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Gotesman M, Shear M, Raheel S, Procassini M, Panosyan EH. Pediatric Immune Thrombocytopenia. Adv Pediatr 2024; 71:229-240. [PMID: 38944486 DOI: 10.1016/j.yapd.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Pediatric immune thrombocytopenia (ITP) is a fairly common bleeding disorder PRESENTING with a decreased number of platelets. The typical clinical presentation involves mild bleeding symptoms with bruising and petechiae and occasional mucosal bleeding. ITP is thought to be an autoimmune disorder and more recently other mechanisms have been described. Most cases resolve spontaneously and can undergo watchful waiting as the platelet count improves. Initially, steroids or intravenous immunoglobulin G (IVIg) can be used to increase platelets. For those cases that do not resolve and become persistent or chronic, there are multiple treatment options, with new agents being studied in adults that will hopefully make it to clinical trials in pediatrics in the future.
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Affiliation(s)
- Moran Gotesman
- The Lundquist Institute of Biomedical Innovation, Torrance, CA, USA; Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA.
| | - Marni Shear
- Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
| | - Sahar Raheel
- Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
| | - Michael Procassini
- Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
| | - Eduard H Panosyan
- The Lundquist Institute of Biomedical Innovation, Torrance, CA, USA; Department of Pediatrics, Harbor UCLA Medical Center, 1000 W Carson Street, Box 468, Torrance, CA 90509, USA
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Yang L, Sang BH, Yang CH, Xiao ZG, Fang CL, Lv Y, Li N, Yang Q, Chai SM, Tian X, Zhang XW, Huang TL. The long-term efficacy of eltrombopag in children with immune thrombocytopenia. Ann Hematol 2024; 103:2721-2727. [PMID: 38916741 DOI: 10.1007/s00277-024-05857-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/17/2024] [Indexed: 06/26/2024]
Abstract
Immune thrombocytopenia (ITP) is the most common autoimmune disorder characterized by decreased platelet counts and impaired platelet production. Eltrombopag has been demonstrated to be safe and effective for children with ITP. It is reported eltrombopag can achieve a sustained response off treatment. However, data on its overall efficacy and safety profile are scarce in children. This study aimed to investigate the long-term efficacy of eltrombopag in children with ITP. Treatment overall response (OR), complete response (CR), response (R), durable response (DR), no response (NR), treatment free remission (TFR), and relapse rate, were assessed in 103 children with ITP during eltrombopag therapy. The OR rate, CR rate, R rate, DR rate, NR rate, TFR rate, and relapse rate were 67.0%, 55.3%, 11.7%, 56.3%, 33.0%, 60%, 36.2%, respectively. Importantly, we discovered that newly diagnosed ITP patients showed a higher DR rate, TFR rate and lower relapse rate compared to persistent and chronic ITP patients. Furthermore, the CR rate, DR rate, and TFR rate of 5 patients under six months were 100%. None of them suffered relapse. The most common adverse event (AEs) was hepatotoxicity (7.77%). Our study highlighted the critical role of eltrombopag as the second-line treatment in children with ITP who were intolerant to first-line therapy.
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Affiliation(s)
- Li- Yang
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Bao-Hua Sang
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Chun-Hui Yang
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Zu-Gang Xiao
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Chun-Lian Fang
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Yu Lv
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Na Li
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Qing Yang
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Shu-Min Chai
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Xin Tian
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China
| | - Xian-Wen Zhang
- Medical Faculty, Kunming University of Science and Technology, No.727 Jingming South Road, Kunming, 650500, China.
| | - Ti-Long Huang
- Department of Hematology, Kunming Children's Hospital, No.288 Qian Xin Road, Kunming, 650228, China.
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González-López TJ, Alperovich G, Burillo E, Espejo-Saavedra Soler M, Rebollo-Gómez E, Hernández I, Justicia JL, Lozano ML. Epidemiology, Treatment Patterns, and Cost Analysis of Immune Thrombocytopenia in Spain between 2014 and 2020: A Population-based Study. TH OPEN 2024; 8:e252-e265. [PMID: 38983689 PMCID: PMC11230702 DOI: 10.1055/a-2336-1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 05/06/2024] [Indexed: 07/11/2024] Open
Abstract
Background Immune thrombocytopenia (ITP) is characterised by low platelet counts and often leads to bleeding, fatigue, and reduced health-related quality of life. Methods This observational, retrospective, population-based study using BIG-PAC® database included Spanish paediatric and adult patients with primary ITP diagnosed in primary care and hospitals between 2014 and 2020 (median follow-up: 4 years). Epidemiology, baseline/clinical characteristics, treatment trends, healthcare resources and costs were analysed. Results The BIG-PAC® database contains records of 1,818,588 patients; 170 adults and 27 children with ITP were included in our analysis. ITP prevalence and annual incidence per 100,000 were estimated in 10.8 (2.8 in chronic ITP [cITP] patients) and 1.5 (0.3 in cITP patients), respectively. Epistaxis was the most common bleeding event, followed by genitourinary and gastrointestinal bleeding; >50%/> 75% of ITP/cITP patients reported fatigue. Chronic patients had lower platelet counts at baseline and required more transfusions. Corticosteroids, immunosuppressants, and thrombopoietin receptor agonists were the most used agents in first-, second- and third-line treatment, respectively. Thirty-five patients, all of them in chronic phase, underwent splenectomy. Patients had on average 13.9, 6.6, and 1.2 visits/year to primary care, haematology/internal medicine, and emergency departments, respectively. More than one-fourth of adult patients took on average 16.3 days of sick leave annually. Mean annual total health care costs were €10,741 (ITP patients) and €19,809 (cITP patients). Conclusion This is the first study to provide an overall perspective on the situation of the Spanish ITP population in terms of epidemiology, treatment trends, health care resources and costs, highlighting unmet patient needs, and direct and indirect costs/resource use between 2014 and 2020.
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Affiliation(s)
| | | | | | | | | | | | | | - María L Lozano
- Department of Haematology, Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, CIBERER-ISCIII, Murcia, Spain
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Pincez T, Fernandes H, Fahd M, Pasquet M, Chahla WA, Granel J, Ducassou S, Thomas C, Garnier N, Jeziorski E, Bayart S, Chastagner P, Cheikh N, Guitton C, Paillard C, Lejeune J, Millot F, Li-Thiao Te V, Mallebranche C, Pellier I, Castelle M, Armari-Alla C, Carausu L, Piguet C, Benadiba J, Pluchart C, Stephan JL, Deparis M, Briandet C, Doré E, Marie-Cardine A, Barlogis V, Leverger G, Héritier S, Aladjidi N, Leblanc T. Pediatric refractory chronic immune thrombocytopenia: Identification, patients' characteristics, and outcome. Am J Hematol 2024; 99:1269-1280. [PMID: 38651646 DOI: 10.1002/ajh.27337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/06/2024] [Indexed: 04/25/2024]
Abstract
Refractory chronic immune thrombocytopenia (r-cITP) is one of the most challenging situations in chronic immune thrombocytopenia (cITP). Pediatric r-cITP is inconsistently defined in literature, contributing to the scarcity of data. Moreover, no evidence is available to guide the choice of treatment. We compared seven definitions of r-cITP including five pediatric definitions in 886 patients with cITP (median [min-max] follow-up 5.3 [1.0-29.3] years). The pediatric definitions identified overlapping groups of various sizes (4%-20%) but with similar characteristics (higher proportion of immunopathological manifestations [IM] and systemic lupus erythematosus [SLE]), suggesting that they adequately captured the population of interest. Based on the 79 patients with r-cITP (median follow-up 3.1 [0-18.2] years) according to the CEREVANCE definition (≥3 second-line treatments), we showed that r-cITP occurred at a rate of 1.15% new patients per year and did not plateau over time. In multivariate analysis, older age was associated with r-cITP. One patient (1%) experienced two grade five bleeding events after meeting r-cITP criteria and while not receiving second-line treatment. The cumulative incidence of continuous complete remission (CCR) at 2 years after r-cITP diagnosis was 9%. In this analysis, splenectomy was associated with a higher cumulative incidence of CCR (hazard ratio: 5.43, 95% confidence interval: 1.48-19.84, p = 7.8 × 10-4). In sum, children with cITP may be diagnosed with r-cITP at any time point of the follow-up and are at increased risk of IM and SLE. Second-line treatments seem to be effective for preventing grade 5 bleeding. Splenectomy may be considered to achieve CCR.
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Affiliation(s)
- Thomas Pincez
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Division of Hematology-Oncology, Charles-Bruneau Cancer Center, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montréal, Québec, Canada
| | - Helder Fernandes
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Mony Fahd
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Unit, Robert-Debré University Hospital, AP-HP, Paris, France
| | - Marlène Pasquet
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital, Toulouse, France
| | - Wadih Abou Chahla
- Department of Pediatric Hematology, Jeanne de Flandre Hospital, Lille University Hospital, Lille, France
| | - Jérome Granel
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Stéphane Ducassou
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Caroline Thomas
- Pediatric Hematology Unit, Nantes University Hospital, Nantes, France
| | - Nathalie Garnier
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon, Lyon, France
| | - Eric Jeziorski
- Pediatric Oncology Hematology Unit, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Sophie Bayart
- Pediatric Hematology Unit, Rennes University Hospital, Rennes, France
| | - Pascal Chastagner
- Department of Pediatric Hematology and Oncology, Children's University Hospital, Nancy, France
| | - Nathalie Cheikh
- Department of Pediatric Hematology-Oncology, Besançon University Hospital, Besançon, France
| | - Corinne Guitton
- Department of Pediatrics, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Catherine Paillard
- Department of Pediatric Hematology and Oncology, Hautepierre University Hospital, Strasbourg, France
| | - Julien Lejeune
- Department of Pediatric Hematology-Oncology, Clocheville Hospital, Tours University Hospital, Tours, France
| | - Frédéric Millot
- Department of Pediatric Hematology, Poitiers University Hospital, Poitiers, France
| | - Valérie Li-Thiao Te
- Department of Pediatric Hematology/Oncology, Amiens University Hospital, Amiens, France
| | - Coralie Mallebranche
- Pediatric Immuno-Hemato-Oncology, Angers University Hospital, CRCI2NA, UMR Inserm CNRS, Université d'Angers, Université de Nantes, Angers, France
| | - Isabelle Pellier
- Pediatric Immuno-Hemato-Oncology, Angers University Hospital, CRCI2NA, UMR Inserm CNRS, Université d'Angers, Université de Nantes, Angers, France
| | - Martin Castelle
- Pediatric Hematology-Immunology and Rheumatology Department, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Corinne Armari-Alla
- Pediatric Hematology-Oncology Department, Grenoble University Hospital, Grenoble, France
| | - Liana Carausu
- Department of Pediatric Hematology, CHU de Brest, Brest, France
| | - Christophe Piguet
- Pediatric Oncology Hematology Unit, Limoges University Hospital, Limoges, France
| | - Joy Benadiba
- Department of Hematology-Oncology Pediatrics, Nice University Hospital, Nice, France
| | - Claire Pluchart
- Pediatric Hematology-Oncology Unit, Institut Jean Godinot, Reims University Hospital, Reims, France
| | - Jean-Louis Stephan
- Department of Pediatric Oncology, University Hospital of Saint Etienne, North Hospital, Saint Etienne, France
| | - Marianna Deparis
- Pediatric Oncology-Hematology Unit Department, Caen University Hospital, Caen, France
| | - Claire Briandet
- Department of Pediatrics, Dijon University Hospital, Dijon, France
| | - Eric Doré
- Pediatric Unit, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Aude Marie-Cardine
- Department of Pediatric Hematology and Oncology, Rouen University Hospital, Rouen, France
| | - Vincent Barlogis
- Department of Pediatric Hematology, La Timone Hospital, Marseille University Hospital, Marseille, France
| | - Guy Leverger
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Oncology Unit, Hôpital Armand Trousseau, AP-HP, Sorbonne Université Paris, Paris, France
| | - Sébastien Héritier
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Oncology Unit, Hôpital Armand Trousseau, AP-HP, Sorbonne Université Paris, Paris, France
| | - Nathalie Aladjidi
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Haemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Thierry Leblanc
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux and Paris, France
- Pediatric Hematology Unit, Robert-Debré University Hospital, AP-HP, Paris, France
- Université Paris-Cité, Paris, France
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Ma J, Cui C, Tang Y, Hu Y, Dong S, Zhang J, Xie X, Meng J, Wang Z, Zhang W, Chen Z, Wu R. Machine learning models developed and internally validated for predicting chronicity in pediatric immune thrombocytopenia. J Thromb Haemost 2024; 22:1167-1178. [PMID: 38103736 DOI: 10.1016/j.jtha.2023.12.006] [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: 08/17/2023] [Revised: 12/01/2023] [Accepted: 12/02/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Primary immune thrombocytopenia (ITP) in children is typically self-limiting; however, 20% to 30% of patients may experience prolonged thrombocytopenia lasting over a year. The challenge is predicting chronicity to ensure personalized treatment approaches. OBJECTIVES To address this issue, we developed and internally validated 4 machine learning (ML) models using demographic and immunologic characteristics to predict the likelihood of chronicity. METHODS The present study was conducted at Beijing Children's Hospital from June 2018 to December 2021, aiming to develop predictive models for determining the chronicity of pediatric ITP. Four ML models, based on a logistic regression classifier, random forest classifier, eXtreme Gradient Boosting (XGBoost), and support vector machine, were employed. These models used a set of 16 variables, including 14 immunologic and 2 demographic predictors. The performance evaluation criteria included prediction accuracy, precision, recall, F1 score, and area under the receiver operating characteristic curve (AUROC). RESULTS Data were collected from 662 patients who were randomly assigned to either a training dataset or a testing dataset using a random number generator. Among them, 26.5% had chronic disease. All models performed well, with AUROC values ranging from 0.81 to 0.84, and XGBoost was selected for its highest AUROC score and interpretability in constructing the predictive model. Age, T helper 17, T helper 17-to-regulatory T cell ratio, T helper 1, and double-negative T cells were identified as significant predictors by the XGBoost algorithm. CONCLUSION We developed a precise predictive model for chronicity in pediatric ITP using ML during the initial phase. The XGBoost model achieved high predictive accuracy by using individual patient clinical parameters and demonstrated commendable interpretability.
