Hospital of Xinjiang Medical University Urumqi China
| | - Jingxia Wang
- Department of Hematology Liaocheng People’s Hospital Liaocheng China
| | - Xiaomin Wang
- Department of Hematology Xinjiang Uiger Municipal People’s Hospital Urumqi China
| | - Guoqiang Liu
- Department of Hematology Shengli Oilfield Central Hospital Dongying China
| | - Xiaoxia Chu
- Department of Hematology Yantai Yuhuangding Hospital Yantai China
| | - Lan Yang
- Department of Hematology Xijing Hospital, Fourth Military Medical University Xi’an China
| | - Ying Feng
- Department of Hematology The Second Affiliated Hospital of Guangzhou Medical University Guangdong China
| | - Fang Zhou
- Department of Hematology Military General Hospital Jinan China
| | - Zhaogang Sun
- Department of Hematology Taian City Central Hospital Taian China
| | - Mei Zhang
- Department of Hematology The First Affiliated Hospital of Xi’an Jiaotong University Xi’an China
| | - Xin Wang
- Department of Hematology Shandong Provincial Hospital Affiliated to Shandong University Jinan China
| | - Zhencheng Wang
- Department of Hematology Zibo Central Hospital Zibo China
| | - Xuehong Ran
- Department of Hematology Weifang People’s Hospital Weifang China
| | - Hongguo Zhao
- Department of Hematology The Affiliated Hospital of Qingdao University Qingdao China
| | - Lei Wang
- Department of Hematology Qingdao Municipal Hospital Qingdao China
| | - Haiyan Zhang
- Department of Hematology Linyi People’s Hospital Linyi China
| | - Kehong Bi
- Department of Hematology Shandong Provincial Qianfoshan Hospital Jinan China
| | - Daqi Li
- Department of Hematology Jinan Central Hospital Jinan China
| | - Chenglu Yuan
- Department of Hematology Qilu Hospital (Qingdao), Shandong University Qingdao China
| | - Ruirong Xu
- Department of Hematology Shandong Provincial Hospital of Traditional Chinese Medicine Jinan China
| | - Yili Wang
- Department of Hematology Weihai Municipal Hospital Weihai China
| | - Yuhong Zhou
- Department of Hematology Zhejiang Provincial Hospital of TCM Hangzhou China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Xin‐guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
- Shandong Province Key Laboratory of Hematology/Immunology, Creative Studio of Scientific and Technologic Leading Talents Qilu Hospital, Shandong University Jinan China
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Sadeghi A, Hosseini SF, Jouzdani SR. Evaluation of treatment plan by three-period pulses of high-dose dexamethasone among patients with primary immune thrombocytopenia on platelet count response and adverse events: A randomized Clinical trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2020; 25:88. [PMID: 33273933 PMCID: PMC7698390 DOI: 10.4103/jrms.jrms_257_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/29/2019] [Accepted: 05/24/2020] [Indexed: 12/24/2022]
Abstract
Background Primary immune thrombocytopenia (ITP) decreases platelet count as well as increases the risk of bleeding due to platelet destruction in an autoimmune disorder. For many years, prednisone (PDN) has been the standard first-line treatment in ITP practical guidelines. The current randomized clinical trial compared the efficacy of treatments between three-pulse high-dose dexamethasone (HD-DXM) and the traditional PDN regimen among untreated patients with ITP in accordance with platelet count responses and adverse events. Materials and Methods We randomly assigned eligible patients with ITP to receive PDN or a three-pulse regimen of HD-DXM. In the HD-DXM group, 40 mg of DXM was administered intravenously for 4 consecutive days and was repeated in 14-day intervals for three pulses of treatment. Patients in the PDN group received 1.0 mg/kg of PDN orally per day for 4 consecutive weeks. The Mann-Whitney test was used for comparing the median of platelet count between the two groups, and logistic regression was used to evaluate odds ratio (OR) in the response rate of platelet count between the two groups. Blindness was not applied for both patients and physicians. Results The initial response rate of platelet count in the HD-DXM group was significantly higher than the PDN group (P < 0.05). According to the results of logistic regression, the initial and sustained response (SR) rate of platelet count in the HD-DXM group was significantly higher than the PDN group (OR: 5.68 and 4.17, respectively, P < 0.05). In fact, in the HD-DXM group, more patients reached SR after the 8-month follow-up (88.9% vs. 66.6%, P < 0.05). Conclusion In patients with ITP disease who have not received any kind of treatment, HD-DXM was more effective than conventional PDN therapy.
