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Dubois S, Layese R, Limal N, Languille L, Kini-Matondo W, Mahevas M, Michel M, Audureau E, Godeau B. When is the use of intravenous immunoglobulin appropriate in immune thrombocytopaenia? Br J Haematol 2024. [PMID: 39389921 DOI: 10.1111/bjh.19817] [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: 07/13/2024] [Accepted: 09/25/2024] [Indexed: 10/12/2024]
Abstract
Intravenous immunoglobulin (IVIg) is the gold standard treatment for severe cases of immune thrombocytopaenia (ITP). However, its cost, limited duration of efficacy and market supply tension have led French guidelines to reserve IVIg for ITP patients with formal contra-indications to corticosteroids, with French bleeding score ('Khellaf score') > 8, and corticosteroid-resistant patients either with Khellaf score ≤ 8 or in preparation for an invasive procedure or during pregnancy. We studied the prescribing practices of IVIg for ITP in real-life conditions and assessed their compliance with French guidelines. A monocentric retrospective study was conducted between 2016 and 2020 among 114 patients hospitalized in our unit, for a total of 208 IVIg treatments. In 37% of cases, the Khellaf score was >8, validating IVIg prescription according to French guidelines. In the remaining cases, reasons noted for use of IVIg included corticosteroid resistance (33.7%), preparation for an invasive procedure (8.5%), context of pregnancy (6.6%) and contra-indication to corticosteroids (3.3%). After analysis, IVIg prescription was considered valid according to current French guidelines in 84.4% of cases. Non-compliant IVIg prescription was more frequent in younger patients (p = 0.027). Concomitant anti-coagulation was also noted as an argument for IVIg prescription outside of the current French guidelines.
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Affiliation(s)
- Sydney Dubois
- Internal Medicine Department, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
- Department of Hematology, Centre Henri Becquerel, Rouen, France
| | - Richard Layese
- Université Paris-Est Créteil, INSERM, IMRB, Creteil, France
- Public Health Department & Clinical Research Unit, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Creteil, France
| | - Nicolas Limal
- Internal Medicine Department, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
| | - Laetitia Languille
- Internal Medicine Department, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
| | - Willy Kini-Matondo
- Pharmacy Department, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France
| | - Matthieu Mahevas
- Internal Medicine Department, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Internal Medicine Department, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
| | - Etienne Audureau
- Public Health Department & Clinical Research Unit, Hôpital Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Creteil, France
- Clinical Epidemiology and Ageing (CEpiA) Unit EA7376, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Bertrand Godeau
- Internal Medicine Department, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Est Créteil (UPEC), Créteil, France
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Ma J, Zhang X, Zhao L, Wu X, Yao Y, Liu W, Wang X, Ju X, Shi X, Sun L, Zheng L, Liu S, Qian J, Wu R. Efficacy and safety of recombinant human thrombopoietin for the treatment of chronic primary immune thrombocytopenia in children and adolescents: A multicentre, randomized, double-blind, placebo-controlled phase III trial. Br J Haematol 2024. [PMID: 39267281 DOI: 10.1111/bjh.19761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 08/28/2024] [Indexed: 09/17/2024]
Abstract
The efficacy and safety of recombinant human thrombopoietin (rhTPO) in children and adolescent patients with chronic primary immune thrombocytopenia (ITP) remains unclear. A multicentre, randomized, double-blind, placebo-controlled phase III trial was performed. Patients aged 6-17 years, diagnosed with ITP and resistant or relapsed to corticosteroid treatment were included. For the trial, part 1 was exploratory and part 2 was the main analysis, with part 1 determining whether part 2 was stratified by age. Patients in part 1 were treated with rhTPO (the 6- to 11-/12- to 17-year-old groups; 1:1). Patients in part 2 were randomized (3:1) to receive either rhTPO treatment or placebo. Patients received rhTPO or placebo at a dose of 300 U/kg once daily for up to 14 days. A total of 68 patients were included [part 1 (12 patients), part 2 (56 patients)]. The total response rate (TRR) in part 1 was 50.0% (95% CI: 21.09%-78.91%). For part 2, the TRR was 58.5% (95% CI: 42.11%-73.68%) and 13.3% (95% CI: 1.66%-40.46%) in the rhTPO and placebo groups (FAS) respectively. The difference in TRR between the rhTPO group and placebo group was 45.2% (95% CI: 22.33%-68.08%) and 44.6% (95% CI: 21.27%-67.85%) on the FAS and per-protocol set (PPS), respectively, which indicates the superiority of rhTPO treatment.
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Affiliation(s)
- Jingyao Ma
- Department of Hematology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoli Zhang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Libo Zhao
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Wu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanhua Yao
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, China
| | - Wei Liu
- Department of Hematology Oncology, Children's Hospital Affiliated of Zhengzhou University, Zhengzhou, China
| | - Xiaohuan Wang
- Department of Hematology, Children's Hospital of Shanxi, Taiyuan, China
| | - Xiuli Ju
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Xiaodong Shi
- Department of Hematology, Capital Institute of Pediatrics, Beijing, China
| | - Lirong Sun
- Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lili Zheng
- Shenyang Sunshine Pharmaceuticals CO. Ltd., Shenyang, China
| | - Shu Liu
- Shenyang Sunshine Pharmaceuticals CO. Ltd., Shenyang, China
| | - Jun Qian
- Shenyang Sunshine Pharmaceuticals CO. Ltd., Shenyang, China
| | - Runhui Wu
- Department of Hematology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
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González-López TJ, Bermejo-Vega N, Cardesa-Cabrera R, Martínez-Robles V, Aguilar-Monserrate G, Pérez-Segura G, Domingo A, Luis-Navarro J, Lakhwani S, Acedo N, Lozano ML, Bernat S, Torres-Tienza A, Ruano A, Jarque I, Galán P, Benet C, Marcellini S, Jimenez-Bárcenas R, Martínez-Carballeira D, De Miguel-Llorente D, Perona-Blázquez A, Gonzalez-Gascón I, Lopez-Ansoar E, Alonso-Alonso JM, Bengochea-Casado ML, Díaz-Gálvez FJ, Moretó A, Moreno-Jiménez G, Hernández-Martin R, de Cabo E, Dávila-Valls J, Cuesta A, Pastoriza C, Hermida-Fernández GJ, García C, Pozas-Mañas MA, Aguilar C, Fernandez-Jimenez D, Navas-Elorza B, López-Santamaría Castro C, Lorenzo A, Ortín X, García M, Piernas S, Díaz-Santa J, Soto I, Provan D, García-Donas Gabaldón G. Fostamatinib effectiveness and safety for immune thrombocytopenia in clinical practice. Blood 2024; 144:646-656. [PMID: 38843478 DOI: 10.1182/blood.2024024250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/12/2024] Open
Abstract
ABSTRACT Fostamatinib, a recently approved Syk inhibitor used in adult primary immune thrombocytopenia (ITP), has been shown to be safe and effective in this disorder. However, clinical trial results may not be similarly reproduced in clinical practice. Here, 138 patients with ITP (both primary and secondary) from 42 Spanish centers who had been treated with fostamatinib were evaluated prospectively and retrospectively. The median age of our cohort (55.8% women) was 66 years (interquartile range [IQR], 56-80). The median time since ITP diagnosis at fostamatinib initiation was 51 months (IQR, 10-166). The median number of therapies before fostamatinib initiation was 4 (IQR, 2-5), including eltrombopag (76.1%), romiplostim (57.2%), and IV immunoglobulins (44.2%). Fifty-eight patients (42.0%) had signs/symptoms of bleeding in the month before treatment initiation. Seventy-nine percent of patients responded to fostamatinib with 53.6% complete responses (platelet count > 100 × 109/L). Eighty-three patients (60.1%) received fostamatinib monotherapy, achieving a high response rate (85.4%). The proportion of time in response during the 27-month period examined was 83.3%. The median time to platelet response was 11 days (IQR, 7-21). Sixty-seven patients (48.5%) experienced adverse events, mainly grade 1 to 2; the commonest of which were diarrhea (n = 28) and hypertension (n = 21). One patient had deep venous thrombosis, and one patient developed acute myocardial infarction. Fostamatinib was shown to be effective with good safety profile in patients with primary and secondary ITP across a wide age spectrum in this real-world study.