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Affiliation(s)
- Jingyao Ma
- Hematology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Chang Cui
- The State Key Laboratory of Multimodal Artificial Intelligence Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China; School of Artificial Intelligence, University of Chinese Academy of Sciences, Beijing, China
| | - Yongqiang Tang
- The State Key Laboratory of Multimodal Artificial Intelligence Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China.
| | - Yu Hu
- Hematology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shuyue Dong
- Hematology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jialu Zhang
- Hematology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xingjuan Xie
- Hematology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jinxi Meng
- Hematology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhifa Wang
- Hematology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Wensheng Zhang
- The State Key Laboratory of Multimodal Artificial Intelligence Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Hematology Center, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
| | - Runhui Wu
- Hematology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
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Daprà V, Giraudo I, Zaniol E, Galliano I, Calvi C, Montanari P, Alliaudi C, Saracco P, Bergallo M. Evaluation of the FCGR2B polymorphism in children with immune thrombocytopenia. Minerva Pediatr (Torino) 2024; 76:93-99. [PMID: 34859644 DOI: 10.23736/s2724-5276.21.05888-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Childhood immune thrombocytopenia (ITP) is an immune-mediated disease characterized by an isolated low platelet count. Pathogenesis of ITP is complex but many patients have platelet specific autoantibodies leading to accelerated clearance of opsonized platelets by Fc-gamma receptor (FcγR) bearing phagocytes, particularly in the spleen. In humans, there are three main types of Fcγ receptors: high-affinity FcγRI and low-affinity FcγRII and FcγRIII. About FcγRII, genetic variation of FCGR2B is associated with response to IVIg treatment in patients with Kawasaki disease and ITP. METHODS We used a TaqMAMA genotyping assay for detection of rs1050501 FCGR2B polymorphism in children with chronic ITP. A SNP rs1050501 (GenBank access number NG_023318.1, Homo sapiens Fc fragment of IgG receptor IIb [FCGR2B]) on chromosome 1 showing a T/C transition in position 15894 on FCGRB2 gene was chosen in this study. A series of experiments was conducted to evaluate the performance of the FCGR2B-MAMAPCR real time on a QuantStudio™ 5 Real-Time PCR System as compared to the 7500 Real-Time PCR System. RESULTS Background noise, genotypes discrimination, variability, allele and genotype frequencies and concordance were obtained. About clinical validation, all 60 samples collected from chronic ITP patients were analyzed. We found 53 on the 60 patients (88.4%) were homozygotes (52 TT and 1 CC) and 7/60 (11.6%) heterozygotes (TC). CONCLUSIONS The ability of the FCGR2B-MAMAPCR real time to detect rs1050501 FCGR2B polymorphism in children with chronic ITP on the QuantStudio™ 5 System is comparable to that on the 7500 System.
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Affiliation(s)
- Valentina Daprà
- Department of Public Health and Pediatrics, University of Turin, School of Medicine, Turin, Italy
- BioMole srl, Turin, Italy
| | - Isaac Giraudo
- Department of Public Health and Pediatrics, University of Turin, School of Medicine, Turin, Italy
- Unit of Hematology, Department of Pediatrics, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Elena Zaniol
- Department of Public Health and Pediatrics, University of Turin, School of Medicine, Turin, Italy
| | - Ilaria Galliano
- Department of Public Health and Pediatrics, University of Turin, School of Medicine, Turin, Italy
| | - Cristina Calvi
- Department of Public Health and Pediatrics, University of Turin, School of Medicine, Turin, Italy
| | - Paola Montanari
- Department of Public Health and Pediatrics, University of Turin, School of Medicine, Turin, Italy
| | - Carla Alliaudi
- Department of Public Health and Pediatrics, University of Turin, School of Medicine, Turin, Italy
| | - Paola Saracco
- Unit of Hematology, Department of Pediatrics, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Massimiliano Bergallo
- Department of Public Health and Pediatrics, University of Turin, School of Medicine, Turin, Italy -
- BioMole srl, Turin, Italy
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Moulinet T, Moussu A, Pierson L, Pagliuca S. The many facets of immune-mediated thrombocytopenia: Principles of immunobiology and immunotherapy. Blood Rev 2024; 63:101141. [PMID: 37980261 DOI: 10.1016/j.blre.2023.101141] [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: 08/30/2023] [Revised: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune condition, due to peripheral platelet destruction through antibody-dependent cellular phagocytosis, complement-dependent cytotoxicity, cytotoxic T lymphocyte-mediated cytotoxicity, and megakaryopoiesis alteration. This condition may be idiopathic or triggered by drugs, vaccines, infections, cancers, autoimmune disorders and systemic diseases. Recent advances in our understanding of ITP immunobiology support the idea that other forms of thrombocytopenia, for instance, occurring after immunotherapy or cellular therapies, may share a common pathophysiology with possible therapeutic implications. If a decent pipeline of old and new agents is currently deployed for classical ITP, in other more complex immune-mediated thrombocytopenic disorders, clinical management is less harmonized and would deserve further prospective investigations. Here, we seek to provide a fresh overview of pathophysiology and current therapeutical algorithms for adult patients affected by this disorder with specific insights into poorly codified scenarios, including refractory ITP and post-immunotherapy/cellular therapy immune-mediated thrombocytopenia.
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Affiliation(s)
- Thomas Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France
| | - Anthony Moussu
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Ludovic Pierson
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Simona Pagliuca
- UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France; Department of Hematology, Regional Competence Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Nancy University Hospital, Vandœuvre-lès-Nancy, France.
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8
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Caseiro Alves ME, Carmo F, Malato M, Cunha F. Immune thrombocytopenia in the setting of acute SARS-CoV-2 infection. BMJ Case Rep 2023; 16:e254352. [PMID: 37385718 DOI: 10.1136/bcr-2022-254352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an immune-mediated event, characterised by the destruction of platelets by autoantibodies resulting in isolated thrombocytopaenia (platelets <100 x109/L). In children, most cases are preceded by a viral infection. Cases of ITP in the setting of SARS-CoV-2 infection have been described. We describe a previously healthy boy, who presented with an extensive frontal and periorbital haematoma, petechial rash on the trunk and coryza. He had suffered a minor head trauma, 9 days before admission. Blood tests revealed a platelet count of 8000/µL. The remainder study was unremarkable, except for a positive SARS-CoV-2 PCR. Treatment comprised a single dose of intravenous immunoglobulin, with increase in platelet count and no recurrence. We made a working diagnosis of an ITP concurrent with a SARS-CoV-2 infection. Although few cases have been described, SARS-CoV-2 might be considered as a trigger for ITP.
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Affiliation(s)
- M Eduarda Caseiro Alves
- Pediatria Médica, Centro Hospitalar e Universitário de Lisboa Central E.P.E, Hospital de Dona Estefânia, Lisboa, Portugal
| | - Filipa Carmo
- Pediatria, Centro Hospitalar e Universitário de Lisboa Norte, E P E, Lisboa, Portugal
| | - Madalena Malato
- Pediatria Geral, Hospital de Vila Franca de Xira, E P E, Vila Franca de Xira, Portugal
| | - Florbela Cunha
- Pediatria Geral, Hospital de Vila Franca de Xira, E P E, Vila Franca de Xira, Portugal
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Wang Z, Wang L, Liu Y, Meng J, Dong S, Ma J, Hu Y, Chen Z, Cheng X, Wu R. Sustained response off treatment in eltrombopag for children with persistent/chronic primary immune thrombocytopenia: A multicentre observational retrospective study in China. Br J Haematol 2023. [PMID: 37128832 DOI: 10.1111/bjh.18842] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 05/03/2023]
Abstract
Eltrombopag (ELT) is effective and safe in adult persistent/chronic immune thrombocytopenia (p/cITP); a proportion could achieve a sustained response off treatment (SRoT); however, data on children are lacking. We attempted to analyse SRoT of ELT in children with p/cITP in this study. A multicentre retrospective observational study was performed in November 2022 for children with p/cITP who used ELT alone for >2 months between January 2017 and November 2021. Clinical data of pre-, during and post-ELT were collected. SRoT was defined as maintaining a platelet count of ≥30 × 109 /L without rescue therapy for at least 6 months off ELT. There were 143 patients enrolled; 69.2% (99/143) achieved an overall response of 43.3% and 25.9% achieved complete response (CR) and response (R). Among the 35 patients analysed from whom ELT was withdrawn, 71.4% (25/35) showed SRoT after discontinuing ELT without additional ITP therapy, with a median follow-up of 0.94 (range, 0.53-3.8) years, equal to 17.5% (25/143) in all patients treated with ELT. Compared with the patients with relapse (n = 10), the SRoT patients (n = 25) had a higher rate of CR (80% [20/25] vs. 40% [4/10]), shorter interval time from initiation to taper (6.4 months vs. 9.4 months), longer time from taper to withdrawal (1.1 years vs. 0.3 years) and a longer duration of ELT treatment (1.6 years vs. 0.5 years) with p < 0.05. Patients who achieved CR could attain SRoT more easily (p = 0.02). ELT had a response in 69.2% of children with p/cITP and 17.5% of them attained SRoT with good tolerance. The patients who achieved CR and began ELT treatment as early as possible, with a longer treatment duration and slower tapering, had a higher probability of SRoT.