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Affiliation(s)
- Alireza Sadeghi
- Department of Hematology-Oncology, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Saeid Rezaei Jouzdani
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Jaime-Pérez JC, Aguilar-Calderón P, Jiménez-Castillo RA, Ramos-Dávila EM, Salazar-Cavazos L, Gómez-Almaguer D. Treatment outcomes and chronicity predictors for primary immune thrombocytopenia: 10-year data from an academic center. Ann Hematol 2020; 99:2513-2520. [DOI: 10.1007/s00277-020-04257-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/07/2020] [Indexed: 01/13/2023]
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Godeau B, Bonnotte B, Michel M. [Challenges and potential solutions in first-line treatments for immune thrombocytopenia in adults]. Rev Med Interne 2020; 42:25-31. [PMID: 32713675 DOI: 10.1016/j.revmed.2020.06.018] [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: 03/05/2020] [Revised: 06/04/2020] [Accepted: 06/20/2020] [Indexed: 10/23/2022]
Abstract
The first line treatment of immune thrombocytopenic purpura (ITP) is well established and based on short course of corticosteroids associated with intravenous immunoglobulins (IVIg) for the most severe forms. Predniso(lo)ne is the corticosteroid agent usually given but dexamethasone appears as an alternative. Some guidelines recommend to use dexamethasone as first line when a rapid increase of platelet count is required. Dexamethasone could be used rather than IVIg for moderate to severe but non life-threatening bleeding manifestations. Other therapeutic options such as anti FcRn monoclonal antibodies or recombinant FcγR currently in development for ITP could be an option in the future. In newly diagnosed ITP, we unfortunately lack robust predictive risk factors of severity and chronic outcome. Identifying such factors could be helpful for considering the early use of some treatments which are commonly used as second or third line.
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Affiliation(s)
- B Godeau
- Service de médecine interne, Centre de références sur les cytopénies auto-immunes de l'adulte, CHU Henri Mondor, APHP, UPEC, 94010 Créteil, France.
| | - B Bonnotte
- Service de médecine interne et immunologie clinique, CHU Dijon Bourgogne, Université Bourgogne-Franche Comté, Inserm, EFS UMR1098, 21000 Dijon, France
| | - M Michel
- Service de médecine interne, Centre de références sur les cytopénies auto-immunes de l'adulte, CHU Henri Mondor, APHP, UPEC, 94010 Créteil, France
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29
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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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Idiopathic thrombocytopenic purpura (ITP) - new era for an old disease. ACTA ACUST UNITED AC 2020; 57:273-283. [PMID: 31199777 DOI: 10.2478/rjim-2019-0014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia is an autoimmune hematological disorder characterized by severely decreased platelet count of peripheral cause: platelet destruction via antiplatelet antibodies which may also affect marrow megakaryocytes. Patients may present in critical situations, with cutaneous and/or mucous bleeding and possibly life-threatening organ hemorrhages (cerebral, digestive, etc.) Therefore, rapid diagnosis and therapeutic intervention are mandatory. Corticotherapy represents the first treatment option, but as in any autoimmune disorder, there is a high risk of relapse. Second line therapy options include: intravenous immunoglobulins, thrombopoietin receptor agonists, rituximab or immunosuppression, but their benefit is usually temporary. Moreover, the disease generally affects young people who need repeated and prolonged treatment and hospitalization and therefore, it is preferred to choose a long term effect therapy. Splenectomy - removal of the site of platelet destruction - represents an effective and stable treatment, with 70-80% response rate and low complications incidence. A challenging situation is the association of ITP with pregnancy, which further increases the risk due to the immunodeficiency of pregnancy, major dangers of bleeding, vital risks for mother and fetus, potential risks of medication, necessity of prompt intervention in the setting of specific obstetrical situations - delivery, pregnancy loss, obstetrical complications, etc. We present an updated review of the current clinical and laboratory data, as well as a detailed analysis of the available therapeutic options with their benefits and risks, and also particular associations (pregnancy, relapsed and refractory disease, emergency treatment).
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Zhang L, Zhang M, Du X, Cheng Y, Cheng G. Safety and efficacy of eltrombopag plus pulsed dexamethasone as first‐line therapy for immune thrombocytopenia. Br J Haematol 2020; 189:369-378. [PMID: 31943136 DOI: 10.1111/bjh.16327] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 08/24/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Lunqing Zhang
- Faculty of Health Science University of Macau Taipa Macau China
| | - Mingjie Zhang
- Faculty of Health Science University of Macau Taipa Macau China
| | - Xin Du
- Shenzhen Second People’s Hospital Shenzhen China
| | | | - Gregory Cheng
- Faculty of Health Science University of Macau Taipa Macau China
- Macau University of Science and Technology Hospital Taipa Macau China
- Health and Humanity Research Centre Hongkong China
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High-dose dexamethasone therapy as the initial treatment for idiopathic thrombocytopenic purpura. Int J Hematol 2020; 111:388-395. [PMID: 31897888 DOI: 10.1007/s12185-019-02808-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 01/26/2023]
Abstract
There is a controversy which short term high dose dexamethasone therapy (HDD) or standard dose prednisolone therapy as the initial treatment leads to long term efficacy in idiopathic thrombocytopenic purpura (ITP) patients. We conducted a multicenter, prospective trial to determine the efficacy and safety of short-term HDD in ITP patients aged 18-80 years with platelet counts of < 20 × 109/l, or < 50 × 109/l and bleeding symptoms. The primary endpoints are the proportion of complete response (CR) plus partial response (R) on day 180 after the completion of the 46-day HDD. Twenty-three patients were enrolled. Test for Helicobacter pylori (H. pylori) was positive for 6 patients and negative for 17 patients. In positive patients, 5 were received successful H. pylori eradication therapy. The proportion of CR + R was 60.9% (14/23) with 90% confidence interval of 41.7-77.8%. For patients with positive H. pylori and successful eradication, the proportion of CR + R was 80.0% (4/5). There was one grade 4 adverse event. Although we have enrolled relatively old, severe ITP patients with a median age of 63 years in this study, the efficacy was comparable to the reported clinical trials with HDD therapy.