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Affiliation(s)
| | - Nuria Bermejo-Vega
- Department of Hematology, Complejo Hospitalario Universitario de Cáceres, Cáceres, Spain
| | | | | | | | - Gloria Pérez-Segura
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Abel Domingo
- Department of Hematology, Fundació Privada Hospital Asil de Granollers, Barcelona, Spain
| | - Josefa Luis-Navarro
- Department of Hematology Hospital General de Riotinto, Minas de Riotinto, Huelva, Spain
| | - Sunil Lakhwani
- Department of Hematology, Hospital Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Natalia Acedo
- Department of Hematology, Hospital Universitario de La Princesa, Madrid, Spain
| | - María Luisa Lozano
- Department of Hematology, Hospital General Universitario José María Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Pascual Parrilla, Centro de Investigación Biomédica en Red de Enfermedades Raras- Instituto de Salud Carlos III, Murcia, Spain
| | - Silvia Bernat
- Department of Hematology, Hospital Universitario de La Plana, Villareal, Spain
| | - Ana Torres-Tienza
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | - Ana Ruano
- Department of Hematology, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Isidro Jarque
- Department of Hematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pilar Galán
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | - Carmen Benet
- Department of Hematology, Hospital Arnau de Vilanova, Valencia, Spain
| | - Shally Marcellini
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | | | | | | | - Alvaro Perona-Blázquez
- Department of Hematology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Elsa Lopez-Ansoar
- Department of Hematology, Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | | | | | | | - Ana Moretó
- Department of Hematology, Hospital Universitario de Cruces, Barakaldo, Spain
| | | | | | - Erik de Cabo
- Department of Hematology, Complejo Hospital de El Bierzo, Ponferrada, Spain
| | | | - Amalia Cuesta
- Department of Hematology, Hospital Sierrallana, Cantabria, Spain
| | - Carmen Pastoriza
- Department of Hematology, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | | | - Covadonga García
- Department of Hematology, Hospital Universitario de Burgos, Burgos, Spain
| | | | - Carlos Aguilar
- Department of Hematology, Complejo Asistencial de Soria, Soria, Spain
| | | | | | | | - Alvaro Lorenzo
- Department of Hematology, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - Xavier Ortín
- Department of Hematology, Hospital Verge de la Cinta, Tortosa, Spain
| | - Marta García
- Department of Hematology, Hospital de Terrassa, Barcelona, Spain
| | - Sonia Piernas
- Department of Hematology, Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Johana Díaz-Santa
- Department of Hematology, Hospital Universitari Doctor Josep Trueta, Girona, Spain
| | - Inmaculada Soto
- Department of Hematology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Drew Provan
- Department of Haematology, Barts and The London School of Medicine, London, United Kingdom
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Zhu Y, Wang Y, Zhao Y, Liu D, Wang X, Zhu L, Tong J, Zhao N, Zheng C. Thrombopoietin receptor agonists regulate myeloid-derived suppressor cell-mediated immunomodulatory effects in ITP. Ann Hematol 2024; 103:2729-2741. [PMID: 38890176 DOI: 10.1007/s00277-024-05846-1] [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: 03/04/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
TPO receptor agonists (TPO-RAs) are a class of clinical second-line regimens for the treatment of primary immune thrombocytopenia (ITP). It can promote megakaryocyte maturation and increase platelet production, but its effect on immunosuppressive cells in patients with ITP has not been explored. Sixty-two ITP patients and 34 healthy controls (HCs) were included in this study. The proportion and functions of myeloid-derived immunosuppressive cells (MDSCs) in ITP patients and HCs were investigated. We found that the proportion and function of MDSCs in ITP patients treated with TPO-RAs were significantly higher than those treated with glucocorticoids (GCs), which was correlated with the clinical efficacy. The proportion and function of cytotoxic Th1 cells and CD8+T cells decreased, while the proportion and immunosuppressive function of Treg cells increased in ITP patients treated with TPO-RAs. We further proved, through MDSC depletion tests, that the inhibitory effect of MDSCs on Th1 cells and the promotion of Treg cells in the original immune micro-environment of GCs-treated ITP patients were impaired; however, these MDSCs' functions were improved in TPO-RAs-treated patients. Finally, we found that the KLF9 gene in MDSCs cells of ITP patients treated with TPO-RAs was down-regulated, which contribute to the higher mRNA expression of GADD34 gene and improved function of MDSCs. These results demonstrate a novel mechanism of TPO-RAs for the treatment of ITP through the assessment of MDSCs and their subsequent impact on T cells, which provides a new basis for TPO-RAs as first-line treatment approach to the treatment of ITP.
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Affiliation(s)
- Yingqiao Zhu
- Department of Hematology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Lujiang Road No 17, Hefei, 230001, China
| | - Yan Wang
- Department of Hematology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Lujiang Road No 17, Hefei, 230001, China
| | - Yue Zhao
- Department of Hematology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Lujiang Road No 17, Hefei, 230001, China
| | - Dan Liu
- Department of Hematology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Lujiang Road No 17, Hefei, 230001, China
| | - Xiaoyu Wang
- Department of Hematology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Lujiang Road No 17, Hefei, 230001, China
| | - Lijun Zhu
- Department of Hematology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Lujiang Road No 17, Hefei, 230001, China
| | - Juan Tong
- Department of Hematology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Lujiang Road No 17, Hefei, 230001, China
| | - Na Zhao
- Department of Hematology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Lujiang Road No 17, Hefei, 230001, China
| | - Changcheng Zheng
- Department of Hematology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Lujiang Road No 17, Hefei, 230001, China.
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Tamr A, Kabbani D, Weinberger JJ. Rifabutin-Induced Thrombocytopenia in a Patient With Uncontrolled HIV: A Case Report. Cureus 2024; 16:e66339. [PMID: 39247045 PMCID: PMC11377851 DOI: 10.7759/cureus.66339] [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] [Accepted: 08/06/2024] [Indexed: 09/10/2024] Open
Abstract
Uncontrolled HIV is associated with a wide range of hematologic abnormalities through direct suppressive effects, opportunistic infections, tumor marrow infiltration, or antiretroviral, antimicrobial, or antitumor therapy. We present a patient with a history of uncontrolled HIV presenting with acute severe thrombocytopenia shortly after starting treatment for disseminated Mycobacterium avium complex (MAC). While the thrombocytopenia was resistant to transfusion and intravenous immunoglobulin (IVIG), it mildly improved with dexamethasone after holding home medications. Etiologies for this patient's thrombocytopenia include uncontrolled HIV infection and medication-induced, likely secondary to rifabutin. We propose a possible combined effect of both factors. Clinicians should be aware of the increased risk of severe, acute medication-induced thrombocytopenia in patients with uncontrolled HIV, given their baseline susceptibility to hematologic abnormalities.
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Affiliation(s)
- Amer Tamr
- Internal Medicine, Henry Ford Health System, Detroit, USA
| | - Dana Kabbani
- Internal Medicine, Wayne State University School of Medicine/Detroit Medical Center, Detroit, USA
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Zhu H, Ruan X, Zhao K, Kuang W, Liu S, Yan W, Fu X, Cheng Z, Li R, Peng H. The miR-641-STIM1 and SATB1 axes play important roles in the regulation of the Th17/Treg balance in ITP. Sci Rep 2024; 14:11243. [PMID: 38755179 PMCID: PMC11098809 DOI: 10.1038/s41598-024-61660-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 05/08/2024] [Indexed: 05/18/2024] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease caused by T-cell dysfunction. Recently, several studies have shown that a disturbed Th17/Treg balance contributes to the development of ITP. MicroRNAs (miRNAs) are small noncoding RNA moleculesthat posttranscriptionally regulate gene expression. Emerging evidences have demonstrated that miRNAs play an important role in regulating the Th17/Treg balance. In the present study, we found that miR-641 was upregulated in ITP patients. In primary T cells, overexpression of miR-641 could cause downregulation of its target genes STIM1 and SATB1, thus inducing a Th17 (upregulated)/Treg (downregulated) imbalance. Inhibition of miR-641 by a miR-641 sponge in primary T cells of ITP patients or by antagomiR-641 in an ITP murine model could cause upregulation of STIM1 and SATB1, thus restoring Th17/Treg homeostasis. These results suggested that the miR-641-STIM/SATB1 axis plays an important role in regulating the Th17/Treg balance in ITP.
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Affiliation(s)
- Hongkai Zhu
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
| | - Xueqin Ruan
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
- Department of Hematology, The People's Hospital of Guangxi Zhuang Autonomous Region, Guangxi Academy of Medical Sciences, P.R. China, Nanning, China
| | - Kexin Zhao
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
| | - Wenyong Kuang
- Department of Hematology, The Affiliated Children's Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Sufang Liu
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
| | - Wenzhe Yan
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
| | - Xianming Fu
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhao Cheng
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China.
| | - Ruijuan Li
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China.
| | - Hongling Peng
- Department of Hematology, The Second Xiangya Hospital, Central South University, No. 139# Renmin Road, Changsha, 410011, Hunan, China
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7
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Frederiksen H. Toxicity due to steroid treatment in ITP remains a concern. Br J Haematol 2024; 204:1600-1601. [PMID: 38553954 DOI: 10.1111/bjh.19426] [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: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 05/15/2024]
Abstract
Corticosteroids are the preferred first-line treatment in ITP in guidelines. The analyses by Wang et al. shows that hospital-registered steroid-related toxicity occurs frequently and emphasizes that exposure should be for a limited duration of time. Commentary on: Wang et al. Longitudinal evaluation of adverse events due to steroid use in primary immune thrombocytopenia: a population-based study. Br J Haematol 2024;204:1986-1993.