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Affiliation(s)
- Zhifa Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lijuan Wang
- Department of Hematology, Henan Province Children's Hospital, Zhengzhou, Henan, China
| | - Yan Liu
- Department of Hematology, Baoding Children's Hospital, Baoding, Hebei, China
| | - Jinxi Meng
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shuyue Dong
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jingyao Ma
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yu Hu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Department of Hematology Research, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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10
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Kapur R. Intravenous immunoglobulins ameliorate thrombin-related platelet functions in childhood immune thrombocytopenia. Br J Haematol 2023. [PMID: 36924289 DOI: 10.1111/bjh.18752] [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: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
Childhood immune thrombocytopenia (ITP) is an acquired haematological disorder characterized by low platelet counts, with a disease course which is usually benign and self-limiting within 3-12 months. An estimated 28%, however, continue to develop chronic ITP and may experience bleeding symptoms and an impaired quality of life. Treatment options in case of severe bleedings include corticosteroids, anti-D or intravenous immunoglobulins (IVIg). The general working mechanism of IVIg remains unresolved and a matter of debate. Schmugge et al now identify that IVIg may have the ability to improve thrombin-induced platelet activation and enhance thrombin generation in a prospective study of 23 children with primary ITP, demonstrating that besides increasing platelet counts IVIg can be efficacious on the level of thrombin-induced platelet activation and coagulation support. Commentary on: Schmugge et al. IVIg treatment increases thrombin activation of platelets and thrombin generation in paediatric patients with immune thrombocytopenia. Br J Haematol 2022 (Online ahead of print). doi: 10.1111/bjh.18702.
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Affiliation(s)
- Rick Kapur
- Sanquin Research, Department of Experimental Immunohematology, Amsterdam and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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11
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Pincez T, Fernandes H, Pasquet M, Abou Chahla W, Granel J, Héritier S, Fahd M, Ducassou S, Thomas C, Garnier N, Barlogis V, Jeziorski E, Bayart S, Chastagner P, Cheikh N, Guitton C, Paillard C, Lejeune J, Millot F, Li-Thiao Te V, Mallebranche C, Pellier I, Neven B, Armari-Alla C, Carausu L, Piguet C, Benadiba J, Pluchart C, Stephan JL, Deparis M, Briandet C, Doré E, Marie-Cardine A, Leblanc T, Leverger G, Aladjidi N. Impact of age at diagnosis, sex, and immunopathological manifestations in 886 patients with pediatric chronic immune thrombocytopenia. Am J Hematol 2023; 98:857-868. [PMID: 36882195 DOI: 10.1002/ajh.26900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 03/02/2023] [Indexed: 03/09/2023]
Abstract
Pediatric chronic immune thrombocytopenia (cITP) is a heterogeneous condition in terms of bleeding severity, second-line treatment use, association with clinical and/or biological immunopathological manifestations (IMs), and progression to systemic lupus erythematosus (SLE). No risk factors for these outcomes are known. Specifically, whether age at ITP diagnosis, sex, or IMs impact cITP outcomes is unknown. We report the outcomes of patients with pediatric cITP from the French nationwide prospective cohort OBS'CEREVANCE. We used multivariate analyses to investigate the effect of age at ITP diagnosis, sex, and IMs on cITP outcomes. We included 886 patients with a median (min-max) follow-up duration of 5.3 (1.0-29.3) years. We identified an age cutoff that dichotomized the risk of the outcomes and defined two risk groups: patients with ITP diagnosed <10 years (children) and ≥ 10 years (adolescents). Adolescents had a two to four-fold higher risk of grade ≥3 bleeding, second-line treatment use, clinical and biological IMs, and SLE diagnosis. Moreover, female sex and biological IMs were independently associated with higher risks of biological IMs and SLE diagnosis, second-line treatment use, and SLE diagnosis, respectively. The combination of these three risk factors defined outcome-specific risk groups. Finally, we showed that patients clustered in mild and severe phenotypes, more frequent in children and adolescents, respectively. In conclusion, we identified that age at ITP diagnosis, sex, and biological IMs impacted the long-term outcomes of pediatric cITP. We defined risk groups for each outcome, which will help clinical management and further studies.
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Affiliation(s)
- Thomas Pincez
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Center, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montréal, Québec, Canada
| | - Helder Fernandes
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Pediatric Hemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Marlène Pasquet
- Pediatric Oncology Immunology Hematology Unit, Children's University Hospital, Toulouse, France
| | - Wadih Abou Chahla
- Department of Pediatric Hematology, Jeanne de Flandre Hospital, Lille University Hospital, Lille, France
| | - Jérome Granel
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Pediatric Hemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Sébastien Héritier
- Sorbonne Université, AP-HP, Armand Trousseau University Hospital, Pediatric Hematology Oncology Unit, Paris, France
| | - Mony Fahd
- Pediatric Hematology Unit, Robert-Debré University Hospital AP-HP, Paris, France
| | - Stéphane Ducassou
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Pediatric Hemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
| | - Caroline Thomas
- Pediatric Hematology Unit, Nantes University Hospital, Nantes, France
| | - Nathalie Garnier
- Institute of Pediatric Hematology and Oncology, Hospices Civils de Lyon, Lyon, France
| | - Vincent Barlogis
- Department of Pediatric Hematology, La Timone Hospital, Marseille University Hospital, Marseille, France
| | - Eric Jeziorski
- Pediatric Oncology Hematology Unit, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Sophie Bayart
- Pediatric Hematology Unit, Rennes University Hospital, Rennes, France
| | - Pascal Chastagner
- Department of Pediatric Hematology and Oncology, Children's University Hospital, Nancy, France
| | - Nathalie Cheikh
- Department of Pediatric Hematology-Oncology, Besançon University Hospital, Besançon, France
| | - Corinne Guitton
- Department of Pediatrics, Bicêtre University Hospital, AP-HP, Le Kremlin-Bicêtre, France
| | - Catherine Paillard
- Department of Pediatric Hematology and Oncology, Hautepierre University Hospital, Strasbourg, France
| | - Julien Lejeune
- Department of Pediatric Hematology-Oncology, Clocheville Hospital, Tours University Hospital, Tours, France
| | - Frédéric Millot
- Department of Pediatric Hematology, Poitiers University Hospital, Poitiers, France
| | - Valérie Li-Thiao Te
- Department of Pediatric Hematology/Oncology, Amiens University Hospital, Amiens, France
| | | | | | - Bénédicte Neven
- Pediatric Hematology-Immunology and Rheumatology Department, Necker-Enfants Malades Hospital, AP-HP, Paris, France
| | - Corinne Armari-Alla
- Pediatric Hematology-Oncology Department, Grenoble University Hospital, Grenoble, France
| | - Liana Carausu
- Department of Pediatric Hematology, CHU de Brest, Brest, France
| | - Christophe Piguet
- Pediatric Oncology Hematology Unit, Limoges University Hospital, Limoges, France
| | - Joy Benadiba
- Department of Hematology-Oncology Pediatrics, Nice University Hospital, Nice, France
| | - Claire Pluchart
- Pediatric Hematology-Oncology Unit, Institut Jean Godinot, Reims University Hospital, Reims, France
| | - Jean-Louis Stephan
- Department of Pediatric Oncology, North Hospital, University Hospital of Saint Etienne, Saint Etienne, France
| | - Marianna Deparis
- Pediatric Oncology- Hematology Unit Department, Caen University Hospital, Caen, France
| | - Claire Briandet
- Department of Pediatrics, Dijon University Hospital, Dijon, France
| | - Eric Doré
- Pediatric Unit, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Aude Marie-Cardine
- Department of Pediatric Hematology and Oncology, Rouen University Hospital, Rouen, France
| | - Thierry Leblanc
- Pediatric Hematology Unit, Robert-Debré University Hospital AP-HP, Paris, France
| | - Guy Leverger
- Sorbonne Université, AP-HP, Armand Trousseau University Hospital, Pediatric Hematology Oncology Unit, Paris, France
| | - Nathalie Aladjidi
- Centre de Référence National des Cytopénies Auto-immunes de l'Enfant (CEREVANCE), Bordeaux, France
- Pediatric Hemato-Immunology, CIC1401, INSERM CICP, Bordeaux University Hospital, Bordeaux, France
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12
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Harris EM, Hillier K, Nolan M, Meleedy-Rey P, Buissereth T, Grace RF. Utilization of an ITP quality improvement pathway improves adherence to management guidelines. Pediatr Blood Cancer 2023; 70:e30074. [PMID: 36518083 DOI: 10.1002/pbc.30074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 12/23/2022]
Abstract
Despite availability of epidemiologic studies and national guidelines for the management of newly diagnosed pediatric immune thrombocytopenia (ITP), practice variation exists among and within hematology practices. We previously described the development of an ITP pathway guiding management based on bleeding symptoms. Over an 8-year period, integration of this iterative ITP pathway into management of newly diagnosed ITP increased observation rates in children with no or mild bleeding symptoms and improved consistency of laboratory evaluation and treatment strategies without increasing adverse outcomes. This quality improvement initiative has been sustainable, acceptable to providers, and increased adherence to guidelines.
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Affiliation(s)
- Emily M Harris
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kirsty Hillier
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Hassenfeld Children's Hospital at NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Michaela Nolan
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Patricia Meleedy-Rey
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Taylah Buissereth
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachael F Grace
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts, USA
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13
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Andersson NG, Lausen B, Mårtensson A, Tedgård U, Kjaersgaard M. Twenty years' experience of immune thrombocytopenia and intracranial haemorrhage in the Nordic countries-A NOPHO study. Acta Paediatr 2023; 112:1097-1100. [PMID: 36596307 DOI: 10.1111/apa.16654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/26/2022] [Accepted: 01/02/2023] [Indexed: 01/05/2023]
Affiliation(s)
- Nadine G Andersson
- Centre for Thrombosis and Hemostasis, Skåne University Hospital, Malmö, Sweden.,Department of Pediatric Hematology, Oncology, and Immunology, Skåne University Hospital, Lund, Sweden
| | - Birgitte Lausen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Annika Mårtensson
- Department of Pediatric Hematology, Oncology, and Immunology, Skåne University Hospital, Lund, Sweden
| | - Ulf Tedgård
- Department of Pediatric Hematology, Oncology, and Immunology, Skåne University Hospital, Lund, Sweden
| | - Mimi Kjaersgaard
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
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14
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Khalifa KAE, El-Hawy MA, Abo Zeid HM, El-Kholy RM. Expression of B-cell activating factor in pediatric patients with immune thrombocytopenia: a single institutional series and review of literature. J Immunoassay Immunochem 2023; 44:41-55. [PMID: 36047579 DOI: 10.1080/15321819.2022.2114363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
B-cell-activating factor (BAFF) is a crucial cytokine supporting survival and differentiation of B cells. Dysregulation of BAFF is involved in the pathogenesis of B-cell related autoimmune diseases including immune thrombocytopenia (ITP). The aim of this study was to evaluate the significance of BAFF expression in pediatric ITP patients. Eighty pediatric patients with ITP are subdivided in three groups. Group I included (32 patients) diagnosed with acute ITP less than 3 months, group II (48 patients) diagnosed with persistent ITP (from 3 to 12 months) and chronic ITP (more than 12 months) and group III 20 healthy controls. Complete blood picture, autoimmune profile, antiplatelet antibodies, coagulation profile, bone marrow examination, and RT-PCR were performed to detect the expression for BAF for all participants in this study. BAFF expression levels significantly increased in cases rather than in controls. BAFF Expression Value significantly increased in groups I & II (3.10 ± 1.99&3.29 ± 2.58) compared to controls (0.83 ± 0.45) as p < .001 for both. On the other hand, groups I & II were comparable in BAFF Expression Value (p = .470). BAFF expression increased in ITP patients, implying a function in the disease's pathogenesis.