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Reference guide for management of adult immune thrombocytopenia in Japan: 2019 Revision. Int J Hematol 2020; 111:329-351. [PMID: 31897887 PMCID: PMC7223085 DOI: 10.1007/s12185-019-02790-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/28/2019] [Accepted: 12/02/2019] [Indexed: 02/08/2023]
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Zhou H, Qin P, Liu Q, Yuan C, Hao Y, Zhang H, Wang Z, Ran X, Chu X, Yu W, Wang X, Hou Y, Peng J, Hou M. A prospective, multicenter study of low dose decitabine in adult patients with refractory immune thrombocytopenia. Am J Hematol 2019; 94:1374-1381. [PMID: 31591739 DOI: 10.1002/ajh.25646] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 12/22/2022]
Abstract
We conducted a prospective, multicenter study to evaluate the efficacy and safety of low-dose decitabine in adult patients with refractory immune thrombocytopenia. Adult patients who did not respond to, did not tolerate, or were unwilling to undergo splenectomy, with either a baseline platelet count less than 30 × 109 /L or the presence of bleeding symptoms and further need of ITP-specific treatments, were enrolled. Patients received decitabine at 3.5 mg/m2 intravenously for three consecutive days per cycle, for three cycles with a four-week interval between cycles. All patients were assessed every week during the first 12 weeks and at four-week intervals thereafter. We screened 49 patients for eligibility. Four patients were excluded and 45 received decitabine. At the end of decitabine treatment, complete response was achieved in eight patients (17.78%), and partial response was achieved in 15 patients (33.33%). The median time to initial response was 28 days (range, 14-70 days). Furthermore, seven relapsed patients received decitabine retreatment and all showed platelet response, including one complete response and six partial responses. Sustained response rates at 6, 12 and 18 months were 44.44% (20/45), 31.11% (14/45) and 20.0% (9/45), respectively. For responders, immune thrombocytopenia-related symptoms, fatigue, psychological health, fear, and overall quality of life were significantly improved. Adverse events were observed in 13 (28.89%) patients. No serious adverse events were recorded. In conclusion, low dose decitabine is potentially effective and safe in the management of adults with refractory immune thrombocytopenia. This trial is registered with clinicaltrials.gov identifier: NCT01568333.
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Affiliation(s)
- Hai Zhou
- Department of Hematology Qilu Hospital, Shandong University Jinan China
| | - Ping Qin
- Department of Hematology Qilu Hospital, Shandong University Jinan China
| | - Qiang Liu
- Department of Hematology Qilu Hospital, Shandong University Jinan China
| | - Chenglu Yuan
- Department of Hematology Qilu Hospital (Qingdao), Shandong University Qingdao China
| | - Yunliang Hao
- Department of Hematology Jining No.1 People's Hospital Jining China
| | - Haiyan Zhang
- Department of Hematology Linyi People's Hospital Linyi China
| | - Zhencheng Wang
- Department of Hematology Zibo Central Hospital Zibo China
| | - Xuehong Ran
- Department of Hematology Weifang People's Hospital Weifang China
| | - Xiaoxia Chu
- Department of Hematology Yantai Yuhuangding Hospital Yantai China
| | - Wenzheng Yu
- Department of Hematology Binzhou Medical University Hospital Binzhou China
| | - Xin Wang
- Department of Hematology Provincial Hospital Affiliated to Shandong University Jinan China
| | - Yu Hou
- Department of Hematology Qilu Hospital, Shandong University Jinan China
| | - Jun Peng
- Department of Hematology Qilu Hospital, Shandong University Jinan China
- Shandong Provincial Key Laboratory of Immunohematology Qilu Hospital, Shandong University Jinan China
- Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province Qilu Hospital, Shandong University Jinan China
| | - Ming Hou
- Department of Hematology Qilu Hospital, Shandong University Jinan China
- Shandong Provincial Key Laboratory of Immunohematology Qilu Hospital, Shandong University Jinan China
- Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province Qilu Hospital, Shandong University Jinan China
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Samson M, Fraser W, Lebowitz D. Treatments for Primary Immune Thrombocytopenia: A Review. Cureus 2019; 11:e5849. [PMID: 31754584 PMCID: PMC6830854 DOI: 10.7759/cureus.5849] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/04/2019] [Indexed: 01/02/2023] Open
Abstract
Immune thrombocytopenic purpura (ITP) is an autoimmune condition that affects nearly 1:10,000 people in the world. It is traditionally defined by a platelet count of less than 100 x 109L, but treatment typically depends on symptomology rather than on the platelet count itself. For primary idiopathic ITP, corticosteroids have been the standard first-line of treatment for symptomatic patients, with the addition of intravenous immune globulin (IVIG) or Rho(D) immune globulin (anti-RhD) for steroid-resistant cases. In cases of refractory or non-responsive ITP, second-line therapy includes splenectomy or rituximab, a monoclonal antibody against the CD20 antigen (anti-CD20). In patients who continue to have severe thrombocytopenia and symptomatic bleeding despite first- and second-line treatments, the diagnosis of "chronic refractory ITP" is appropriate, and third-line treatments are evaluated. This manuscript describes the efficacy of different treatment options for primary ITP and introduces the reader to various third-line options that are emerging as a means of treating chronic refractory ITP.