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Affiliation(s)
- Henrik Frederiksen
- Department of Haematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Shah S, Yadav R, Bhattarai A, Dahal K, Tharu S, Gautam S, Rawal L, Thapa S, Sah SK, Sharma S, Gundabolu K. Safety and efficacy of danazol in immune thrombocytopenia: a systematic review. Res Pract Thromb Haemost 2024; 8:102444. [PMID: 38988949 PMCID: PMC11234045 DOI: 10.1016/j.rpth.2024.102444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/13/2024] [Indexed: 07/12/2024] Open
Abstract
Background The treatment landscape for relapsed or refractory immune thrombocytopenia (ITP) after corticosteroids is complex. Objectives We aimed to assess the efficacy of danazol in treating ITP and evaluate the safety and adverse events following its administration. Methods We searched the databases PubMed, EMBASE, and ClinicalTrials.gov for all published studies assessing danazol's efficacy and safety in treating ITP. The retrieved studies were screened by title and abstract, followed by full-text screening based on the eligibility requirements. The quality assessment was performed using a set of questionnaires. The data were extracted on the descriptive characteristics of the studies and participants, drug dosage, efficacy measures, and adverse effects, and the data were synthesized. Results A total of 17 studies consisting of 901 participants were included. The overall response rate is around 61% in this analysis. Among the participants, 315 (34.9%) were men. The age of participants ranged from 16 to 86 years. Danazol combined with other pharmacologic interventions, including all-trans-retinoic acid or glucocorticoids, generated better results. The most common side effects appear to be liver injury and elevation of liver enzymes, weight gain, oligomenorrhea, amenorrhea, and myalgia. Conclusion Danazol at low-to-medium doses was well tolerated and succeeded in improving ITP. Danazol therapy may be helpful in the treatment of chronic ITP that is corticosteroid refractory and when corticosteroids or splenectomy (or both) is contraindicated. Danazol can be considered for further research and development in treating primary immune thrombocytopenia.
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Affiliation(s)
- Sangam Shah
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Rukesh Yadav
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | | | - Krishna Dahal
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Sunraj Tharu
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Sandesh Gautam
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Laba Rawal
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Sangharsha Thapa
- Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | | | - Sumit Sharma
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Krishna Gundabolu
- Fred and Pamela Buffett Cancer Center, Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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9
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Witkowski M, Ryżewska W, Robak T. Thrombopoietin receptor agonist and rituximab combination therapy in patients with refractory primary immune thrombocytopenia. Blood Coagul Fibrinolysis 2024; 35:108-114. [PMID: 38358901 DOI: 10.1097/mbc.0000000000001283] [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: 02/17/2024]
Abstract
The aim of our study was to evaluate the efficacy of this therapy in patients with refractory primary immune thrombocytopenia. It is crucial to develop alternative treatment methods for this patient group in order to achieve better response. This combination therapy combines two different mechanisms of action, which is promising in terms of targeting pathophysiology of immune thrombocytopenia. We conducted a retrospective study, which included all patients who were diagnosed with refractory primary immune thrombocytopenia and received TPO-RA and rituximab at the General Hematology Department, Copernicus Memorial Hospital in Lodz, Poland. We assessed the response, time to response and treatment-free remission (TFR). After 1 month of treatment, the complete response (CR1, PLT >100 g/l) was achieved in 62.5% patients, and response (R1, PLT >30 g/l) was achieved in 62.5% patients. The median PLT was 175 × 10 9 /l. Within 1 month of treatment, 87.5% of patients achieved TFR. Adequately, after 6 months, CR6 and R6 was 62.5 and 75%. The median PLT was 182 × 10 9 /l. Treatment-free remission 6 months after completion was in 50% of patients. The study group achieved response to treatment, which suggests that combination of TPO-RA and rituximab is effective and relatively well tolerated. Prospective study on larger group of patients is needed to better evaluate the efficiency and safety of this treatment.
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Affiliation(s)
- Michał Witkowski
- Department of General Haematology, Copernicus Memorial Hospital, Lodz
| | - Wiktoria Ryżewska
- Jozef Stus Memorial Multispecialty Municipal Hospital, Poznan
- Students' Scientific Circle at the Haematology Clinic
| | - Tadeusz Robak
- Haematology Clinic, Medical University in Lodz, Lodz, Poland
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10
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Mazzucconi MG, Rodeghiero F, Avvisati G, De Stefano V, Gugliotta L, Ruggeri M, Vianelli N, Fazi P, Paoloni F, Sargentini V, Baldacci E, Ferretti A, Martino B, Vincelli ID, Carli G, Fortuna S, Di Ianni M, Ranalli P, Palandri F, Polverelli N, Lugli E, Rivolti E, Patriarca A, Rago A, D'Adda M, Gentile M, Siragusa S, Sibilla S, Carella AM, Rossi E, Battistini R, Zaja F, Bocchia M, Di Renzo N, Musto P, Crugnola M, Giuffrida AC, Krampera M, Tafuri A, Santoro C. Prednisone vs high-dose dexamethasone in newly diagnosed adult primary immune thrombocytopenia: a randomized trial. Blood Adv 2024; 8:1529-1540. [PMID: 38231017 DOI: 10.1182/bloodadvances.2023010975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 01/18/2024] Open
Abstract
ABSTRACT A debate exists regarding which type of corticosteroids (standard-dose prednisone [PDN] or high-dose dexamethasone [HD-DXM]) is the best first-line treatment for adult patients with newly diagnosed untreated primary immune thrombocytopenia (pITP). An ad hoc study compared PDN with HD-DXM in newly diagnosed untreated patients with pITP (aged ≥18 but ≤80 years, platelet count of ≤20 or >20 but <50 × 109/L, and bleeding score of ≥8). Patients were randomised to receive PDN 1 mg/kg per day from days 0 to 28 (Arm A) or HD-DXM 40 mg per day for 4 days, every 14 days, for 3 consecutive courses (Arm B). Fifty-nine of 113 patients (52.2%) were randomized to Arm A and 54 of 113 (47.8%) to Arm B. In evaluable patients, total initial responses (complete response [CR], partial response [PR], minimal response [MR]) were 44 of 56 (78.57%) in Arm A and 46 of 49 (93.88%) in Arm B at days 42 and 46, respectively (P = 0.0284). Total final responses (at day 180 from initial response) were 26 of 43 (60.47%) in Arm A and 23 of 39 (58.97%) in Arm B (P = 0.8907). Total persistent responses (at 12 months from initial response) were 25 of 31 (80.65%) in Arm A and 20 of 36 (55.56%) in Arm B (P = 0.0292). Seven relapses occurred. Median follow-up was 44.4 months. Overall survival was 100% at 48 months, overall disease-free survival was 81.11% at 48 months from day 180. PDN and pulsed HD-DXM were well tolerated; HD-DXM allows effective initial responses but less long lasting than PDN. This trial was registered at www.clinicaltrials.gov as #NCT00657410.