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Affiliation(s)
- Khaled A E Khalifa
- Clinical Pathology Department, Faculty of Medicine, Menoufia University, Shibin al Kawm, Egypt
| | - Mahmoud A El-Hawy
- Pediatrics Department, Faculty of Medicine, Menoufia University, Shib?n al Kawm, Egypt
| | - Heba M Abo Zeid
- Clinical Pathology Department, Faculty of Medicine, Menoufia University, Shibin al Kawm, Egypt
| | - Reem M El-Kholy
- Clinical Pathology Department, Faculty of Medicine, Menoufia University, Shibin al Kawm, Egypt
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15
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Adapted guideline for the diagnosis and treatment of primary immune thrombocytopenia for Chinese children (2021). Pediatr Investig 2022; 6:63-74. [PMID: 35774524 PMCID: PMC9218990 DOI: 10.1002/ped4.12305] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/19/2021] [Indexed: 01/19/2023] Open
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16
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An Update on Pediatric Immune Thrombocytopenia (ITP): Differentiating Primary ITP, IPD, and PID. Blood 2021; 140:542-555. [PMID: 34479363 DOI: 10.1182/blood.2020006480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/20/2021] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is the most common acquired thrombocytopenia in children and is caused by both immune-mediated decreased platelet production and increased platelet destruction. In the absence of a diagnostic test, ITP must be differentiated from other thrombocytopenic disorders, including inherited platelet disorders (IPD). In addition, a diagnosis of secondary ITP due to a primary immune deficiency (PID) with immune dysregulation may not be apparent at diagnosis but can alter management and should be considered in an expanding number of clinical scenarios. The diagnostic evaluation of children with thrombocytopenia will vary based on the clinical history and laboratory features. Access to genotyping has broadened the ability to specify the etiology of thrombocytopenia, while increasing access to immunophenotyping, functional immunologic and platelet assays, and biochemical markers has allowed for more in-depth evaluation of patients. With this greater availability of testing, diagnostic algorithms in patients with thrombocytopenia have become complex. In this article, we highlight the diagnostic evaluation of thrombocytopenia in children with a focus on ITP, including consideration of underlying genetic and immune disorders, and utilize hypothetical patient cases to describe disease manifestations and strategies for treatment of pediatric ITP.
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17
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Shimano KA, Neunert C, Bussel JB, Klaassen RJ, Bhat R, Pastore YD, Lambert MP, Bennett CM, Despotovic JM, Forbes P, Grace RF. Quality of life is an important indication for second-line treatment in children with immune thrombocytopenia. Pediatr Blood Cancer 2021; 68:e29023. [PMID: 33764667 DOI: 10.1002/pbc.29023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND The decision to initiate second-line treatment in children with immune thrombocytopenia (ITP) is complex and involves many different factors. METHODS In this prospective, observational, longitudinal cohort study of 120 children from 21 centers, the factors contributing to the decision to start second-line treatments for ITP were captured. At study entry, clinicians were given a curated list of 12 potential reasons the patient required a second-line treatment. Clinicians selected all that applied and ranked the top three reasons. RESULTS Quality of life (QOL) was the most frequently cited reason for starting a second-line therapy. Clinicians chose it as a reason to treat in 88/120 (73%) patients, as among the top three reasons in 68/120 (57%), and as the top reason in 32/120 (27%). Additional factors ranked as the top reason to start second-line treatment included severity of bleeding (22/120, 18%), frequency of bleeding (19/120, 16%), and severity of thrombocytopenia (18/120, 15%). Patients for whom QOL (p = .006) or sports participation (p = .02) were ranked reasons were more likely to have chronic ITP, whereas those for whom severity (p = .003) or frequency (p = .005) of bleeding were ranked reasons were more likely to have newly diagnosed or persistent ITP. Parental anxiety, though rarely the primary impetus for treatment, was frequently cited (70/120, 58%) as a contributing factor. CONCLUSION Perceived QOL is the most frequently selected reason pediatric patients start second-line therapies for ITP. It is critical that studies of treatments for childhood ITP include assessments of their effects on QOL.
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Affiliation(s)
| | - Cindy Neunert
- Columbia University Medical Center, New York, New York, USA
| | | | | | - Rukhmi Bhat
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Michele P Lambert
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Carolyn M Bennett
- Emory University School of Medicine, Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorders Center, Atlanta, Georgia, USA
| | - Jenny M Despotovic
- Texas Children's Hematology Center, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Forbes
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts, USA
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18
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Misdiagnosed thrombocytopenia in children and adolescents: analysis of the Pediatric and Adult Registry on Chronic ITP. Blood Adv 2021; 5:1617-1626. [PMID: 33710335 DOI: 10.1182/bloodadvances.2020003004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/23/2021] [Indexed: 02/06/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) in children is a diagnosis of exclusion, but cases of secondary ITP and nonimmune thrombocytopenia (non-IT) are generally difficult to recognize in a timely fashion. We describe a pediatric population with a revised diagnosis of secondary ITP or non-IT within 24 months of follow-up. Data were extracted from the Pediatric and Adult Registry on Chronic ITP, an international multicenter registry collecting data prospectively in patients with newly diagnosed primary ITP. Between 2004 and 2019, a total of 3974 children aged 3 months to 16 years were included. Secondary ITP and non-IT were reported in 113 patients (63 female subjects). Infectious (n = 53) and autoimmune (n = 42) diseases were identified as the main causes, with median ages at diagnosis of 3.2 years (interquartile range: 1.2; 6.7 years) and 12.4 years (interquartile range: 7.6; 13.7 years), respectively. Other causes included malignancies, aplastic anemia, immunodeficiency, and drug use. Patients with malignancy and aplastic anemia had significantly higher initial platelet counts (37 and 52 × 109/L) than did those with infection or autoimmune diseases (12 and 13 × 109/L). Characteristics of patients with secondary ITP due to infection were similar to those of children with primary ITP at first presentation, indicating similar mechanisms. Significant differences were found for age, sex, comorbidities, initial bleeding, sustained need for treatment, and disease persistence for the remaining noninfectious group compared with primary ITP. Based on our findings, we propose a diagnostic algorithm that may serve as a basis for further discussion and prospective trials.
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19
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IVMP+IVIG raises platelet counts faster than IVIG alone: results of a randomized, blinded trial in childhood ITP. Blood Adv 2021; 4:1492-1500. [PMID: 32282882 DOI: 10.1182/bloodadvances.2019001343] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/09/2020] [Indexed: 01/19/2023] Open
Abstract
Children with immune thrombocytopenia (ITP) rarely suffer from life-threatening bleeds (eg, intracranial hemorrhage). In such settings, the combination of IV methylprednisolone (IVMP) with IV immune globulin (IVIG) is used to rapidly increase platelet counts (PCs). However, there are no controlled data to support using combination therapy over IVIG alone. We conducted a randomized, double-blind, placebo-controlled study to evaluate the rapidity of the PC increment and associated adverse events (AEs) between 2 regimens: A (IV placebo) and B (IVMP 30 mg/kg), both given over 1 hour, followed in both cases by IVIG (Gamunex 10%) 1 g/kg over 2-3 hours in children 1-17 years old with primary ITP and PCs <20 × 109/L in whom physicians had decided to treat with IVIG. Thirty-two children (ages: median, 8 years; range, 1.2-17.5 years) with a mean baseline PC of 9.2 × 109/L participated. Eighteen were randomized to regimen A and 14 to regimen B. By 8 hours after initiating therapy, 55% of all children had a PC ≥20 × 109/L (no group difference). By 24 hours, mean PCs were 76.9 × 109/L (B) vs 55 × 109/L (A) (P = .06; P = .035 when adjusted for intergroup differences in patient ages). No patient experienced severe bleeding/unexpected severe AEs. There were statistically fewer IVIG-related headaches in the group receiving combination therapy (P = .046). Our findings show a rapid response to IVIG with/without steroids and provide evidence to support the use of IVMP+IVIG in life-threatening situations. This trial was registered at www.clinicaltrials.gov as #NCT00376077.
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20
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Thrombopoietin receptor agonists as an emergency treatment for severe newly diagnosed immune thrombocytopenia in children. Blood 2021; 137:138-141. [PMID: 33410895 DOI: 10.1182/blood.2020006807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/08/2020] [Indexed: 01/19/2023] Open
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21
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Randall MM, Nurse J, Singh KP. Tranexamic Acid in a Case Report of Life-threatening Nontraumatic Hemorrhage in Immune Thrombocytopenic Purpura. Clin Pract Cases Emerg Med 2020; 4:421-423. [PMID: 32926702 PMCID: PMC7434249 DOI: 10.5811/cpcem.2020.5.46955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 05/11/2020] [Indexed: 01/19/2023] Open
Abstract
Introduction Immune thrombocytopenic purpura (ITP) is an autoimmune-mediated disorder in which the body produces antibodies that destroy platelets, causing an increased risk of bleeding and bruising. Tranexamic acid (TXA) is a medication that prevents clot breakdown and is used to treat uncontrolled bleeding. Case Report We present the case of an 11-year-old female with significant epistaxis and hypotension in the emergency department. Traditional therapies were initiated; however, the patient continued to have bleeding and remained hypotensive, so intravenous TXA was given. The patient’s bleeding then resolved. Conclusion TXA may be a safe and effective adjunct to traditional therapies for the treatment of life-threatening hemorrhage in ITP patients.
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Affiliation(s)
- Melanie M Randall
- Loma Linda University Medical Center and Children's Hospital, Department of Emergency Medicine, Loma Linda, California
| | - Jason Nurse
- San Gorgonio Memorial Hospital, Department of Emergency Medicine, Banning, California
| | - Karan P Singh
- San Gorgonio Memorial Hospital, Department of Emergency Medicine, Banning, California
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22
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Singh G, Bansal D, Wright NAM. Immune Thrombocytopenia in Children: Consensus and Controversies. Indian J Pediatr 2020; 87:150-157. [PMID: 31927692 DOI: 10.1007/s12098-019-03155-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/05/2019] [Indexed: 01/19/2023]
Abstract
Newly diagnosed immune thrombocytopenia (ITP) is a relatively common disorder of childhood that does not require an exhaustive laboratory workup for diagnosis. A history and physical exam with a review of the peripheral smear are crucial for excluding secondary causes of thrombocytopenia. Several guidelines have been published to guide physicians in the management of ITP. However, the decision for treatment can be arduous. The management strategy should not be focussed on the platelet count but the severity of bleeding symptoms. Agents for treating acute ITP, including corticosteroids, immunoglobulin and anti-D immunoglobulin, do not seem to have a significant impact on the natural history of the disease. The majority of children with ITP do not need therapy and have a spontaneous resolution of the disease. Some children can develop chronic ITP that is not commonly life-threatening but can lead to impaired quality of life. Traditional therapies such as rituximab and splenectomy for chronic ITP are not without significant adverse effects. Thrombopoietin receptor agonists are newer agents for the treatment of chronic ITP and hold promise, however, their cost currently precludes use in most of the patients in low-middle-income countries. This review compares and contrasts the specific treatments available for the treatment of ITP to help the reader make a balanced choice. This review, based on a series of case examples, will help physicians in making decisions about choosing a practical management strategy for patients with newly diagnosed as well as chronic ITP.
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Affiliation(s)
- Gurpreet Singh
- Division of Hematology/Immunology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 28 Oki Dr Nw, Calgary, T3B 6A8, Canada
| | - Deepak Bansal
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nicola A M Wright
- Division of Hematology/Immunology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 28 Oki Dr Nw, Calgary, T3B 6A8, Canada.