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Affiliation(s)
- Margot Samson
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - William Fraser
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - David Lebowitz
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
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36
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Witkowski M, Witkowska M, Robak T. Autoimmune thrombocytopenia: Current treatment options in adults with a focus on novel drugs. Eur J Haematol 2019; 103:531-541. [DOI: 10.1111/ejh.13319] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 12/13/2022]
Affiliation(s)
| | - Magdalena Witkowska
- Copernicus Memorial Hospital Lodz Poland
- Department of Experimental Hematology Medical University of Lodz Lodz Poland
| | - Tadeusz Robak
- Copernicus Memorial Hospital Lodz Poland
- Department of Hematology Medical University of Lodz Lodz Poland
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Bussel J, Miltiadous O. Immune Thrombocytopenia: Are We Stuck in the Mud or Is There Light at the End of the Tunnel? Clin Hematol Int 2019; 1:173-179. [PMID: 34595428 PMCID: PMC8432374 DOI: 10.2991/chi.d.190805.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 11/17/2022] Open
Abstract
The differences in diagnosis and management between immune thrombocytopenia (ITP) and leukemia are striking. Leukemia diagnosis and management have evolved substantially over the past 30 years and are now relatively precise. The tendency for leukemic cells to be the overwhelming majority of circulating and/or bone marrow cells certainly continues to facilitate developments, as does improved molecular assessment. Furthermore, randomized controlled clinical trials of competing regimens in well-defined populations have advanced treatment as well. Currently, ITP diagnosis and management depend very much on the experience and preferences of the hematologist. There are no unequivocally useful molecular tests, no agreement on which testing needs to be performed, and no consensus on treatment. Future studies using advanced techniques would ideally change this over time but, thus far, progress in ITP has been slow. However, the increasing ability to do single-cell DNA and RNA studies and flow cytometric dissection of small populations of cells could radically change the approach to ITP if critical distinctions were uncovered.
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Affiliation(s)
- James Bussel
- Pediatrics, Division of Hematology-Oncology, Weill Cornell Medicine, New York, NY
| | - Oriana Miltiadous
- Pediatrics, Division of Hematology-Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Umakanthan JM, Dhakal P, Gundabolu K, Kallam A, Almquist DR, Bhatt VR. Initial management of immune thrombocytopaenia in adults based on risk stratification. Postgrad Med J 2019; 95:558-562. [PMID: 31320499 DOI: 10.1136/postgradmedj-2019-136636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/25/2019] [Accepted: 06/28/2019] [Indexed: 12/31/2022]
Abstract
Patients with immune thrombocytopaenia (ITP) have a wide spectrum of disease severity and bleeding risk even at similar platelet counts. Hence, additional clinical and laboratory factors may be considered in the evaluation of bleeding risk in ITP. Risk stratification based on predicted bleeding risk may help to identify high-risk patients and guide the initial management of ITP in adults requiring treatment. Recent evidence supports the use of high-dose dexamethasone therapy over prednisone in the initial management of ITP because of improved initial response rates, shorter median time to response and better safety profile. A risk-stratified approach to management of ITP is hoped to reduce bleeding complications in high-risk patients; however, the outcomes of such management approach need to be studied prospectively. Additionally, whether therapy intensification or combination of dual therapy such as intravenous immunoglobulin or rituximab in combination with dexamethasone can reduce bleeding complications in high-risk ITP should be studied in the future.
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Affiliation(s)
- Jaydev Manikkam Umakanthan
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Prajwal Dhakal
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Krishna Gundabolu
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Avyakta Kallam
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Daniel R Almquist
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Kim CH, Choi YS, Moon JY, Kim DY, Lee SY, Lee HJ, Yun HJ, Kim S, Jo DY, Song IC. Methylprednisolone versus intravenous immune globulin as an initial therapy in adult primary immune thrombocytopenia. Korean J Intern Med 2019; 34:383-389. [PMID: 29172399 PMCID: PMC6406098 DOI: 10.3904/kjim.2015.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 06/10/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND/AIMS Few studies have addressed whether there are differences in clinical efficacy between intravenous methylprednisolone (methyl-Pd) and intravenous immunoglobulin (IVIg) use. METHODS We retrospectively compared platelet responses and toxicities associated with these two treatments in adult patients with immune thrombocytopenia. Patients received intravenous methyl-Pd therapy followed by oral prednisolone (Pd) from 1993 to 2002 and IVIg together with oral Pd from 2003 to 2008. RESULTS Early response and maintenance of the response were assessed at 7 days and 6 months after treatment, respectively. Of the 87 patients enrolled, 77 (88.5%) were eligible for analysis. Early responses occurred in 30 of 39 patients (76.9%) receiving methyl-Pd versus 33 of 38 patients (86.6%) receiving IVIg (p = 0.187). The response was maintained in 28 patients (71.8%) in the methyl-Pd arm and in 23 patients (60.5%) in the IVIg arm (p = 0.187). The time to a complete response in the IVIg arm (6 days; range, 1 to 35) was shorter than that in the methyl-Pd arm (13.5 days; range, 2 to 29) (p = 0.002). Side effects were mild and tolerable in both arms. Five years after initiating treatment, 7 of 18 patients (38.9%) and five of 14 patients (35.7%) were still maintaining a response in the methyl-Pd and IVIg arms, respectively. CONCLUSION These results indicate that neither the early response rate nor the long-term outcome differed between the methyl-Pd and IVIg treatments. However, IVIg induced a complete response more rapidly than did methyl-Pd.