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Affiliation(s)
- Maria Gabriella Mazzucconi
- Hematology, Dipartimento Medicina Traslazionale e di Precisione, Università degli Studi Sapienza, Rome, Italy
| | - Francesco Rodeghiero
- Hematology Project Foundation, Vicenza Affiliated to the Department of Hematology, San Bortolo Hospital, Vicenza, Italy
| | | | - Valerio De Stefano
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Luigi Gugliotta
- Unità Operativa Complessa di Ematologia, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Marco Ruggeri
- Unità Operativa Complessa (UOC) Ematologia, Azienda Unità Locale Socio Sanitaria 8 Berica-Ospedale di Vicenza, Vicenza, Italy
| | - Nicola Vianelli
- Istituto di Ematologia Seràgnoli, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy
| | - Paola Fazi
- Gruppo Italiano Malattie EMatologiche Adulto Foundation, Franco Mandelli Onlus, Rome, Italy
| | - Francesca Paoloni
- Gruppo Italiano Malattie EMatologiche Adulto Foundation, Franco Mandelli Onlus, Rome, Italy
| | - Valeria Sargentini
- Gruppo Italiano Malattie EMatologiche Adulto Foundation, Franco Mandelli Onlus, Rome, Italy
| | - Erminia Baldacci
- UOC Ematologia, Azienda Ospedaliero Universitaria Policlinico Umberto I, Rome, Italy
| | - Antonietta Ferretti
- Hematology, Dipartimento Medicina Traslazionale e di Precisione, Università degli Studi Sapienza, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Bruno Martino
- Dipartimento Emato-Oncologia, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | | | - Giuseppe Carli
- Hematology Project Foundation, Vicenza Affiliated to the Department of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Stefania Fortuna
- Hematology Project Foundation, Vicenza Affiliated to the Department of Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Mauro Di Ianni
- UOC Ematologia Clinica, Azienda Sanitaria Locale (ASL) Pescara PO Santo Spirito, Pescara, Italy
| | - Paola Ranalli
- UOC Ematologia Clinica, Azienda Sanitaria Locale (ASL) Pescara PO Santo Spirito, Pescara, Italy
| | - Francesca Palandri
- Istituto di Ematologia Seràgnoli, IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy
| | - Nicola Polverelli
- Struttura Semplice a Valenza Dipartimentale Centro Trapianti Midollo per Adulti, Azienda Socio Sanitaria Territoriale (ASST) degli Spedali civili di Brescia, Brescia, Italy
| | - Elisabetta Lugli
- Ematology, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy
| | - Elena Rivolti
- Ematology, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy
| | - Andrea Patriarca
- Struttura Complessa a Direzione Universitaria Ematologia, Azienda Ospedlaiero Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Angela Rago
- UOC Ematologia, ASL Latina-Ospedale S.M. Goretti, Latina, Italy
| | - Mariella D'Adda
- Unità Operativa (UO) Ematologia, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera of Cosenza, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Sergio Siragusa
- UOC di Ematologia, Azienda Ospedaliera Universitaria Policlinico di Palermo, Palermo, Italy
| | - Silvia Sibilla
- UO Ematologia, Ente Ecclesiastico Cardinale G. Panico, Tricase, Italy
| | - Angelo Michele Carella
- UOC Ematologia e Centro Trapianti Cellule Staminali Emopoietiche, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Elena Rossi
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Roberta Battistini
- UOC Ematologia e Centro Trapianti CSE, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Francesco Zaja
- Dipartimento Scienze Mediche, Università degli Studi di Trieste Unità Complessa Operativa Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Monica Bocchia
- UOC Ematologia e Trapianti, Azienda Ospedlaiero Universitaria Senese Policlinico Le Scotte, Siena, Italy
| | - Nicola Di Renzo
- UOC di Ematologia e Trapianto di Cellule Staminali, Ospedale Vito Fazzi ASL Lecce, Lecce, Italy
| | - Pellegrino Musto
- Department of Precision and Regenerative Medicine and Ionian Area, Aldo Moro University School of Medicine and Unit of Hematology and Stem Cell Transplantation, Azienda Ospedaliero Universitaria Consorziale Policlinico, Bari, Italy
| | - Monica Crugnola
- Hematology Unit and Bone Marrow Transplantation Center, Azienda Ospedaliera Universitaria, Parma, Italy
| | - Anna Chiara Giuffrida
- UOC Medicina Trasfusionale, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Mauro Krampera
- UOC di Ematologia e Centro Trapianto di Midollo Osseo, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Agostino Tafuri
- Hematology, University Hospital Sant'Andrea, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristina Santoro
- UOC Ematologia, Azienda Ospedaliero Universitaria Policlinico Umberto I, Rome, Italy
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11
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Fogerty AE, Kuter DJ. How I treat thrombocytopenia in pregnancy. Blood 2024; 143:747-756. [PMID: 37992219 DOI: 10.1182/blood.2023020726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/12/2023] [Accepted: 11/02/2023] [Indexed: 11/24/2023] Open
Abstract
ABSTRACT Thrombocytopenia is a common hematologic abnormality in pregnancy, encountered in ∼10% of pregnancies. There are many possible causes, ranging from benign conditions that do not require intervention to life-threatening disorders necessitating urgent recognition and treatment. Although thrombocytopenia may be an inherited condition or predate pregnancy, most commonly it is a new diagnosis. Identifying the responsible mechanism and predicting its course is made challenging by the tremendous overlap of clinical features and laboratory data between normal pregnancy and the many potential causes of thrombocytopenia. Multidisciplinary collaboration between hematology, obstetrics, and anesthesia and shared decision-making with the involved patient is encouraged to enhance diagnostic clarity and develop an optimized treatment regimen, with careful consideration of management of labor and delivery and the potential fetal impact of maternal thrombocytopenia and any proposed therapeutic intervention. In this review, we outline a diagnostic approach to pregnant patients with thrombocytopenia, highlighting the subtle differences in presentation, physical examination, clinical course, and laboratory abnormalities that can be applied to focus the differential. Four clinical scenarios are presented to highlight the pathophysiology and treatment of the most common causes of thrombocytopenia in pregnancy: gestational thrombocytopenia, preeclampsia, and immune thrombocytopenia.
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Affiliation(s)
| | - David J Kuter
- Hematology Division, Massachusetts General Hospital, Boston, MA
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12
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Mititelu A, Onisâi MC, Roșca A, Vlădăreanu AM. Current Understanding of Immune Thrombocytopenia: A Review of Pathogenesis and Treatment Options. Int J Mol Sci 2024; 25:2163. [PMID: 38396839 PMCID: PMC10889445 DOI: 10.3390/ijms25042163] [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: 12/21/2023] [Revised: 01/24/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
The management of immune thrombocytopenia (ITP) and the prediction of patient response to therapy still represent a significant and constant challenge in hematology. ITP is a heterogeneous disease with an unpredictable evolution. Although the pathogenesis of ITP is currently better known and its etiology has been extensively studied, up to 75% of adult patients with ITP may develop chronicity, which represents a significant burden on patients' quality of life. A major risk of ITP is bleeding, but knowledge on the exact relationship between the degree of thrombocytopenia and bleeding symptoms, especially at a lower platelet count, is lacking. The actual management of ITP is based on immune suppression (corticosteroids and intravenous immunoglobulins), or the use of thrombopoietin receptor agonists (TPO-RAs), rituximab, or spleen tyrosine kinase (Syk) inhibitors. A better understanding of the underlying pathology has facilitated the development of a number of new targeted therapies (Bruton's tyrosine kinase inhibitors, neonatal Fc receptors, strategies targeting B and plasma cells, strategies targeting T cells, complement inhibitors, and newer TPO-RAs for improving megakaryopoiesis), which seem to be highly effective and well tolerated and result in a significant improvement in patients' quality of life. The disadvantage is that there is a lack of knowledge of the predictive factors of response to treatments, which would help in the development of an optimized treatment algorithm for selected patients.
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Affiliation(s)
- Alina Mititelu
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania; (M.-C.O.); (A.M.V.)
| | - Minodora-Cezarina Onisâi
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania; (M.-C.O.); (A.M.V.)
| | - Adrian Roșca
- Department of Physiology, Carol Davila University of Medicine and Pharmacy, 050471 Bucharest, Romania;
| | - Ana Maria Vlădăreanu
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania; (M.-C.O.); (A.M.V.)
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13
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Foy P, Friedman KD, Michaelis LC. How I diagnose and treat thrombocytopenia in geriatric patients. Blood 2024; 143:214-223. [PMID: 37956435 DOI: 10.1182/blood.2022017634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/31/2023] [Accepted: 08/16/2023] [Indexed: 11/15/2023] Open
Abstract
ABSTRACT Thrombocytopenia in older individuals is a common but diagnostically challenging condition that has variable clinical impact to those who are affected. Diagnostic approach requires evaluation of the preexisting clinical conditions, detailed review of medications, and assessment for disorders that warrant urgent treatment. In this article, we describe a systematic approach to diagnosis of thrombocytopenia and present a schematic review for management strategies. Three clinical scenarios are presented that are relevant for their prevalence and management challenges in an older adult population. The first scenario addresses primary immune thrombocytopenia (ITP) and reviews different treatment options. The second one addresses complications of thrombocytopenia in management of the myelodysplastic syndrome. The last one reviews diagnostic challenges of drug-induced ITP.
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Affiliation(s)
- Patrick Foy
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Laura C Michaelis
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
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14
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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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15
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Su J, Xu M, Dong Z, Wang Q, Ma L, Xiao P, Chen X. Efficacy and safety of azathioprine plus prednisone versus prednisone alone as first-line treatment for antinuclear antibody-positive immune thrombocytopenia: a retrospective cohort study. Hematology 2023; 28:2196864. [PMID: 37014744 DOI: 10.1080/16078454.2023.2196864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/26/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE Antinuclear antibody (ANA)-positive immune thrombocytopenia (ITP) patients have an unsatisfactory prognosis due to the more severe conditions of these patients and poor response to first-line glucocorticoids (GCs). The current study intended to compare the efficacy and safety of AZA plus prednisone and prednisone alone as first-line treatment in ANA-positive ITP patients. METHODS Fifteen ANA-positive ITP patients receiving AZA plus prednisone (AZA + GC group) and eighteen ANA-positive ITP patients receiving prednisone alone (GC group) as first-line treatment were retrospectively enrolled. RESULTS The complete response (CR) rate (60.0% versus 22.2%) (P = 0.038) was increased in the AZA + GC group versus the GC group, while the overall response rate (86.7% versus 55.6%) (P = 0.070) only showed an increasing trend that did not achieve statistical significance. In addition, multivariate analysis revealed that AZA + GC (versus GC) (odds ratio = 31.331, P = 0.018) was independently associated with a higher possibility of achieving CR. Additionally, accumulating relapse-free duration was prolonged in the AZA + GC group versus the GC group (median: 7.8 months versus 3.4 months) (P = 0.038). Additionally, the multivariate analysis suggested that AZA + GC (versus GC) (hazard ratio = 0.306, P = 0.007) was independently correlated with longer accumulating relapse-free duration. The incidence of adverse events did not differ between the two groups (all P > 0.05), and the common adverse events in the AZA + GC group were pneumonia (13.3%), anemia (13.3%), cough (13.3%), nausea (6.7%), and granulocytopenia (6.7%), which were all tolerable and manageable. CONCLUSION First-line AZA plus prednisone realizes a better hematological response and relapse-free duration with acceptable adverse events compared to prednisone alone in ANA-positive ITP patients.