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Towner S, Berger ZE, Titman P, New HV, Theodore K, Brown G, Sibson KR. Fatigue, executive function and psychological effects in children with immune thrombocytopenia: a cross-sectional study. Br J Haematol 2020; 189:534-542. [PMID: 31978938 DOI: 10.1111/bjh.16387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/17/2019] [Indexed: 01/19/2023]
Abstract
Childhood ITP is often considered to be a relatively mild haematological disorder, with only a minority of patients requiring treatment for troublesome bleeding. Over recent years, wider effects of the condition have been identified in some adults, particularly relating to fatigue and cognitive impairment. In this study, we sought to investigate such effects in a group of children with ITP and further our understanding of their psychological profile. Children attending routine haematology outpatient clinics and their parents were asked to complete standardised questionnaires designed to assess a range of psychological and cognitive factors. Although the majority of children had some scores within the normal range, a significantly high proportion had difficulties with fatigue (70·6%), emotional and behavioural symptoms (25·7%) or executive functioning (19·4%). Quality of life and subjective evaluation of the illness (appraisal) correlated significantly with each of these domains, but bleeding severity and platelet count did not. Our findings provide valuable insight into the broader impact of childhood ITP, which could aid in providing holistic care, potentially contribute to decisions regarding medical treatment, and guide future research.
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Affiliation(s)
- Sarah Towner
- Department of Clinical Psychology, Royal Holloway, University of London, Egham, UK
| | - Zoe E Berger
- Psychological Services, Great Ormond Street Hospital, London, UK
| | - Penny Titman
- Psychological Services, Great Ormond Street Hospital, London, UK
| | - Helen V New
- Department of Paediatrics, Imperial College Healthcare NHS Trust, NHS Blood and Transplant, London, UK
| | - Kate Theodore
- Department of Clinical Psychology, Royal Holloway, University of London, Egham, UK
| | - Gary Brown
- Department of Clinical Psychology, Royal Holloway, University of London, Egham, UK
| | - Keith R Sibson
- Haematology Department, Great Ormond Street Hospital, London, UK
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Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, Ghanima W, Godeau B, González-López TJ, Grainger J, Hou M, Kruse C, McDonald V, Michel M, Newland AC, Pavord S, Rodeghiero F, Scully M, Tomiyama Y, Wong RS, Zaja F, Kuter DJ. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv 2019; 3:3780-3817. [PMID: 31770441 PMCID: PMC6880896 DOI: 10.1182/bloodadvances.2019000812] [Citation(s) in RCA: 550] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/18/2019] [Indexed: 01/19/2023] Open
Abstract
Over the last decade, there have been numerous developments and changes in treatment practices for the management of patients with immune thrombocytopenia (ITP). This article is an update of the International Consensus Report published in 2010. A critical review was performed to identify all relevant articles published between 2009 and 2018. An expert panel screened, reviewed, and graded the studies and formulated the updated consensus recommendations based on the new data. The final document provides consensus recommendations on the diagnosis and management of ITP in adults, during pregnancy, and in children, as well as quality-of-life considerations.
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Affiliation(s)
- Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University and Canadian Blood Services, Hamilton, ON, Canada
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Beng H Chong
- St. George Hospital, NSW Health Pathology, University of New South Wales, Sydney, NSW, Australia
| | - Nichola Cooper
- Department of Haematology, Hammersmith Hospital, London, United Kingdom
| | | | - Waleed Ghanima
- Departments of Research, Medicine and Oncology, Østfold Hospital Trust, Grålum, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Bertrand Godeau
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | | | - John Grainger
- Department of Haematology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Ming Hou
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, China
| | | | - Vickie McDonald
- Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Marc Michel
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Adrian C Newland
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sue Pavord
- Haematology Theme Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, United Kingdom
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Osaka, Japan
| | - Raymond S Wong
- Sir YK Pao Centre for Cancer and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy; and
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Cooper N, Cines DB. The child with immune thrombocytopenia: to treat or not to treat, is that still the question? Haematologica 2019; 104:2132-2134. [PMID: 31666343 DOI: 10.3324/haematol.2019.229179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Nichola Cooper
- Centre for Haematology, Department of Medicine, Imperial College, Hammersmith Hospital, London, UK
| | - Douglas B Cines
- Departments of Pathology and Laboratory Medicine and Medicine, University of Pennsylvania-Perelman School of Medicine, Philadelphia, PA, USA
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Balch A, Wilkes J, Thorell E, Pavia A, Sherwin CMT, Enioutina EY. Changing trends in IVIG use in pediatric patients: A retrospective review of practices in a network of major USA pediatric hospitals. Int Immunopharmacol 2019; 76:105868. [PMID: 31487613 DOI: 10.1016/j.intimp.2019.105868] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/06/2019] [Accepted: 08/27/2019] [Indexed: 01/19/2023]
Abstract
The use of immunoglobulins is gradually increasing. Intravenous immunoglobulins (IVIG) are used as replacement therapy for primary and secondary immune deficiencies, and as an anti-inflammatory and immunomodulatory medication for the treatment of neurologic, dermatologic, and rheumatologic diseases. The objective of this study was to analyze trends in the IVIG use in pediatric patients hospitalized to 47 US-based children's hospitals from 2007 to 2014. IVIG was used for the treatment of >2300 primary diagnoses in 53,648 unique patients. The number of IVIG admissions increased by 30.2% during the study period, while the mean rate of IVIG admissions/100,000 admissions increased only 5.8%. Most patients receiving IVIG were children and adolescents. IVIG was frequently used off-label or for the treatment of FDA-approved indications in children under two years of age and BMT patients <20 years of age. Primary immune deficiencies represented only 1.2% of all IVIG admissions. Pediatric patients with mucocutaneous lymph node syndrome (Kawasaki disease, KD) and idiopathic thrombocytopenic purpura (ITP) were two primary consumers of the IVIG. Another top-ranked indications were acute infectious polyneuritis (Guillain-Barré syndrome, GBS) and prophylaxis of infections in patients receiving antineoplastic chemotherapy. IVIG usage is a dynamic process guided by emerging evidence and FDA approval for new indications. IVIG was mostly prescribed for treatment of diseases with pathologic immune responses to foreign of self-antigens. These indications usually, require higher amounts of IVIG per admission. More studies are needed to understand whether IVIG treatments of off-label indications are effective and cost-efficient.
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Affiliation(s)
- Alfred Balch
- Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob Wilkes
- Intermountain Healthcare, Salt Lake City, UT, USA
| | - Emily Thorell
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Andrew Pavia
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, OH, USA
| | - Elena Y Enioutina
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Shaw J, Kilpatrick K, Eisen M, Tarantino M. The incidence and clinical burden of immune thrombocytopenia in pediatric patients in the United States. Platelets 2019; 31:307-314. [DOI: 10.1080/09537104.2019.1635687] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Jaime Shaw
- Center for Observational Research, Amgen, Thousand Oaks, CA, USA
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Suntsova EV, Maschan AA, Baydildina DD, Kalinina II, Petrova UN, Pshonkin AV, Novichkova GA. Thrombopoietin receptor agonist switch in children with persistent and chronic severe immune thrombocytopenia: A retrospective analysis in a large tertiary center. Pediatr Blood Cancer 2019; 66:e27704. [PMID: 30854783 DOI: 10.1002/pbc.27704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 02/04/2019] [Accepted: 02/20/2019] [Indexed: 01/19/2023]
Abstract
We retrospectively analyzed sequential therapy with romiplostim and eltrombopag in 23 children with immune thrombocytopenia: switching from romiplostim to eltrombopag (10 patients) or vice versa (13 patients). The median age of patients at enrollment in the study was 5.6 years (2-15 years). Switching from romiplostim to eltrombopag was effective in eight (80%) patients, whereas switching from eltrombopag to romiplostim was effective in eight (62%) patients. The response rate was similar in patients failing the first thrombopoietin receptor agonist and those who had previous response. To date, all responders continue to maintain platelets over 50 × 109 /L at 13-39 months after switching.
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Affiliation(s)
- Elena V Suntsova
- Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology, Moskva, Russia
| | - Alexey A Maschan
- Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology, Moskva, Russia
| | - Dina D Baydildina
- Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology, Moskva, Russia
| | - Irina I Kalinina
- Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology, Moskva, Russia
| | - Uliana N Petrova
- Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology, Moskva, Russia
| | - Alexey V Pshonkin
- Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology, Moskva, Russia
| | - Galina A Novichkova
- Dmitri Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology, Moskva, Russia
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Das A, Bhatia P, Trehan A. 6-Mercaptopurine Fails to Improve Platelet Count in Pediatric Chronic Immune Thrombocytopenia. Indian J Hematol Blood Transfus 2019; 35:176-178. [PMID: 30828169 DOI: 10.1007/s12288-018-1012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/31/2018] [Indexed: 01/19/2023] Open
Affiliation(s)
- Anirban Das
- Paediatric Haematology/Oncology Unit, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Prateek Bhatia
- Paediatric Haematology/Oncology Unit, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
| | - Amita Trehan
- Paediatric Haematology/Oncology Unit, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012 India
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30
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Cuker A, Bass AD, Nadj C, Agius MA, Steingo B, Selmaj KW, Thoits T, Guerreiro A, Van Wijmeersch B, Ziemssen T, Meuth SG, LaGanke CC, Thangavelu K, Rodriguez CE, Baker DP, Margolin DH, Jannsens A. Immune thrombocytopenia in alemtuzumab-treated MS patients: Incidence, detection, and management. Mult Scler 2019; 26:48-56. [PMID: 30785358 PMCID: PMC6950888 DOI: 10.1177/1352458518816612] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Alemtuzumab is a highly effective therapy for relapsing-remitting multiple
sclerosis (RRMS), and immune thrombocytopenia (ITP) has been identified as a
risk. Objective: To examine ITP incidence, treatment, and outcomes during the clinical
development of alemtuzumab for RRMS and discuss postmarketing experience
outside clinical trials. Methods: CAMMS223 and Comparison of Alemtuzumab and Rebif® Efficacy in
Multiple Sclerosis (CARE-MS) I and II investigated two annual courses of
alemtuzumab 12 mg (or 24 mg in CAMMS223/CARE-MS II) versus subcutaneous
interferon beta-1a three times per week. Patients completing core studies
could enroll in an extension. Monthly monitoring for ITP continued until
48 months after the last alemtuzumab infusion. Results: Of 1485 alemtuzumab-treated MS patients in the clinical development program,
33 (2.2%) developed ITP (alemtuzumab 12 mg, 24 [2.0%]; alemtuzumab 24 mg, 9
[3.3%]) over median 6.1 years of follow-up after the first infusion; most
had a sustained response to first-line ITP therapy with corticosteroids,
platelets, and/or intravenous immunoglobulin. All cases occurred within
48 months of the last alemtuzumab infusion. Postmarketing surveillance data
suggest that the ITP incidence is not higher in clinical practice than in
clinical trials. Conclusion: Alemtuzumab-associated ITP occurs in approximately 2% of patients and is
responsive to therapy. Careful monitoring is key for detection and favorable
outcomes.