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Affiliation(s)
- Chul Hee Kim
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Yoon Seok Choi
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Ji Young Moon
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Duck Yong Kim
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - So Yeon Lee
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyo Jin Lee
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hwan Jung Yun
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Samyong Kim
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Deog Yeon Jo
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Ik Chan Song
- Department of Internal Medicine, Chungnam National University School of Medicine, Daejeon, Korea
- Correspondence to Ik Chan Song, M.D. Division of Hematology/Oncology, Department of Internal Medicine, Chungnam National University, 282 Munhwa-ro, Junggu, Daejeon 35015, Korea Tel: +82-42-280-8381 Fax: +82-42-257-5753 E-mail:
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Wang L, Xu L, Hao H, Jansen AJG, Liu G, Li H, Liu X, Zhao Y, Peng J, Hou M. First line treatment of adult patients with primary immune thrombocytopenia: a real-world study. Platelets 2019; 31:55-61. [PMID: 30744465 DOI: 10.1080/09537104.2019.1572875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Liang Wang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
- Department of Hematology, Shengli Oilfield Central Hospital, Dongying, China
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Shandong University, Jinan, China
| | - Lei Xu
- Department of Hematology, Shengli Oilfield Central Hospital, Dongying, China
| | - Hongyuan Hao
- Department of Hematology, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - A. J. Gerard Jansen
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Guoqiang Liu
- Department of Hematology, Shengli Oilfield Central Hospital, Dongying, China
| | - Honglei Li
- Department of Hematology, Shengli Oilfield Central Hospital, Dongying, China
| | - Xinguang Liu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yajing Zhao
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Shandong University, Jinan, China
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Qilu Hospital, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Shandong University, Jinan, China
- Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province, Qilu Hospital, Shandong University, Jinan, China
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Rama Krishna M, Gottam US, Mahendra N. Disseminated tuberculosis with severe immune thrombocytopenia. Respir Med Case Rep 2019; 27:100812. [PMID: 30949428 PMCID: PMC6430074 DOI: 10.1016/j.rmcr.2019.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/15/2019] [Accepted: 02/15/2019] [Indexed: 12/03/2022] Open
Abstract
Immune thrombocytopenia is an autoimmune condition with increased platelet destruction. Immune thrombocytopenic purpura is an uncommon and rare manifestation of tuberculosis. A search of the literature available on TB-associated ITP identified only around 50 cases published between 1964 and 2016. We present an uncommon and interesting case of severe isolated immune thrombocytopenia secondary to bilateral tubercular cervical lymphadenopathy and pott's spine in 26 year old Indian male. Due to severe thrombocytopenia patient was managed with IVIg and steroids along with anti tubercular therapy. Early diagnosis and treatment with Anti tubercular therapy is important for effective control of bleeding manifestations.
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Affiliation(s)
| | - Uma Sri Gottam
- Corresponding author. Nakshatra residency, Plot 9&10, Flat 101 Pragathi Nagar colony, Opp road to JNTU, Hyderabad, 500090, Telangana, India.
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Zhou H, Liu L, Shu X, Wang X, Song Y. Clinical Efficacy and Safety of High-Dose Dexamethasone Plus Low-Dose Rituximab as First-Line Therapy in Newly Diagnosed Primary Immune Thrombocytopenia. Indian J Hematol Blood Transfus 2019; 35:507-512. [PMID: 31388265 DOI: 10.1007/s12288-018-1061-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 12/11/2018] [Indexed: 01/10/2023] Open
Abstract
Standard-dose prednisone as first-line therapy for primary immune thrombocytopenia (ITP) can not obtain high long-term responses. Results from high-dose dexamethasone course administered in adult newly diagnosed ITP were promising. The role of standard-dose rituximab in first-line treatment of newly diagnosed ITP were also investigated. We retrospectively analyzed the efficacy and safety of high-dose dexamethasone plus low-dose (100 mg/w) rituximab for treatment of adults newly diagnosed ITP. A total of eighteen patients received dexamethasone 40 mg/day for 4 consecutive days (days + 1 to + 4), rituximab 100 mg once weekly for a total of 4 weeks (days + 7, + 14, + 21 and + 28). Non-responders accepted the repeated dexamethasone treatment every 2 weeks for a total of up to 3 treatment cycles. The overall response was 100% at 28th day. Median follow-up was 17 months (1-33 months). Six patients (33.3%) relapsed. Sustained complete response or response after 6 months and 12 months of follow-up were reached in 83.3% (15/18) and 61.5% (8/13) of patients respectively. The 12-month and 15-month cumulative relapse-free survival were 69.3% and 60.7%. Incidence of adverse effects was 11.1% (2/18). High-dose dexamethasone plus low-dose rituximab therapy had high efficacy and well tolerability as first-line treatment option in newly diagnosed ITP.