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Affiliation(s)
- Junnan Su
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Meihong Xu
- Department of Physical Examination, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Zhigao Dong
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Qingqing Wang
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Lili Ma
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Pingping Xiao
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Xuyan Chen
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
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16
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Tan Y, Che L, Bi H, Fan S, Zhou Z, Min H. Clinical features and treatment effect of HIV-associated immune thrombocytopenia-single center Ten-Years data summary. Platelets 2023; 34:2200836. [PMID: 37114424 DOI: 10.1080/09537104.2023.2200836] [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: 04/29/2023]
Abstract
Thrombocytopenia represents one of the most prevalent hematologic complications observed in patients infected with the human immunodeficiency virus (HIV). In this study, we sought to analyze the clinical characteristics and treatment outcomes of patients with coexisting HIV and thrombocytopenia. Specifically, we retrospectively examined the medical records of 45 patients diagnosed with HIV/AIDS and thrombocytopenia at the Yunnan Infectious Diseases Specialist Hospital between January 2010 and December 2020, all of whom received highly active antiretroviral therapy (HAART) with/without glucocorticoids. The median follow-up period was 79 days, ranging between 14 and 368 days, the total platelet count was higher after receiving treatment than before (Z = -5.662, P < .001). Among the cohort, 27 patients (60.0%) responded to treatment, with 12 patients (44.44%) experiencing relapse during the follow-up period. The response rate (80.00%) of newly diagnosed ITP were significantly higher than of persistent ITP (28.57%) and chronic ITP (38.46%) (\x 2 = 9.560, P = .008) and the relapse rate of the newly diagnosed ITP (30.00%) was significantly lower than the persistent ITP and chronic ITP (100.00%, 80.00%) (\x2 = 6.750, P = .034). Notably, we found that the number of CD4+ T cells, duration of HIV infection, selection of HAART and type of glucocorticoids administered displayed no statistically significant effect on platelet count, treatment response, or relapse rate. However, we observed a significant decrease in platelet count in hepatitis C virus-positive individuals coinfected with HIV compared to those with HIV alone (Z = -2.855, P = .003). Our findings suggest that patients diagnosed with HIV and thrombocytopenia exhibit a low response rate to treatment and have an increased likelihood of relapse.
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Affiliation(s)
- YaXian Tan
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, Chinaand
| | - Lei Che
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, Chinaand
| | - Hui Bi
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, Chinaand
| | - ShanShan Fan
- Department II of Infectious Diseases, Yunnan Infectious Diseases Specialist Hospital, Kunming, Yunnan, China
| | - ZePing Zhou
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, Chinaand
| | - HaiYan Min
- Department II of Infectious Diseases, Yunnan Infectious Diseases Specialist Hospital, Kunming, Yunnan, China
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17
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Shi Y, Huang C, Zhou Y, Jiang H, Zhao Y, Li M, Zeng X, Zhao J. Tacrolimus shows adequate efficacy in patients with antiphospholipid antibodies associated thrombocytopenia: a retrospective cohort study. Clin Exp Med 2023; 23:5433-5443. [PMID: 37930607 DOI: 10.1007/s10238-023-01248-1] [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: 09/13/2023] [Accepted: 10/27/2023] [Indexed: 11/07/2023]
Abstract
Thrombocytopenia is a common manifestation associated with the presence of antiphospholipid antibodies (aPL). The aim of this study is to investigate the efficacy and safety of tacrolimus treatment in aPL associated thrombocytopenia. This is a single-center retrospective study. Patients who had persistent positive aPL and thrombocytopenia that was treated with tacrolimus were included. A total of 49 patients [38 females (77.6%)] were enrolled from Nov 2013 to Apr 2022 with a median treatment duration of 22 months. Seventeen fulfilled classification criteria of antiphospholipid syndrome (APS), 18 systemic lupus erythematosus (SLE). The median age of study patients was 37 years (IQR 31, 48). Forty-three (87.8%) patients were on concomitant use of glucocorticoids, 6 on tacrolimus monotherapy. The overall response rate in this cohort was 85.7% (n = 42), including 49% of complete responses (n = 24). The median time to achieve a response was 3 months. Nine (18.4%) patients with overall response experienced a loss of response. The response rate during follow-up in patients with monotherapy was noninferior. Patients with positive antinuclear antibody (ANA) showed the tendency of maintaining response (p = 0.028). The 19 patients who were on medium and high dosage of glucocorticoids (> 15 mg prednisone/d) managed to taper glucocorticoids rapidly. Side effects were reported in 12.2% (n = 6) of the patients (elevated creatinine, general malaise, elevated liver enzyme). Tacrolimus has adequate efficacy, steroid-sparing effect and is well tolerated for aPL associated thrombocytopenia. Patients with positive ANA might benefit the most from tacrolimus treatment.
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Affiliation(s)
- Yu Shi
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Can Huang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yangzhong Zhou
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Hui Jiang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yongqiang Zhao
- Department of Hematology, Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.
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18
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Song M, Wang X, Sun M, Wang L, Wang X, Liu Y, Fan W, Li Q, Guo X. Relationships of platelet glycoprotein specific antibody with therapeutic efficacy of short-term high-dose dexamethasone and bleeding score in the newly diagnosed adult patients with primary immune thrombocytopenia. Hematology 2023; 28:2255801. [PMID: 37702365 DOI: 10.1080/16078454.2023.2255801] [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: 07/15/2023] [Accepted: 09/01/2023] [Indexed: 09/14/2023] Open
Abstract
Objectives: We aimed to investigate relationships of platelet glycoprotein (GP) specific antibody with therapeutic efficacy of high-dose dexamethasone (HD-DXM) and bleeding score in primary immune thrombocytopenia (ITP) adults. Methods: A retrospective study was carried out to analyze relationships of polymorphism of GP specific antibody with initial therapeutic efficacy of HD-DXM and bleeding score of newly diagnosed ITP adults between 1 June, 2016 and 31 January, 2020. Results: 59 patients were involved in the study, with 33 cases of responders and 26 cases of non-responders between June 2016 and January 2020. At admission, there were 31 (52.5%) GP antibody-positive patients. Initial therapy of HD-DXM was effective for 78.6% GP antibody-negative patients and 35.5% GP antibody-positive patients, with a better therapeutic efficacy in patients with anti-GP Ib/IX antibody or anti-GP IIb/IIIa antibody but not in those with anti-GP Ib/IX antibody plus anti-GP IIb/IIIa antibody. Notably, therapeutic efficacy is much worse for minority (Uyghur) patients compared with corresponding Han patients. Similarly, it was much lower in GP antibody-positive patients compared with corresponding negative ones at low and medium bleeding score, with no response in GP antibody-positive patients at high bleeding score. Furthermore, there was a moderate negative correlation between therapeutic efficacy and GP-specific antibody (p < 0.05), but no obvious linear relationship between clinical bleeding degree and GP-specific antibody (p > 0.05). Conclusion: Collectively, the newly diagnosed ITP adults with GP-specific antibody have a poor response to short-term HD-DXM, especially in minority (Uyghur) patients with GP-specific antibody in China.
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Affiliation(s)
- Mengting Song
- Hematology Center, the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Institute of Hematology, Urumqi, People's Republic of China
| | - Xiujuan Wang
- Hematology Center, the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Institute of Hematology, Urumqi, People's Republic of China
| | - Mingling Sun
- Hematology Center, the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Institute of Hematology, Urumqi, People's Republic of China
| | - Lei Wang
- Hematology Center, the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Institute of Hematology, Urumqi, People's Republic of China
| | - Xinyou Wang
- Hematology Center, the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Institute of Hematology, Urumqi, People's Republic of China
| | - Ying Liu
- Hematology Center, the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Institute of Hematology, Urumqi, People's Republic of China
| | - Wenxia Fan
- Hematology Center, the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Institute of Hematology, Urumqi, People's Republic of China
| | - Qinzhi Li
- Hematology Center, the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Institute of Hematology, Urumqi, People's Republic of China
| | - Xinhong Guo
- Hematology Center, the First Affiliated Hospital of Xinjiang Medical University, Xinjiang Institute of Hematology, Urumqi, People's Republic of China
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19
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Bourdin V, Bigot W, Vanjak A, Burlacu R, Lopes A, Champion K, Depond A, Amador-Borrero B, Sene D, Comarmond C, Mouly S. Drug-Drug Interactions Involving Dexamethasone in Clinical Practice: Myth or Reality? J Clin Med 2023; 12:7120. [PMID: 38002732 PMCID: PMC10672071 DOI: 10.3390/jcm12227120] [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: 09/19/2023] [Revised: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Concomitant administration of multiple drugs frequently causes severe pharmacokinetic or pharmacodynamic drug-drug interactions (DDIs) resulting in the possibility of enhanced toxicity and/or treatment failure. The activity of cytochrome P450 (CYP) 3A4 and P-glycoprotein (P-gp), a drug efflux pump sharing localization and substrate affinities with CYP3A4, is a critical determinant of drug clearance, interindividual variability in drug disposition and clinical efficacy, and appears to be involved in the mechanism of numerous clinically relevant DDIs, including those involving dexamethasone. The recent increase in the use of high doses of dexamethasone during the COVID-19 pandemic have emphasized the need for better knowledge of the clinical significance of drug-drug interactions involving dexamethasone in the clinical setting. We therefore aimed to review the already published evidence for various DDIs involving dexamethasone in vitro in cell culture systems and in vivo in animal models and humans.