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Affiliation(s)
- Adam Cuker
- Departments of Medicine and Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ann D Bass
- Neurology Center of San Antonio, San Antonio, TX, USA
| | | | - Mark A Agius
- Woodland Clinic, Dignity Health, Woodland, CA, USA
| | | | | | - Timothy Thoits
- College of Human Medicine, MSU Spectrum Health, Grand Rapids, MI, USA
| | - Alexandre Guerreiro
- Instituto de Doenças Neurológicas do Hospital Mãe de Deus, Porto Alegre, Brazil
| | - Bart Van Wijmeersch
- Rehabilitation and MS Centre Overpelt, BIOMED, University of Hasselt, Hasselt, Belgium
| | - Tjalf Ziemssen
- Center of Clinical Neuroscience, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Sven G Meuth
- Department of Neurology, University of Münster, Münster, Germany
| | | | | | - Claudio E Rodriguez
- Sanofi, Cambridge, MA, USA.,Current affiliation: Sunovion Pharmaceuticals, Marlborough, MA, USA
| | | | - David H Margolin
- Sanofi, Cambridge, MA, USA.,Current affiliation: Cerevance, Inc., Boston, MA, USA
| | - Ann Jannsens
- Department of Haematology, University Hospitals Leuven, Leuven, Belgium
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Arbach O, Taumberger AB, Wietek S, Cervinek L, Salama A. Efficacy and safety of a new intravenous immunoglobulin (Panzyga ® ) in chronic immune thrombocytopenia. Transfus Med 2019; 29:48-54. [PMID: 30687970 PMCID: PMC6850321 DOI: 10.1111/tme.12573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 10/02/2018] [Accepted: 11/30/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of intravenous immunoglobulin (IVIG) 10% (Panzyga® ), a novel human normal IVIG 10%, in patients with chronic immune thrombocytopenia (ITP). BACKGROUND First-line treatment options in ITP include IVIGs. METHODS In this prospective, open-label, non-controlled, multicentre, phase III study, patients received a daily dose of IVIG 10% (1 g kg-1 body weight) for two consecutive days. The primary end point was clinical response rate; secondary end points included alternate response definitions, time to response, response duration, platelet counts, regression of bleeding and safety. RESULTS Forty patients were enrolled (57·5% male, mean age 36·7 years); the full analysis set comprised 36 patients. A clinical response was seen for 29 of 36 patients (80·6%). Median time to response and response duration was 2 days and 14 days, respectively. IVIG 10% was well tolerated at a maximum infusion rate of 8 mg (kg min)-1 in all but one patient; adverse events were mainly mild to moderate in severity, and the most frequent was headache (42·5%). CONCLUSION IVIG 10% is well tolerated even at a high infusion speed and induces a rapid platelet count increase, thus decreasing the bleeding rate and the severity of bleeding events. TRIAL REGISTRY ClinicalTrials.gov record: NCT01349790.
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Affiliation(s)
- O. Arbach
- Immunhaematology, Institut für Transfusionsmedizin, Universitätsmedizin BerlinBerlinGermany
- SPARK/Validation Fund, Berlin Health InnovationsBerlinGermany
| | - A. B. Taumberger
- Clinical Project Management, Octapharma Pharmazeutika Produktionsges.m.b.H.ViennaAustria
| | - S. Wietek
- Clinical Project Management, Octapharma Pharmazeutika Produktionsges.m.b.H.ViennaAustria
| | - L. Cervinek
- Department of Internal Medicine, Hematology and OncologyUniversity Hospital BrnoBrnoCzech Republic
| | - A. Salama
- Immunhaematology, Institut für Transfusionsmedizin, Universitätsmedizin BerlinBerlinGermany
- Klinik für Gynäkologie, Campus Virchow‐KlinikumCharite Universitätsmedizin BerlinBerlinGermany
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Grainger JD, Blanchette VS, Grotzinger KM, Roy A, Bussel JB. Health-related quality of life in children with chronic immune thrombocytopenia treated with eltrombopag in the PETIT study. Br J Haematol 2018; 185:102-106. [PMID: 30592022 DOI: 10.1111/bjh.15732] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/12/2018] [Indexed: 01/19/2023]
Abstract
The PETIT (Eltrombopag in Pediatric Patients with Thrombocytopenia from Chronic ITP) trial showed that in children aged 1-17 years with chronic or persistent immune thrombocytopenia (ITP), eltrombopag improved platelet counts, decreased clinically significant bleeding and reduced rescue medication need. We report the health-related quality of life (HRQoL) results from the PETIT study using the Kids' ITP Tools (KIT). A limitation was that PETIT was not powered for the HRQoL analysis. Eltrombopag did not impact children's HRQoL assessed by the KIT. Although median KIT scores in children treated with eltrombopag with platelet responses were numerically higher compared with non-responders in some age groups, the interquartile ranges overlapped.
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Affiliation(s)
- John D Grainger
- Central Manchester University Hospitals NHS Foundation Trust, NIHR/Wellcome Trust Manchester CRF, Royal Manchester Children's Hospital, University of Manchester, Manchester, England
| | - Victor S Blanchette
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - James B Bussel
- Department of Pediatrics, Division of Hematology/Oncology, Weill Cornell Medicine, New York, NY, USA
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Despotovic JM, Grimes AB. Pediatric ITP: is it different from adult ITP? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:405-411. [PMID: 30504339 PMCID: PMC6246008 DOI: 10.1182/asheducation-2018.1.405] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Immune thrombocytopenia (ITP) has historically been thought to occur in 2 distinct forms: childhood ITP and adult ITP. This division is based largely on the presumption that childhood ITP is often benign and self-limited, whereas ITP in adults tends to be more chronic and difficult to treat. Although data exist to justify a different approach to the diagnosis and treatment in young children and the elderly, ITP in older children, adolescents, and younger adults is likely to share more similar pathology. This article will highlight the most recent data describing the natural history, diagnostic approach, management strategies, and disease-related outcomes in children and adults with ITP. These data reveal many unexpected similarities between the 2 groups, while confirming some of the more well-described differences. Discussion of these findings aims to highlight similarities and differences between ITP in children and adults, which will underscore important areas of future research and/or changes in management guidelines.
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Affiliation(s)
- Jenny M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, TX
| | - Amanda B Grimes
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, TX
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35
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Tremblay G, Dolph M, Bhor M, Said Q, Roy A, Elliott B, Briggs A. Cost-consequence model comparing eltrombopag and romiplostim in pediatric patients with chronic immune thrombocytopenia. CLINICOECONOMICS AND OUTCOMES RESEARCH 2018; 10:715-721. [PMID: 30464564 PMCID: PMC6223346 DOI: 10.2147/ceor.s177338] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Immune thrombocytopenia (ITP) is an auto-immune disorder characterized by enhanced platelet destruction and, subsequently, the potential for increased bleeding. Thrombopoietin receptor (TPO-R) agonists have recently emerged as promising therapies for ITP patients who are refractory to other treatments. While eltrombopag (EPAG) is the only TPO-R agonist US Food and Drug Administration approved for use in pediatric patients, romiplostin (ROMI) has been used in Phase III clinical studies. Methods A cost-consequence model (CCM) was developed to evaluate the costs of EPAG, ROMI, and watch-and-rescue (W&R) in relation to their respective treatment outcomes in previously-treated pediatric chronic ITP (cITP) over a 26-week time horizon. The costs of drugs, administration, routine care, rescue medications, adverse events, and mortality were included. Data on platelet count response rate, bleeding events, and adverse events were derived from all relevant identified Phase III-registered clinical trials, health outcomes were compared via indirect treatment comparison. Results The overall estimated cost of EPAG per patient was US$66,550, compared to US$101,056 for ROMI and US$32,720 for W&R. EPAG's lower cost compared to ROMI was largely due to lower drug costs (US$62,202 vs US$84,396), administration costs (US$0 vs US$1,955), and significantly lower costs due to severe bleeding (US$354 vs US$10,191). When assessing cost per severe bleeding event avoided, EPAG was dominant over ROMI (less expensive and more effective). EPAG was again dominant over ROMI when assessing the cost per responder and per bleeding event (any grade). Sensitivity analysis was consistent with the base case findings. Conclusion EPAG was the preferred TPO-R agonist to treat cITP when indirectly compared to ROMI, largely driven by its favorable severe bleeding outcomes and lower drug and administration costs.
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Affiliation(s)
| | - Mike Dolph
- Health Economics, Purple Squirrel Economics, New York, NY, USA,
| | - Menaka Bhor
- Health Economics and Outcomes Research, Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Qayyim Said
- Health Economics and Outcomes Research, Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Anuja Roy
- Health Economics and Outcomes Research, Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Brian Elliott
- Hematology, Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Andrew Briggs
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, Scotland, UK
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Youssef MAM, Salah Eldeen E, Elsayh KI, Taha SF, Abo-Elela MGM. High dose dexamethasone as an alternative rescue therapy for active bleeding in children with chronic ITP: clinical and immunological effects. Platelets 2018; 30:886-892. [DOI: 10.1080/09537104.2018.1530347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Mervat A M Youssef
- Assiut Children Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Eman Salah Eldeen
- Assiut Clinical Pathology Department, Faculty of medicine, Assiut University, Assiut, Egypt
| | - Khalid I Elsayh
- Assiut Children Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Samaher F Taha
- Assiut Children Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
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Li J, Pan Z, Liu H, Ding F, Shu Q, Li X. Retrospective analysis of the risk of hemorrhage associated with moderate and severe thrombocytopenia of 173 patients with systemic lupus erythematosus. Medicine (Baltimore) 2018; 97:e11356. [PMID: 29979417 PMCID: PMC6076144 DOI: 10.1097/md.0000000000011356] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The aim of the study was to observe the risk of hemorrhage from moderate and severe thrombocytopenia in systemic lupus erythematosus (SLE).A retrospective analysis was undertaken of cases admitted to Qilu Hospital, China. Blood platelet counts (BPCs) of ≤20 × 10/L represent severe thrombocytopenia, and a BPC of 21 to 50 × 10/L indicates moderate thrombocytopenia. A comparison was made from the perspective of severity with a view to determine the influence of thrombocytopenia on the risk of hemorrhage and the results.Moderate and severe thrombocytopenia occurred in 173 cases, accounting for 15.2% of the total hospitalized patients with SLE with a male to female ratio of 1:23.7. The average age of those patients was 34.8 ± 14.6 years. In the group of severe thrombocytopenia, patients without visceral involvement had a mean age of onset of 31.4 ± 14.2 years with a median of 28.0 years compared with 37.8 ± 14.8 years with a median of 38.5 years for patients with visceral involvement; this difference was statistically significant (P = .034). Seventy-one (76.3%) of 93 patients with severe thrombocytopenia and 20 (25.0%) of 80 patients with moderate thrombocytopenia developed hemorrhagic conditions of various grades, the difference between both were markedly statistically significant. Twenty-three patients with SLE died. Nine deaths were due to a hemorrhage caused by thrombocytopenia, while more were caused by infection.Severe thrombocytopenia is a significant adverse prognostic factor of SLE. SLE with the main manifestation of thrombocytopenia tends to make younger visceral organ owners suffer.
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Intravenous immunoglobulin vs observation in childhood immune thrombocytopenia: a randomized controlled trial. Blood 2018; 132:883-891. [PMID: 29945954 DOI: 10.1182/blood-2018-02-830844] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 06/13/2018] [Indexed: 01/19/2023] Open
Abstract
Management of children with newly diagnosed immune thrombocytopenia (ITP) consists of careful observation or immunomodulatory treatment. Observational studies suggest a lower risk for chronic ITP in children after intravenous immunoglobulin (IVIg) treatment. In this multicenter randomized trial, children aged 3 months to 16 years with newly diagnosed ITP, platelet counts 20 × 109/L or less, and mild to moderate bleeding were randomly assigned to receive either a single infusion of 0.8 g/kg IVIg or careful observation. Primary outcome was development of chronic ITP, which at the time of study initiation was defined as a platelet count lower than 150 × 109/L after 6 months. Two hundred six children were allocated to receive IVIg (n = 102) or careful observation (n = 104). Chronic ITP occurred in 18.6% of the patients in the IVIg group and 28.9% in the observation group (relative risk [RR], 0.64; 95% confidence interval [CI], 0.38-1.08). Platelet counts lower than 100 × 109/L at 12 months (current definition of chronic ITP) were observed in 10% of children in the IVIg group and 12% in the observation group (RR, 0.83; 95% CI, 0.38-1.84). Complete response rates in the first 3 months were significantly higher in the IVIg group. Immunoglobulin G Fc receptor IIb genetic variations were associated with early complete response in both groups. Grade 4 to 5 bleeding occurred in 9% of the patients in the observation group vs 1% in the IVIg group. This trial was registered at www.trialregister.nl as NTR 1563.