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Affiliation(s)
- Hu Zhou
- Department of Hematology, Affiliated Tumor Hospital of Zhengzhou University, Tumor Hospital of Henan Province, Institute of Hematology of Henan Province, 127 Dongming Road, Zhengzhou, 450000 People's Republic of China
| | - Liu Liu
- 2Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Xinhui Shu
- Department of Hematology, Affiliated Tumor Hospital of Zhengzhou University, Tumor Hospital of Henan Province, Institute of Hematology of Henan Province, 127 Dongming Road, Zhengzhou, 450000 People's Republic of China
| | - Xiaoran Wang
- Department of Hematology, Affiliated Tumor Hospital of Zhengzhou University, Tumor Hospital of Henan Province, Institute of Hematology of Henan Province, 127 Dongming Road, Zhengzhou, 450000 People's Republic of China
| | - Yongping Song
- Department of Hematology, Affiliated Tumor Hospital of Zhengzhou University, Tumor Hospital of Henan Province, Institute of Hematology of Henan Province, 127 Dongming Road, Zhengzhou, 450000 People's Republic of China
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43
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Lucchini E, Fanin R, Cooper N, Zaja F. Management of immune thrombocytopenia in elderly patients. Eur J Intern Med 2018; 58:70-76. [PMID: 30274902 DOI: 10.1016/j.ejim.2018.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/08/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Abstract
Despite the improvement in understanding its pathogenesis and the introduction of novel treatment options, the management of primary immune thrombocytopenia (ITP) still remains challenging. Considering its increased incidence with aging and prolonged life-expectancy, ITP is often diagnosed in elderly patients, a subset that deserves some special precautions. Ensure the diagnosis is a crucial step, and carefully attention must be given in excluding other causes of thrombocytopenia, especially among older people that frequently suffer from many comorbidities. When it comes to treatment decision, it is worth keeping into account that the elderly have an increased risk of bleeding, thrombosis and infections, that they often require many concomitant therapies, including antiplatelet or anticoagulant agents, and that treatment-related toxicities are often increased and sometimes more dangerous that the disease itself. There are not dedicated guidelines, and only few specific studies. Steroids with or without IVIG remain the first-line treatment. Splenectomy is less effective than in youngers and burdened by an increased thrombotic and infectious risk. Rituximab is a good option in non-immunocompromised patients, but long-term remissions are few. Eltrombopag and romiplostim have a good safety and efficacy profile, and have become a prominent drug in this subset, even if they are associated with a possible increased risk of thrombosis, and long-term toxicity is unknown. Other drugs, such as dapsone and danazol, have a well-known efficacy and safety profile, and still represent a valid option among elderly patients.
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Affiliation(s)
- Elisa Lucchini
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy.
| | - Renato Fanin
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy
| | | | - Francesco Zaja
- S.C. Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
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Lee HO, Chang SH, Baek HJ, Kim HS, Park SM, Shin MG, Kook H. The Efficacy of High Dose Dexamethasone Therapy in Children with Immune Thrombocytopenic Purpura. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2018. [DOI: 10.15264/cpho.2018.25.2.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hyun Ok Lee
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Seong Hwan Chang
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Hee Jo Baek
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Ho Sung Kim
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Su Min Park
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Myung Geun Shin
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Hoon Kook
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
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45
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Lu YY, Guan N, Meng QH, Li ML, Liu YY, Wang Y. [Efficacy of recombinant human thrombopoietin combined with high-dose dexamethasone in the treatment of refractory immune thrombocytopenia in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:534-537. [PMID: 30022753 PMCID: PMC7389201 DOI: 10.7499/j.issn.1008-8830.2018.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 05/15/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To explore the efficacy and safety of recombinant human thrombopoietin (rhTPO) combined with high-dose dexamethasone (DXM) in the treatment of children with refractory immune thrombocytopenic purpura (ITP). METHODS Fifty-eight ITP children who had failed first-line therapy were randomly divided into two groups: DXM treatment (n=27) and rhTPO + DXM treatment (n=31). The DXM treatment group received two continuous cycles of DXM treatment; in each cycle, patients received high-dose DXM (0.6 mg/kg daily) by intravenous drip for 4 days every 28 days. The rhTPO group received subcutaneous injection of rhTPO (300 U/kg daily) for 14 days additional to DXM treatment. The overall response rate (marked response rate + slight response rate) and adverse reactions were evaluated after 3, 7, and 14 days and 1, 2, and 3 months of treatment. RESULTS After 7 and 14 days and 1 month of treatment, the rhTPO + DXM treatment group had a significantly higher marked response rate and a significantly higher overall response rate than the DXM treatment group (P<0.05). After 2 months of treatment, the rhTPO + DXM treatment group had a significantly higher overall response rate than the DXM group (P<0.05). One patient in the DXM treatment group had liver damage during the first week of treatment. There was no hypertension, fever, rash, allergy, or weakness in the two groups. CONCLUSIONS rhTPO combined with high-dose DXM is an effective and safe approach for treating refractory ITP.