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Affiliation(s)
- Venceslas Bourdin
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - William Bigot
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Anthony Vanjak
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Ruxandra Burlacu
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Amanda Lopes
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Karine Champion
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Audrey Depond
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Blanca Amador-Borrero
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
| | - Damien Sene
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
- INSERM U976, Hôpital Saint-Louis, 75010 Paris, France
| | - Chloe Comarmond
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
- INSERM U976, Hôpital Saint-Louis, 75010 Paris, France
| | - Stéphane Mouly
- Internal Medicine Department, Département Médico-Universitaire INVICTUS, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris (APHP).Nord—Université Paris-Cité, 75010 Paris, France; (V.B.); (W.B.); (A.V.); (R.B.); (A.L.); (K.C.); (A.D.); (B.A.-B.); (D.S.); (C.C.)
- INSERM UMR-S1144, Hôpital Fernand Widal, 75010 Paris, France
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20
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Grodzielski M, Cidlowski JA. Glucocorticoids regulate thrombopoiesis by remodeling the megakaryocyte transcriptome. J Thromb Haemost 2023; 21:3207-3223. [PMID: 37336437 PMCID: PMC10592358 DOI: 10.1016/j.jtha.2023.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/18/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Glucocorticoids are widely known for their immunomodulatory action. Their synthetic analogs are used to treat several autoimmune diseases, including immune thrombocytopenia. However, their efficacy and mechanisms of action in immune thrombocytopenia are not fully understood. OBJECTIVES To investigate the mechanism of glucocorticoid actions on platelet production. METHODS The actions of glucocorticoids on platelet production were studied combining in vivo, ex vivo and in vitro approaches. RESULTS Dexamethasone reduced bleeding in mice and rapidly increased circulating young platelet counts. In vitro glucocorticoid treatment stimulated proplatelet formation by megakaryocytes and platelet-like particle release. This effect was blocked by glucocorticoid receptor antagonist RU486, indicating a glucocorticoid receptor-dependent mechanism. Genome-wide analysis revealed that dexamethasone regulates the expression of >1000 genes related to numerous cellular functions, including predominant cytoplasm and cytoskeleton reorganization. Dexamethasone and other glucocorticoids induced the expression of Gda (the gene encoding guanine deaminase), which has been reported to have a role in dendrite development. Inhibition of guanine deaminase enzymatic activity blocked dexamethasone stimulation of proplatelet formation, implicating a critical role for this enzyme in glucocorticoid-mediated platelet production. CONCLUSION Our findings identify glucocorticoids as new regulators of thrombopoiesis.
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Affiliation(s)
- Matías Grodzielski
- Molecular Endocrinology Group, Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina, USA
| | - John A Cidlowski
- Molecular Endocrinology Group, Signal Transduction Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina, USA.
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21
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González-López TJ, Schifferli A. Early immunomodulation in immune thrombocytopenia-A report of the ICIS meeting in Lenzerheide, Switzerland 2022. Br J Haematol 2023; 203:101-111. [PMID: 37735547 DOI: 10.1111/bjh.19082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
The only way to prevent immune thrombocytopenia (ITP) from becoming refractory would be to restore tolerance to platelets at an early phase of the disease. Numerous immune alterations probably accumulate in chronic ITP; thus, the chances of cure decrease significantly with time. Currently, sustained remission off treatment (SROT) is a clinical definition describing patients who can discontinue their ITP treatment without risk and maintain a state of remission. Different treatment strategies are presently being evaluated with the goal of attaining SROT, mostly combining drugs targeting the innate and/or the adaptive immune system, the inflammation state, so as increasing the platelet load. In this sense, thrombopoietin receptor agonists (TPO-RAs) have shown promising results if used as upfront treatment. TPO-RAs seem to exhibit immunomodulation and immune tolerance properties, increasing not only the platelet antigen mass but also increasing the transforming growth factor-β concentration, and stimulating regulatory T and B lymphocytes. However, more immunological studies are needed to establish accurate molecular alterations in ITP that are potentially reversed with treatments.
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Affiliation(s)
| | - Alexandra Schifferli
- Department of Haematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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22
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Crickx E, Mahévas M, Michel M, Godeau B. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging 2023; 18:115-130. [PMID: 36726813 PMCID: PMC9885884 DOI: 10.2147/cia.s369574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
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Affiliation(s)
- Etienne Crickx
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris, Université Paris-Est-Créteil, Paris, France,INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Correspondence: Bertrand Godeau, Service de Médecine Interne, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), 51 avenue du maréchal de Lattre de Tassigny, Créteil, 94000, France, Tel +331 49 81 29 05, Fax +331 49 81 29 02, Email
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23
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Liu XG, Hou Y, Hou M. How we treat primary immune thrombocytopenia in adults. J Hematol Oncol 2023; 16:4. [PMID: 36658588 PMCID: PMC9850343 DOI: 10.1186/s13045-023-01401-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an immune-mediated bleeding disorder characterized by decreased platelet counts and an increased risk of bleeding. Multiple humoral and cellular immune abnormalities result in accelerated platelet destruction and suppressed platelet production in ITP. The diagnosis remains a clinical exclusion of other causes of thrombocytopenia. Treatment is not required except for patients with active bleeding, severe thrombocytopenia, or cases in need of invasive procedures. Corticosteroids, intravenous immunoglobulin, and anti-RhD immunoglobulin are the classical initial treatments for newly diagnosed ITP in adults, but these agents generally cannot induce a long-term response in most patients. Subsequent treatments for patients who fail the initial therapy include thrombopoietic agents, rituximab, fostamatinib, splenectomy, and several older immunosuppressive agents. Other potential therapeutic agents, such as inhibitors of Bruton's tyrosine kinase and neonatal Fc receptor, are currently under clinical evaluation. An optimized treatment strategy should aim at elevating the platelet counts to a safety level with minimal toxicity and improving patient health-related quality of life, and always needs to be tailored to the patients and disease phases. In this review, we address the concepts of adult ITP diagnosis and management and provide a comprehensive overview of current therapeutic strategies under general and specific situations.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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24
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Bishop AA, Krohn E, Vakayil VR, Pribyl K, Reding MT, Tignanelli C, Harmon JV. A laparoscopic approach to address massive splenomegaly, symptomatic cholelithiasis, and a planned postoperative pregnancy: A case report. Clin Case Rep 2023; 11:e6831. [PMID: 36703775 PMCID: PMC9869644 DOI: 10.1002/ccr3.6831] [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: 06/19/2022] [Revised: 11/04/2022] [Accepted: 12/13/2022] [Indexed: 01/25/2023] Open
Abstract
We report long-term follow-up of a patient who underwent a tailored laparoscopic procedure for symptomatic cholelithiasis, massive splenomegaly, and a planned pregnancy. There were no complications, and the patient remained symptom-free at the 5-year follow-up. We supplemented our case report with national surgical data demonstrating the safety of laparoscopic splenectomy.
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Affiliation(s)
| | - Eric Krohn
- Department of SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
| | | | - Kyle Pribyl
- Department of SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Mark T. Reding
- Department of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | | | - James V. Harmon
- Department of SurgeryUniversity of MinnesotaMinneapolisMinnesotaUSA
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25
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Safety and efficacy of splenectomy for the treatment of chronic immune thrombocytopenia. Ann Hematol 2022; 101:2781-2784. [PMID: 36175771 DOI: 10.1007/s00277-022-04985-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/14/2022] [Indexed: 11/01/2022]
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26
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First-line Therapy for Immune Thrombocytopenia: Time for Change. Hemasphere 2022; 6:e783. [PMID: 36168521 PMCID: PMC9509069 DOI: 10.1097/hs9.0000000000000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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27
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Developing and validating a mortality prediction model for ICH in ITP: a nationwide representative multicenter study. Blood Adv 2022; 6:4320-4329. [PMID: 35679462 PMCID: PMC9327537 DOI: 10.1182/bloodadvances.2022007226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/24/2022] [Indexed: 02/05/2023] Open
Abstract
Intraparenchymal hemorrhage, platelet count, serious infections, severe bleeding events, and Glasgow coma scale predict poor prognosis. A prognostic model was developed and validated, and an application was established.