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Schifferli A, Holbro A, Chitlur M, Coslovsky M, Imbach P, Donato H, Elalfy M, Graciela E, Grainger J, Holzhauer S, Riccheri C, Rodeghiero F, Ruggeri M, Tamary H, Uglova T, Wu R, Kühne T. A comparative prospective observational study of children and adults with immune thrombocytopenia: 2-year follow-up. Am J Hematol 2018. [PMID: 29516627 DOI: 10.1002/ajh.25086] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Comparative clinical studies of children and adults with immune thrombocytopenia (ITP) are poorly covered in the literature. However, the accepted classification of ITP-childhood ITP and adult ITP-results in considerable differences in treatment protocols and practice guidelines. The analysis of the Pediatric and Adult Registry on Chronic ITP (PARC-ITP) of patients at first presentation demonstrated fewer differences in clinical and laboratory findings at initial diagnosis between children and adults than expected. The present report of 2-year follow-up data supports the hypothesis that there are common aspects of childhood and adult ITP. Data of 3360 children and 420 adults were collected during the time of 2004 until 2015 at initial diagnosis. Follow-up information was available for 51% and 33% of children and 66% and 49% of adults at 12- and 24-months, respectively. Similarities were found in unexpected areas of ITP, such as the rate of late remission at 12 and 24 months, reported bleeding sites, platelet count in bleeders, and the frequency of treated patients with persistent or chronic ITP. Differences were confirmed for the overall rate of remission and treatment modalities. Unexpected differences were found in the percentage of nonbleeders, with more adults in the nonbleeder group. More studies are needed to investigate different age groups with the aim to optimize their management.
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Affiliation(s)
- Alexandra Schifferli
- Department of Hematology/OncologyUniversity Children's Hospital BaselBasel Switzerland
| | - Andreas Holbro
- Department of HematologyUniversity Hospital BaselBasel Switzerland
| | - Meera Chitlur
- Carmen and Ann Adams Department of Pediatrics, Division of Hematology/OncologyChildren's Hospital of Michigan, Wayne State UniversityDetroit Michigan
| | | | - Paul Imbach
- Chairperson Intercontinental Cooperative ITP Study Group (ICIS)Basel Switzerland
| | - Hugo Donato
- Hematology/Oncology, Hospital del Niño de San Justo, San JustoBuenos Aires Argentina
| | - Mohsen Elalfy
- Pediatric Hematology and OncologyPediatric Hospital Ain Shams UniversityCairo Egypt
| | - Elena Graciela
- Department of Hemalogy‐Oncology Pedro de ElizaldeChildren Hospital Buenos AiresBuenos Aires Argentina
| | - John Grainger
- Department of HaematologyRoyal Manchester Children's HospitalManchester United Kingdom
| | - Susanne Holzhauer
- Department of Pediatric Hematology and OncologyCharité Berlin Germany
| | - Cecilia Riccheri
- Servicio de Pediatria Hospital Alejandro Posadas Buenos AiresBuenos Aires Argentina
| | | | - Marco Ruggeri
- Hematology DepartmentSan Bortolo HospitalVicenza Italy
| | - Hannah Tamary
- Hematology Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Sackler Faculty of MedicineTel Aviv UniversityTel Aviv Israel
| | - Tatjana Uglova
- Department of Clinical ResearchBelarusian Research Center of Pediatric Oncology, Hematology and ImmunologyMinsk Belarus
| | - Runhui Wu
- Hematology Oncology Center, Beijing Children's Hospital CapitalBeijing China
| | - Thomas Kühne
- Department of Hematology/OncologyUniversity Children's Hospital BaselBasel Switzerland
- Chairperson Intercontinental Cooperative ITP Study Group (ICIS)Basel Switzerland
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A characteristic flow cytometric pattern with broad forward scatter and narrowed side scatter helps diagnose immune thrombocytopenia (ITP). Int J Hematol 2018; 108:151-160. [PMID: 29663189 DOI: 10.1007/s12185-018-2454-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/07/2018] [Accepted: 04/08/2018] [Indexed: 01/24/2023]
Abstract
Various disorders cause severe thrombocytopenia, which can lead to critical hemorrhage. Procedures that rapidly support the diagnosis and risk factors for serious bleeding were explored, with a focus on immune thrombocytopenia (ITP). Twenty-five patients with thrombocytopenia, including 13 with newly diagnosed ITP, 3 with chronic ITP, 6 with aplastic anemia (AA), and 3 with other thrombocytopenia (one acute myeloid leukemia, one acute lymphoblastic leukemia, and one hemophagocytic lymphohistiocytosis), were reviewed. In addition to platelet-related parameters obtained by an automated hematology analyzer, flow cytometric analysis of platelets was performed. A characteristic flow cytometric pattern with broad forward scatter and narrowed side scatter, which is specific to ITP, but not other types of thrombocytopenia, was found. CD62P-positive platelets were increased in newly diagnosed ITP cases compared to control (P < 0.0001), AA (P = 0.0032). Moreover, detection of dramatic changes in these parameters on sequential monitoring may suggest internal hemorrhage, even absent skin or visible mucosal bleeding. The bleeding score for visible mucosae had a negative correlation with platelet count and a positive correlation with immature platelet fraction (%), forward scatter, and CD62P. This characteristic flow cytometric pattern makes it possible to distinguish ITP from other thrombocytopenic disorders.
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Bennett CM, Neunert C, Grace RF, Buchanan G, Imbach P, Vesely SK, Kuhne T. Predictors of remission in children with newly diagnosed immune thrombocytopenia: Data from the Intercontinental Cooperative ITP Study Group Registry II participants. Pediatr Blood Cancer 2018; 65. [PMID: 28792679 DOI: 10.1002/pbc.26736] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/12/2017] [Accepted: 07/02/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) during childhood spontaneously remits in up to 80% of children. Predictors of remission are not well understood. PROCEDURE We analyzed data from Intercontinental Cooperative ITP Study Group (ICIS) Registry II, a large prospective cohort of children with ITP, to investigate factors that might predict remission. RESULTS In ICIS Registry II, 705 patients had data collected through 12 months following diagnosis, with 383 patients having data available at 24 months as well. Younger age and pharmacologic treatment at diagnosis were significantly associated with disease resolution at 12 and 24 months (P < 0.0001 for both) as was bleeding at diagnosis (P < 0.0001 and P = 0.0213, respectively). Gender and platelet count at diagnosis were not significantly correlated with remission. In the multivariable analysis, remission at 12 months was associated with younger age, higher bleeding grade at diagnosis, and treatment with a combination of intravenous immunoglobulin (IVIG) and corticosteroids at diagnosis. Only younger age and treatment with IVIG and steroids in combination at diagnosis were associated with remission at 24 months. Patients <1 year of age had the highest odds of achieving remission at both 12 months (OR 4.7, 95% CI: 2.0-10.6) and 24 months (OR 7.0, 95% CI: 2.3-20.8). CONCLUSIONS Younger age, bleeding severity at diagnosis, and initial treatment with a combination of corticosteroids and IVIG are associated with remission at 12 months in the ICIS Registry II. Patients <1 year of age have the highest likelihood of remission. The relationship of bleeding and treatment at diagnosis requires further study to clarify whether these are independent predictors of remission.
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Affiliation(s)
- Carolyn M Bennett
- Department of Pediatrics, Children's Healthcare of Atlanta, Aflac Cancer and Blood Disorder Center, Emory University School of Medicine, Atlanta, Georgia
| | - Cindy Neunert
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Rachael F Grace
- Department of Pediatric Hematology/Oncology, Dana-Farber Boston Children's Cancer and Blood Disorder Center, Boston, Massachusetts
| | - George Buchanan
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Paul Imbach
- Prof. Emeritus of the Medical Faculty, University of Basel, Switzerland
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Thomas Kuhne
- Division of Oncology/Hematology, University Children's Hospital, Basel, Switzerland
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43
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Zhang J, Liang Y, Ai Y, Xie J, Li Y, Zheng W. Thrombopoietin-receptor agonists for children with immune thrombocytopenia: a systematic review. Expert Opin Pharmacother 2017; 18:1543-1551. [PMID: 28845713 DOI: 10.1080/14656566.2017.1373091] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Jiaxing Zhang
- Chinese Evidence-based Medicine Center, Sichuan University, Chengdu, China
- Department of Pharmacy, Guizhou Provincial People’s Hospital, Guiyang, China
| | - Yi Liang
- Health Outcomes and Pharmacy Practice, College of Pharmacy, The University of Texas at Austin, TX, USA
| | - Yuan Ai
- Department of Pediatric Hematology and Oncology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Juan Xie
- Department of Pharmacy, Guizhou Provincial People’s Hospital, Guiyang, China
| | - Youping Li
- Chinese Evidence-based Medicine Center, Sichuan University, Chengdu, China
| | - Wenyi Zheng
- Department of Laboratory Medicine, Karolinska Institute, Experimental Cancer Medicine, Clinical Research Center, Stockholm, Sweden
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44
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Grimaldi-Bensouda L, Nordon C, Leblanc T, Abenhaim L, Allali S, Armari-Alla C, Berger C, Courcoux MF, Fouyssac F, Guillaumat C, Guitton C, Le Moine P, Mazingue F, Pondarré C, Thomas C, Pasquet M, Perel Y, Leverger G, Aladjidi N. Childhood immune thrombocytopenia: A nationwide cohort study on condition management and outcomes. Pediatr Blood Cancer 2017; 64. [PMID: 27905681 DOI: 10.1002/pbc.26389] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 10/29/2016] [Accepted: 11/08/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Nationwide prospective cohort study exploring (i) the factors associated with treatment initiation (vs. watchful waiting) in children with primary immune thrombocytopenia (ITP) followed in routine clinical practice and (ii) the predictors of chronicity at 12 months. PROCEDURE Between 2008 and 2013, 23 centers throughout France consecutively included 257 children aged 6 months-18 years and diagnosed with primary ITP over a 5-year period. Data on ITP clinical features along with medical management were collected at baseline and 12 months. Multivariate logistic regressions were used to determine (i) and (ii) as defined above, providing odds ratio (OR) with 95% confidence interval (95% CI). RESULTS One hundred thirty-seven (53%) children were males, median age was 4.6 years, median platelet count was 7 × 109/l, and 214 (81%) patients initiated medication. Factors independently associated with treatment initiation included platelet counts <10 × 109/l (P < 0.0001) and mucocutaneous bleeding symptoms at baseline (P < 0.001). At 12 months, data were available for 211 (82%) children, of whom 160 (74%) had recovered. Predictors of chronicity included female gender (OR = 2.2; 95% CI = 1.0-4.8), age ≥10 years (OR = 2.6; 95% CI = 1.1-6.0), and platelet counts ≥10 × 109 /l (OR = 3.2; 95% CI = 1.5-6.9). CONCLUSIONS In routine clinical practice, the decision to apply a watchful waiting strategy seems to be driven by platelet counts even in the absence of bleeding symptoms, resulting in treatment being initiated in more than 80% of the children surveyed. Overall, younger children with ITP showed good prognosis, with lower platelet counts and, to a lesser extent, male gender predicting more favorable outcomes.