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Affiliation(s)
- Yuan-Yuan Lu
- Department of Pediatrics, Weifang People's Hospital, Weifang, Shandong 261041, China.
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46
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Liu XG, Bai XC, Chen FP, Cheng YF, Dai KS, Fang MY, Feng JM, Gong YP, Guo T, Guo XH, Han Y, Hong LJ, Hu Y, Hua BL, Huang RB, Li Y, Peng J, Shu MM, Sun J, Sun PY, Sun YQ, Wang CS, Wang SJ, Wang XM, Wu CM, Wu WM, Yan ZY, Yang FE, Yang LH, Yang RC, Yang TH, Ye X, Zhang GS, Zhang L, Zheng CC, Zhou H, Zhou M, Zhou RF, Zhou ZP, Zhu HL, Zhu TN, Hou M. Chinese guidelines for treatment of adult primary immune thrombocytopenia. Int J Hematol 2018; 107:615-623. [PMID: 29619624 DOI: 10.1007/s12185-018-2445-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/22/2018] [Accepted: 03/22/2018] [Indexed: 02/05/2023]
Abstract
Primary immune thrombocytopenia (ITP) is a bleeding disorder commonly encountered in clinical practice. The International Working Group (IWG) on ITP has published several landmark papers on terminology, definitions, outcome criteria, bleeding assessment, diagnosis, and management of ITP. The Chinese consensus reports for diagnosis and management of adult ITP have been updated to the 4th edition. Based on current consensus positions and new emerging clinical evidence, the thrombosis and hemostasis group of the Chinese Society of Hematology issued Chinese guidelines for management of adult ITP, which aim to provide evidence-based recommendations for clinical decision making.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, 250012, China
| | - Xiao-Chuan Bai
- General Hospital of Ningxia Medical University, Yinchuan, China
| | - Fang-Ping Chen
- Xiangya Hospital, Centre South University, Changsha, China
| | | | - Ke-Sheng Dai
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Mei-Yun Fang
- The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | | | - Yu-Ping Gong
- West China Hospital, Sichuan University, Chengdu, China
| | - Tao Guo
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin-Hong Guo
- The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Yue Han
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | | | - Yu Hu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bao-Lai Hua
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Rui-Bing Huang
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yan Li
- The First Hospital of Chinese Medical University, Shenyang, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, 250012, China
| | - Mi-Mi Shu
- Xijing Hospital, The Fourth Military Medical University, Xi'an, China
| | - Jing Sun
- Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - Pei-Yan Sun
- Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Beijing, China
| | - Chun-Sen Wang
- Sichuan Provincial People's Hospital, Chengdu, China
| | - Shu-Jie Wang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Min Wang
- People's Hospital of Xinjiang Uygur Autonomous Region, Ürümqi, China
| | - Cong-Ming Wu
- Hainan Provincial People's Hospital, Haikou, China
| | - Wen-Man Wu
- Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen-Yu Yan
- Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Feng-E Yang
- Union Hospital of Fujian Medical University, Fuzhou, China
| | - Lin-Hua Yang
- The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Ren-Chi Yang
- Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, Tianjin, China
| | - Tong-Hua Yang
- The First People's Hospital of Yunnan Province, Kunming, China
| | - Xu Ye
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guang-Sen Zhang
- The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lei Zhang
- Institute of Haematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences, Tianjin, China
| | | | - Hu Zhou
- Henan Cancer Hospital, Zhengzhou, China
| | - Min Zhou
- Chengdu Women and Children's Hospital, Chengdu, China
| | | | - Ze-Ping Zhou
- The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hong-Li Zhu
- Chinese PLA General Hospital, Beijing, China
| | - Tie-Nan Zhu
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, 250012, China.
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Kühne T. Advances in chemical pharmacotherapy for the treatment of pediatric immune thrombocytopenia. Expert Opin Pharmacother 2018; 19:667-676. [PMID: 29589486 DOI: 10.1080/14656566.2018.1458091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder of heterogeneous pathophysiological mechanisms. Treatment endpoints include elevation of platelets and reduction of bleeding risk, elevation of quality of life, reduction of concomitant therapies and prevention from bleeding. Persistent and chronic ITP is more common in adults but occurs in children. Standard therapies include corticosteroids and immunoglobulins, both associated with side effects. There are new treatments, such as thrombopoietin-receptor agonists and promising investigational drugs. AREAS COVERED Experience from the management of adults is valuable for children with persistent and chronic symptomatic ITP. In this review first- and second-line therapies, but also investigational drugs for children with ITP are discussed. EXPERT OPINION Although time-consuming and based on experience, children with no or mild bleeding can be safely managed with a watch and wait strategy. Chronic symptomatic immune thrombocytopenia is an area of second-line treatments based on a highly individualized approach. Furthermore, there are investigational drugs, which may also be of benefit for children with chronic symptomatic ITP.