Intracranial hemorrhage (ICH) is a rare and life-threatening hemorrhagic event in patients with immune thrombocytopenia (ITP). However, its mortality and related risk factors remain unclear. Herein, we conducted a nationwide multicenter real-world study of ICH in adult ITP patients. According to data from 27 centers in China from 2005 to 2020, the mortality rate from ICH was 33.80% (48/142) in ITP adults. We identified risk factors by logistic univariate and multivariate logistic regression for 30-day mortality in a training cohort of 107 patients as follows: intraparenchymal hemorrhage (IPH), platelet count ≤10 × 109/L at ICH, a combination of serious infections, grade of preceding bleeding events, and Glasgow coma scale (GCS) level on admission. Accordingly, a prognostic model of 30-day mortality was developed based on the regression equation. Then, we evaluated the performance of the prognostic model through a bootstrap procedure for internal validation. Furthermore, an external validation with data from a test cohort with 35 patients from 11 other centers was conducted. The areas under the receiver operating characteristic (ROC) curves for the internal and external validation were 0.954 (95% confidence interval [CI], 0.910-0.998) and 0.942 (95% CI, 0.871-1.014), respectively. Both calibration plots illustrated a high degree of consistency in the estimated and observed risk. In addition, the decision curve analysis showed a considerable net benefit for patients. Thus, an application (47.94.162.105:8080/ich/) was established for users to predict 30-day mortality when ICH occurred in adult patients with ITP.
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28
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Lebowa W, Zdziarska J, Sacha T. Immune Thrombocytopenia: Characteristics of the Population and Treatment Methods-One-Center Experience. Hamostaseologie 2022; 43:132-141. [PMID: 35654406 DOI: 10.1055/a-1767-0304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a disease with variable clinical presentation, requiring different treatment lines. AIM The study aimed to characterize a group of ITP patients in terms of clinical picture and disease treatment, as well as to present the current standard of care of ITP in Poland, in the context of local and international guidelines. MATERIALS AND METHODS The study included adult patients diagnosed with ITP, treated at the Department of Haematology of the Jagiellonian University Hospital in Krakow from January 2006 to January 2021. Patient characteristics, clinical manifestation of ITP, and treatment methods were analyzed. RESULTS A total of 245 ITP patients were included. 57.1% of them were asymptomatic at diagnosis. Most common symptoms were thrombocytopenic purpura (68.2%), followed by epistaxis (34.7%) and gum bleeds (19.2%). Life-threatening bleedings were noted in three cases (1.2%). 23.2% of patients did not require treatment. Prednisone was the most commonly used first-line therapy (75.5% of patients). Treatment with eltrombopag and romiplostim was used in 40.4 and 8.5% of patients requiring second-line therapy, respectively. 14.3% of all patients ultimately underwent splenectomy, including 51.5% of those who needed second-line treatment. The initial response rate was 74.3%; however, post-splenectomy relapses occurred in 22.9% of patients. CONCLUSIONS ITP is a disease of mild clinical course, often asymptomatic. Chronic disease often requires multiple treatment lines and balancing between bleeding risk and treatment toxicity, based on individual risk-benefit assessment. Local access restrictions to thrombopoietin receptor agonists determined the treatment strategy.
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Affiliation(s)
- Weronika Lebowa
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Joanna Zdziarska
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Tomasz Sacha
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland.,Department of Haematology, Jagiellonian University Medical College, Cracow, Poland
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Gómez-Almaguer D, Rojas-Guerrero EA, Gómez-De León A, Colunga-Pedraza PR, Jaime-Pérez JC. Alternatives for managing patients with newly diagnosed immune thrombocytopenia: a narrative review. Expert Rev Hematol 2022; 15:493-501. [PMID: 35615916 DOI: 10.1080/17474086.2022.2082936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is an acquired bleeding disorder. Conventionally, first-line ITP therapy aims to obtain a rapid response and stop or decrease the risk of bleeding by increasing the platelet count. At this point, the duration of the response, the tolerability, and the long-term safety of pharmacologic interventions are considered less of a priority. Combination treatments that simultaneously address multiple disease mechanisms are an attractive strategy to increase efficacy in acute ITP therapy. In this review, we discuss the treatment of newly diagnosed ITP patients, emphasizing the use of new combinations to benefit from their synergy. AREAS COVERED This article summarizes conventional treatment, recent and novel combinations, and COVID-19 management recommendations of newly diagnosed ITP patients. EXPERT OPINION The key areas for improvement consider the long-term effects of conventional first-line therapy, reducing relapse rates, and extending responses to achieve long-term remission. Although corticosteroids remain first-line therapy, restricting their use to avoid toxicity and the increasing use of rituximab and TPO-RAs in the first three months after diagnosis open the landscape for future interventions in frontline therapy for ITP. First-line therapy intensification or synergistic drug combination offers a potential and realistic shift in future treatment guidelines.
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Affiliation(s)
- David Gómez-Almaguer
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Edgar A Rojas-Guerrero
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Andrés Gómez-De León
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Perla R Colunga-Pedraza
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - José C Jaime-Pérez
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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Nishimoto M, Nakane T, Koh H, Nakashima Y, Yamamura R, Nakamae H, Hino M, Ohta K. Phagocytosis of Mature Granulocytes by Bone Marrow Macrophages in an Elderly Man with Adult-Onset Primary Autoimmune Neutropenia. Hematol Rep 2022; 14:165-171. [PMID: 35735735 PMCID: PMC9223026 DOI: 10.3390/hematolrep14020024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/31/2022] [Accepted: 05/24/2022] [Indexed: 11/16/2022] Open
Abstract
Adult-onset primary autoimmune neutropenia (AIN) is an extremely rare but sometimes life-threatening disease. Its pathophysiology is still to be clarified. We describe a case with adult-onset primary AIN with phagocytosis of mature granulocytes by macrophages in bone marrow. A 77-year-old male was referred to our hospital with severe neutropenia. Based on the normal cellular bone marrow without morphological dysplasia and the positivity of anti-neutrophil antibodies in the serum, adult-onset primary AIN was diagnosed. After five years from the initiation of granulocyte colony-stimulating-factor therapy, neutropenia had progressed. At that time, the second bone marrow examination revealed segmented neutrophils phagocytosed by macrophages. Continuous low dose prednisolone succeeded to increase the neutrophil count. An impressive morphological feature of AIN indicated the destruction of mature granulocytes in bone marrow by antibody-dependent cellular phagocytosis mediated by granulocyte-specific antibodies. More cases should be accumulated to elucidate the precise mechanism and establish the optimal therapy.
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Affiliation(s)
- Mitsutaka Nishimoto
- Hematology Ohta Clinic, Shinsaibashi, Osaka 5420081, Japan; (T.N.); (R.Y.); (K.O.)
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka 5458585, Japan; (H.K.); (Y.N.); (H.N.); (M.H.)
- Correspondence: ; Tel.: +81-6-6645-3881
| | - Takahiko Nakane
- Hematology Ohta Clinic, Shinsaibashi, Osaka 5420081, Japan; (T.N.); (R.Y.); (K.O.)
| | - Hideo Koh
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka 5458585, Japan; (H.K.); (Y.N.); (H.N.); (M.H.)
| | - Yasuhiro Nakashima
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka 5458585, Japan; (H.K.); (Y.N.); (H.N.); (M.H.)
| | - Ryosuke Yamamura
- Hematology Ohta Clinic, Shinsaibashi, Osaka 5420081, Japan; (T.N.); (R.Y.); (K.O.)
| | - Hirohisa Nakamae
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka 5458585, Japan; (H.K.); (Y.N.); (H.N.); (M.H.)
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka 5458585, Japan; (H.K.); (Y.N.); (H.N.); (M.H.)
| | - Kensuke Ohta
- Hematology Ohta Clinic, Shinsaibashi, Osaka 5420081, Japan; (T.N.); (R.Y.); (K.O.)
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Liu Y, Wang Y, Zhang C, Feng Q, Hou M, Peng J, Hu X, Wang S. HDAC3 single-nucleotide polymorphism rs2530223 is associated with increased susceptibility and severity of primary immune thrombocytopenia. Int J Lab Hematol 2022; 44:875-882. [PMID: 35484920 DOI: 10.1111/ijlh.13857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/03/2022] [Accepted: 04/03/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is an autoimmune hemorrhagic disorder characterized by a low platelet count and increased risk of bleeding. We previously reported that low-dose chidamide, a histone deacetylase (HDAC) inhibitor, restores immune tolerance in patients with ITP. This study aimed to evaluate the association of a single-nucleotide polymorphism (SNP) rs2530223 in the HDAC3 gene with susceptibility to ITP and its clinical features. METHODS Patients with ITP and age-matched healthy participants were recruited for this case-control study. Genotyping of the HDAC3 rs2530223 polymorphism was performed using MassARRAY platform. RESULTS Individuals with T allele of HDAC3 rs2530223 exhibited a 1.472-fold increased risk of ITP susceptibility (OR 1.472; 95% CI 1.100-1.969; p = .009), while ones with the TT genotype under the codominant and recessive models, and the TC/TT genotypes under the dominant model all revealed increased risk of ITP susceptibility (dominant odds ratio[OR] 1.965; 95% CI: 1.046-3.656; p = .036; codominant OR 2.264; 95% CI 1.175-4.360; p = .015; and recessive OR 1.512; 95% CI 1.028-2.224; p = .036, respectively). Regarding platelet counts in ITP patients, we observed that the TC/TT genotypes exhibited a 3.932-fold increased risk for platelet (PLT) <30 × 109 /L (OR 3.932; 95% CI 1.426-10.842; p = .008). CONCLUSION This study indicates that HDAC3 rs2530223 may be an important genetic factor related to ITP susceptibility and platelet count in ITP patients, providing new perspectives on disease progression, new therapeutic targets, and severity prediction.