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Affiliation(s)
| | | | - Thierry Leblanc
- Department of Pediatric Hematology, Robert-Debré Hospital, AP-HP, Paris, France.,French Reference Center for Rare Diseases and Autoimmune Cytopenias of Childhood (CEREVANCE), Pellegrin Hospital, Bordeaux, France
| | | | - Slimane Allali
- Department of General Pediatrics, Necker Hospital, AP-HP and Paris Descartes University, Paris, France
| | - Corinne Armari-Alla
- Department of Pediatric Hematology, Grenoble University Hospital, Grenoble, France
| | - Claire Berger
- Department of Pediatric Hematology, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Mary-France Courcoux
- Department of Immunology and Hematology, Armand-Trousseau Hospital, Paris, France
| | - Fanny Fouyssac
- Department of Pediatric Hematology, Nancy University Hospital, Vandoeuvre-les-Nancy, France
| | - Cécile Guillaumat
- Department of General Pediatrics, Sud-Francilien Hospital, Corbeil-Essonnes, France
| | - Corinne Guitton
- Department of Pediatric Rheumatology and Hematology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Philippe Le Moine
- Department of Pediatrics and Clinical Genetics, Morvan University Hospital, Brest, France
| | - Françoise Mazingue
- Department of Pediatric Hematology, Lille University Hospital, Lille, France
| | - Corinne Pondarré
- Department of Pediatrics, Intercommunal Hospital, Creteil, France
| | - Caroline Thomas
- Pediatric Intensive Care and Onco-Hematology Units, Nantes University Hospital, Nantes, France
| | - Marlène Pasquet
- Department of Pediatric Hematology and Immunology, Purpan University Hospital and INSERM U1037, Toulouse, France
| | - Yves Perel
- French Reference Center for Rare Diseases and Autoimmune Cytopenias of Childhood (CEREVANCE), Pellegrin Hospital, Bordeaux, France.,Department of Pediatric Hematology, CIC 1401, INSERM CICP, Pellegrin Hospital, Bordeaux, France
| | - Guy Leverger
- French Reference Center for Rare Diseases and Autoimmune Cytopenias of Childhood (CEREVANCE), Pellegrin Hospital, Bordeaux, France.,Department of Immunology and Hematology, Armand-Trousseau Hospital, Paris, France
| | - Nathalie Aladjidi
- French Reference Center for Rare Diseases and Autoimmune Cytopenias of Childhood (CEREVANCE), Pellegrin Hospital, Bordeaux, France.,Department of Pediatric Hematology, CIC 1401, INSERM CICP, Pellegrin Hospital, Bordeaux, France
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Buchbinder D, Nugent D, Hsieh L. Spotlight on romiplostim in the treatment of children with chronic immune thrombocytopenia: design, development, and potential place in therapy. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:1055-1063. [PMID: 28408804 PMCID: PMC5384698 DOI: 10.2147/dddt.s113191] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia. In approximately one-third of cases, the duration of thrombocytopenia will extend beyond 12 months consistent with a diagnosis of chronic ITP. Minor bleeding manifestations are common in chronic ITP while severe or life-threatening bleeding complications are uncommon. Moreover, spontaneous resolution occurs in the majority of children with chronic ITP necessitating treatment in only those children with ongoing bleeding manifestations or impairment in health-related quality of life (HRQOL). The characterization of thrombopoietin (TPO) and remarkable advancements in our understanding of the pathophysiology of ITP has led to the development of a new class of agents, the TPO-receptor agonists that have documented efficacy in the amelioration of thrombocytopenia and bleeding manifestations in chronic ITP. Romiplostim is a second-generation TPO-receptor agonist that has undergone limited evaluation in the treatment of chronic ITP in children. Evolving data suggest that romiplostim may be a safe and effective agent in the treatment of chronic ITP in children. Additional data are needed to confirm its ability to increase platelet counts, decrease bleeding manifestation, and improve the HRQOL of children and caregivers impacted by chronic ITP.
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Affiliation(s)
- David Buchbinder
- Division of Hematology, CHOC Children's Hospital and UC Irvine Medical Center, CA, USA
| | - Diane Nugent
- Division of Hematology, CHOC Children's Hospital and UC Irvine Medical Center, CA, USA
| | - Loan Hsieh
- Division of Hematology, CHOC Children's Hospital and UC Irvine Medical Center, CA, USA
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Kühne T. Diagnosis and management of immune thrombocytopenia in childhood. Hamostaseologie 2016; 37:36-44. [PMID: 27699328 DOI: 10.5482/hamo-16-06-0017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 09/20/2016] [Indexed: 01/19/2023] Open
Abstract
Evidence-based medicine is growing in immune thrombocytopenia (ITP), but solid clinical data are still lacking in many areas. A majority of children has self-limited ITP, but chronic symptomatic ITP exists also in pediatrics. Management includes a watch-and-wait strategy for children with newly diagnosed ITP and no or mild bleeding, and immunoglobulins and corticosteroids, if more bleeding and mucous membrane involvement is present. Treatment endpoints differ in clinical research and in clinical practice. The requirement of platelet enhancing drugs needs to be better defined in guidelines. Second-line therapies for children are rarely required and include thrombopoietin-receptor agonists, rituximab, dexamethasone and immunosuppressants. Thrombopoietin-receptor agonists are successful in adult but also in pediatric ITP. The strategical position of splenectomy differs from that in adults. Although effective in children it is less frequently used because of its life-long cumulative risk of infectious diseases and a higher potential of spontaneous remission in ITP, providing a strong argument to defer splenectomy. The rarity of ITP makes clinical research expensive.
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Affiliation(s)
- Thomas Kühne
- Thomas Kühne, MD, Division of Oncology / Hematology, University Children's Hospital, Spitalstrasse 33, 4031 Basel, Switzerland, Phone: +41-61-704-1212, Fax: +41-61-704-1213, E-Mail:
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Abstract
OBJECTIVES Classically, immune thrombocytopenia (ITP) was thought to be caused by the destruction and insufficient production of platelets, as mediated by autoantibodies. More recently other immune mechanisms that contribute to the disease have been discovered. This review attempts to address the main unresolved questions in ITP. METHODS We review the most current knowledge of the pathophysiology of ITP. Immunological effects of available therapies are also described. DISCUSSION The trigger may be a loss of tolerance due to molecular mimicry with cross-reaction of antibodies arising from infectious agents or drugs, genetic factors, and/or platelet Toll receptors. This loss of tolerance activates autoreactive effector B and T lymphocytes, which in turn initiates platelet destruction, mediated by cytotoxic T lymphocytes and the release of pro-inflammatory cytokines (IL-2/IL-17) by T helper (Th) cells (Th1/Th17). Th2 (anti-inflammatory) and regulatory B (Breg) and Treg cells are also inhibited (with decrease in IL-10/TGF-β), which leads to the disease becoming chronic. Some isotypes of autoantibodies may increase the bleeding risk. Corticosteroids, rituximab, and thrombopoietin receptor agonists (A-TPOs) all increase levels of Tregs and TGF-β. The A-TPOs also increase Breg levels, which could explain why complete remission has been seen in some cases. CONCLUSION A better understanding of the immunomodulatory effects of each ITP therapy is needed to best manage the disease.
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Affiliation(s)
- María Perera
- a Haematology Service , University Hospital Doctor Negrín , Las Palmas de Gran Canaria, Spain
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48
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How I treat refractory immune thrombocytopenia. Blood 2016; 128:1547-54. [DOI: 10.1182/blood-2016-03-603365] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/04/2016] [Indexed: 01/19/2023] Open
Abstract
Abstract
This article summarizes our approach to the management of children and adults with primary immune thrombocytopenia (ITP) who do not respond to, cannot tolerate, or are unwilling to undergo splenectomy. We begin with a critical reassessment of the diagnosis and a deliberate attempt to exclude nonautoimmune causes of thrombocytopenia and secondary ITP. For patients in whom the diagnosis is affirmed, we consider observation without treatment. Observation is appropriate for most asymptomatic patients with a platelet count of 20 to 30 × 109/L or higher. We use a tiered approach to treat patients who require therapy to increase the platelet count. Tier 1 options (rituximab, thrombopoietin receptor agonists, low-dose corticosteroids) have a relatively favorable therapeutic index. We exhaust all Tier 1 options before proceeding to Tier 2, which comprises a host of immunosuppressive agents with relatively lower response rates and/or greater toxicity. We often prescribe Tier 2 drugs not alone but in combination with a Tier 1 or a second Tier 2 drug with a different mechanism of action. We reserve Tier 3 strategies, which are of uncertain benefit and/or high toxicity with little supporting evidence, for the rare patient with serious bleeding who does not respond to Tier 1 and Tier 2 therapies.
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Tarantino MD, Bussel JB, Blanchette VS, Despotovic J, Bennett C, Raj A, Williams B, Beam D, Morales J, Rose MJ, Carpenter N, Nie K, Eisen M. Romiplostim in children with immune thrombocytopenia: a phase 3, randomised, double-blind, placebo-controlled study. Lancet 2016; 388:45-54. [PMID: 27103127 DOI: 10.1016/s0140-6736(16)00279-8] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The thrombopoietin receptor agonist romiplostim could be an effective treatment in symptomatic children with persistent or chronic immune thrombocytopenia. We aimed to assess whether romiplostim is safe and effective in children with immune thrombocytopenia of more than 6 months' duration. METHODS In this phase 3 double-blind study, eligible participants were children with immune thrombocytopenia aged 1 year to 17 years and mean platelet counts 30 × 10(9)/L or less (mean of two measurements during the screening period) with no single count greater than 35 × 10(9)/L, and were recruited from 27 sites in the USA, Canada, and Australia. Participants were randomly assigned (2:1) through the interactive voice response system to receive weekly romiplostim or placebo for 24 weeks stratified by age (1 year to <6 years, 6 years to <12 years, 12 years to <18 years), adjusting the dose weekly from 1 μg/kg to 10 μg/kg to target platelet counts of 50-200 × 10(9)/L. Patients and investigators were blinded to the treatment assignment. The primary analysis included all randomised patients and the safety analysis included all randomised patients who received at least one dose of investigational product. The primary endpoint, durable platelet response, was defined as achievement of weekly platelet responses (platelet counts ≥50 × 10(9)/L without rescue drug use in the preceding 4 weeks) in 6 or more of the final 8 weeks (weeks 18-25). This study is registered with ClinicalTrials.gov, NCT 01444417. FINDINGS Between Jan 24, 2012, and Sept 3, 2014, 62 patients were randomly assigned; 42 to romiplostim and 20 to placebo. Durable platelet response was seen in 22 (52%) patients in the romiplostim group and two (10%) in the placebo group (p=0·002, odds ratio 9·1 [95% CI 1·9-43·2]). Durable platelet response rates with romiplostim by age were 38% (3/8) for 1 year to younger than 6 years, 56% (10/18) for 6 years to younger than 12 years, and 56% (9/16) for 12 years to younger than 18 years. One (5%) of 19 patients in the placebo group had serious adverse events compared with 10 (24%) of 42 patients in the romiplostim group. Of these serious adverse events, headache and thrombocytosis, in one (2%) of 42 patients in the romiplostim group, were considered treatment related. No patients withdrew due to adverse events. INTERPRETATION In children with chronic immune thrombocytopenia, romiplostim induced a high rate of platelet response with no new safety signals. Ongoing romiplostim studies will provide further information as to long-term efficacy, safety, and remission in children with immune thrombocytopenia. FUNDING Amgen Inc.
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Affiliation(s)
- Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, University of Illinois College of Medicine-Peoria, IL, USA.
| | - James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | | | | | - Carolyn Bennett
- Emory University School of Medicine, Children's Healthcare of Atlanta and the Aflac Cancer and Blood Disorder Service, Atlanta, GA, USA
| | - Ashok Raj
- Pediatric Blood and Cancer Disorders Clinic, Louisville, KY, USA
| | - Bronwyn Williams
- Lady Cilento Children's Hospital, South Brisbane, QLD, Australia
| | - Donald Beam
- Cook Children's Medical Center, Texas, TX, USA
| | - Jaime Morales
- Children's Hospital New Orleans and Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Melissa J Rose
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Kun Nie
- Amgen Inc, Thousand Oaks, CA, USA
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Allen JD. When and how to treat childhood immune thrombocytopenia. Nurse Pract 2016; 41:18-25. [PMID: 27258844 DOI: 10.1097/01.npr.0000484317.83554.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Childhood immune thrombocytopenia is an autoimmune process resulting in an isolated thrombocytopenia that puts the child at risk for bleeding and can negatively impact quality of life. Pharmacologic intervention aims to stabilize the platelet count, with the goal of achieving hemostasis and maximizing health-related quality of life.
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Affiliation(s)
- Jennifer D Allen
- Jennifer D. Allen s a pediatric nurse practitioner at Memorial Sloan Kettering Cancer Center, New York, N.Y
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