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Affiliation(s)
- Thomas Kühne
- a Division of Oncology/Hematology , University Children's Hospital , Basel , Switzerland
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48
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Atorvastatin enhances bone marrow endothelial cell function in corticosteroid-resistant immune thrombocytopenia patients. Blood 2018; 131:1219-1233. [PMID: 29288170 DOI: 10.1182/blood-2017-09-807248] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/18/2017] [Indexed: 12/15/2022] Open
Abstract
Key Points
Impaired BM EPCs were found in corticosteroid-resistant ITP patients. Atorvastatin improved BM EPC quantity and function, representing a novel therapy approach for corticosteroid-resistant ITP patients.
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Shao X, Wu B, Cheng L, Li F, Zhan Y, Liu C, Ji L, Min Z, Ke Y, Sun L, Chen H, Cheng Y. Distinct alterations of CD68 +CD163 + M2-like macrophages and myeloid-derived suppressor cells in newly diagnosed primary immune thrombocytopenia with or without CR after high-dose dexamethasone treatment. J Transl Med 2018; 16:48. [PMID: 29499727 PMCID: PMC5833082 DOI: 10.1186/s12967-018-1424-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 02/20/2018] [Indexed: 12/13/2022] Open
Abstract
Background Although impaired myeloid-derived suppressor cells (MDSCs) recently have been studied in immune thrombocytopenia (ITP), another myeloid-derived cell population signified as M2 macrophages has not been investigated properly in ITP patients. In the present study, we intended to determine the features of circulating M2-like macrophages, to examine its relationship with MDSCs, and to explore their prognostic values in ITP. Methods Peripheral blood mononuclear cells from healthy controls and primary ITP patients were isolated to test the circulating M2-like macrophages and MDSCs. The circulating M2-like macrophage population defined as CD68+CD163+ and circulating MDSC population as CD11b+CD33+HLA-DR− were determined by flow cytometry. Plasma inflammatory cytokines were measured by multiplex ELISA. Results The percentages of MDSCs were found to be expanded in newly diagnosed patients of ITP, especially among those of the complete response (CR) group (p < 0.0001). Positive linear correlation was verified between percentages of M2-like macrophages and MDSCs. The same correlation was also determined in the CR group. After treatment, the percentages of M2-like macrophages and MDSCs were both increased significantly in CR group, while those patients among the PR + NR group manifested a significant numeric decrease of MDSCs but only a moderate decrease in M2-like macrophages. MIP-1α/CCL3 was negatively correlated with M2-like macrophages while MCP-1 possessed a positive correlation with M2-like macrophages, eotaxin-1/CCL11 was negatively correlated with MDSCs and interleukin-1β (IL-1β) was found to be negatively correlated with both M2-like macrophages and MDSCs. Conclusions The present findings indicated critical roles of both circulating M2-like macrophages and MDSCs in ITP. The positive correlation between them might be related to inflammatory factors-mediated bidirectional interactions or partially due to their similar background patterns during differentiation. MIP-1α/CCL3, MCP-1, eotaxin-1/CCL11 and IL-1β might play a critical role in the expansion of both M2 macrophages and MDSCs population in ITP patients, which deserves further investigation. Electronic supplementary material The online version of this article (10.1186/s12967-018-1424-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xia Shao
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Boting Wu
- Department of Transfusion Medicine, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Luya Cheng
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Feng Li
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China.,Department of Hematology, Zhongshan Hospital Qingpu Branch, Fudan University, Shanghai, 201700, China
| | - Yanxia Zhan
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Chanjuan Liu
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Lili Ji
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Zhihui Min
- Institute of Clinical Science, Department of Hematology, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China.,Shanghai Institute of Clinical Bioinformatics, Fudan University Center for Clinical Bioinformatics, Shanghai, 200032, China
| | - Yang Ke
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Lihua Sun
- Department of Hematology, Zhongshan Hospital Qingpu Branch, Fudan University, Shanghai, 201700, China
| | - Hao Chen
- Department of Thoracic Surgery, Zhongshan Hospital Qingpu Branch, Fudan University, Shanghai, 201700, China
| | - Yunfeng Cheng
- Department of Hematology, Zhongshan Hospital Fudan University, Shanghai, 200032, China. .,Department of Hematology, Zhongshan Hospital Qingpu Branch, Fudan University, Shanghai, 201700, China. .,Institute of Clinical Science, Department of Hematology, Zhongshan Hospital, Fudan University, 180 Fenglin Rd, Shanghai, 200032, China. .,Shanghai Institute of Clinical Bioinformatics, Fudan University Center for Clinical Bioinformatics, Shanghai, 200032, China.
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50
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Ozelo MC, Colella MP, de Paula EV, do Nascimento ACKV, Villaça PR, Bernardo WM. Guideline on immune thrombocytopenia in adults: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. Project guidelines: Associação Médica Brasileira - 2018. Hematol Transfus Cell Ther 2018; 40:50-74. [PMID: 30057974 PMCID: PMC6001928 DOI: 10.1016/j.htct.2017.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 11/29/2017] [Indexed: 02/07/2023] Open
Affiliation(s)
| | | | | | | | - Paula Ribeiro Villaça
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Wanderley Marques Bernardo
- Universidade de São Paulo, Faculdade de Medicina Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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