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Affiliation(s)
- Yan Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yin Wang
- Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Cheng Zhang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qi Feng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiang Hu
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shuwen Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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Ni X, Li D, Yuan C, Yu Y, Wang H, Wang L, Yu T, Qin P, Peng J, Hou M, Shi Y, Hou Y. Single-dose versus low-dose rituximab in corticosteroid-resistant or relapsed ITP: A multicenter, randomized, controlled study. Am J Hematol 2022; 97:440-447. [PMID: 35049070 DOI: 10.1002/ajh.26473] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/18/2021] [Accepted: 01/13/2022] [Indexed: 01/19/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune bleeding disorder, in which rituximab (RTX) induces the best long-term effect among recommended second-line treatments. Nevertheless, the optimal regimen of RTX remains unclear. We herein conducted a prospective, multicenter, open-label, randomized controlled trial to compare the efficacy and safety of RTX at two different dosage regimens in patients with corticosteroid-resistant or relapsed ITP. Recruited patients were randomly assigned (1:1) to receive either RTX at a repeated low dose (100 mg weekly for 4 weeks, LD-RTX) or at a single dose (375 mg/m2 , S-RTX). Overall response was achieved in 64.3% of patients who received LD-RTX versus 67.4% of those receiving S-RTX (p = .759). The complete response (CR) rate was 23.8% after LD-RTX and 28.3% after S-RTX (p = .635). In health-related quality of life, S-RTX improved patients' psychological status, quality of life, social activities, and work compared with LD-RTX. Furthermore, S-RTX significantly reduced physician visits without compromising efficacy. Our findings demonstrate that a S-RTX is comparable to LD-RTX in effectiveness and safety for treatment of corticosteroid-resistant or relapsed ITP. The single-dosage regimen optimizes the use of medical resources, improves the cost-effectiveness of RTX, and represents a promising and more convenient replacement for LD-RTX in ITP. This study has been completed and is registered with ClinicalTrials.gov, number NCT03258866.
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Affiliation(s)
- Xiaofei Ni
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Daqi Li
- Jinan Central Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Chenglu Yuan
- Jinan Central Hospital, Cheeloo College of Medicine Shandong University Jinan China
- Department of Hematology, Qilu Hospital (Qingdao) Shandong University Qingdao China
| | - Yafei Yu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Haoyi Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Lingjun Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Tianshu Yu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Ping Qin
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
- Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Yan Shi
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
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Park YH, Kim DY, Kim S, Choi YB, Shin DY, Kim JS, Lee WS, Mun YC, Jang JH, Lee JW, Kook H, Party OBOKAAW. Management of immune thrombocytopenia: 2022 update of Korean experts recommendations. Blood Res 2022; 57:20-28. [PMID: 35342042 PMCID: PMC8958378 DOI: 10.5045/br.2022.2022043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 01/19/2023] Open
Abstract
Despite the availability of therapies to treat patients with immune thrombocytopenia (ITP), there is currently little data from randomized trials to assist clinicians in managing patients. The evidence-based guidelines of the Korean Society of Hematology Aplastic Anemia Working Party (KSHAAWP) are intended to support patients and physicians in the management of ITP. Experts from the KSHAAWP discussed and described this guideline according to the current treatment situation for ITP in Korea and finalized the guidelines. The expert panel recommended the management of ITP in adult and pediatric patients with newly diagnosed, persistent, and chronic disease refractory to first-line therapy with minor bleeding. Management approaches include observation and administration of corticosteroids, intravenous immunoglobulin, anti-D immunoglobulin, and thrombopoietin receptor agonists. Currently, evidence supporting strong recommendations for various management approaches is lacking. Therefore, a large focus was placed on shared decision-making, especially regarding second-line treatment.
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Affiliation(s)
- Young Hoon Park
- Division of Hematology-Oncology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Dae-Young Kim
- Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji Univerisity, Seoul, Korea
| | - Seongkoo Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Bae Choi
- Department of Pediatrics, Ajou University School of Medicine, Ajou Univeristy Hospital, Suwon, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Won Sik Lee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Yeung-Chul Mun
- Division of Hematology-Oncology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hoon Kook
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Hwasun, Korea
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Li C, Sun M, Li R, Wang S, Shao L, Xu M, Yao M, Wang L, Hou M, Feng Q, Peng J. Association of metformin treatment and outcome in adult patients with ITP and pre-existing T2DM. Br J Haematol 2022; 197:367-372. [PMID: 35288929 DOI: 10.1111/bjh.18121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/19/2022] [Accepted: 02/21/2022] [Indexed: 12/15/2022]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune haemorrhagic disease that could manifest with comorbid type 2 diabetes mellitus (T2DM). However, the exact impact of T2DM in patients with ITP remains uncertain. In this study, we performed a retrospective cohort study of 458 participants with ITP. The prevalence of T2DM was 7.6% in this population (35 patients), which was slightly lower than the Chinese nationwide prevalence of T2DM, calculated to be approximately 10.9%. The participants with pre-existing T2DM displayed a significantly higher response to therapy than those without T2DM (71% vs. 53%). Furthermore, in the T2DM cohort, the response rate reached 88% when metformin was included in the treatment regimen. This clinical evidence suggests that metformin therapy might improve the clinical outcomes of ITP.
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Affiliation(s)
- Chaoyang Li
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Meng Sun
- Jinan Vocational College of Nursing, Jinan, China.,Department of Pharmaceutics, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ranran Li
- Department of Radiology, Ningjin County People's Hospital, Dezhou, China
| | - Shuwen Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Linlin Shao
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Miao Xu
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medcine, Shandong University, Jinan, China
| | - Meiyue Yao
- Medical College, Qilu Institute of Technology, Jinan, China
| | - Lin Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medcine, Shandong University, Jinan, China
| | - Qi Feng
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medcine, Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, China
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Comparative efficacy of 19 drug therapies for patients with idiopathic thrombocytopenic purpura: a multiple-treatments network meta-analysis. Ann Hematol 2022; 101:953-961. [PMID: 35149911 DOI: 10.1007/s00277-022-04784-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 02/01/2022] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is the most common clinical bleeding disorder with a high mortality rate and poor long-term survival quality in severe patients. There is controversy on how to choose the appropriate treatment. We systematically reviewed 19 randomized controlled trials (including 2615 participants) from January 1, 2015, to April 20, 2021. These investigations compared multiple drugs or their combinations in the therapeutic dose range for the treatment of ITP. The primary endpoint was based on the proportion of patients who responded to these therapies. The efficacy of eltrombopag plus rituximab, avatrombopag, dexamethasone plus anti-HP, and dexamethasone plus rhTPO was significantly higher than placebo (OR: 46.66, 29.44, 2.66, 1.86) or dexamethasone alone (OR: 46.22, 29.01, 2.22, 1.40). Placebo, oral immunosuppressants, and dexamethasone plus oseltamivir were less effective than the other ITP therapies tested. Eltrombopag plus rituximab may be the best choice when starting treatment for ITP.
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Wu YJ, Liu H, Zeng QZ, Liu Y, Wang JW, Wang WS, Jia-Feng, Zhou HB, Huang QS, He Y, Fu HX, Zhu XL, Jiang Q, Jiang H, Chang YJ, Xu LP, Huang XJ, Zhang XH. All- trans retinoic acid plus low-dose rituximab vs low-dose rituximab in corticosteroid-resistant or relapsed ITP. Blood 2022; 139:333-342. [DOI: i:10.1182/blood.2021013393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Abstract
The study aimed to compare the efficacy and safety of all-trans retinoic acid (ATRA) plus low-dose rituximab (LD-RTX) with LD-RTX monotherapy in corticosteroid-resistant or relapsed immune thrombocytopenia (ITP) patients. Recruited patients were randomized at a ratio of 2:1 into 2 groups: 112 patients received LD-RTX plus ATRA, and 56 patients received LD-RTX monotherapy. Overall response (OR), defined as achieving a platelet count of ≥30 × 109/L confirmed on ≥2 separate occasions (≥7 days apart), at least a doubling of the baseline platelet count without any other ITP-specific treatment, and the absence of bleeding within 1 year after enrollment, was observed in more patients in the LD-RTX plus ATRA group (80%) than in the LD-RTX monotherapy group (59%) (between-group difference, 0.22; 95% CI, 0.07-0.36). Sustained response (SR), defined as maintenance of a platelet count >30 × 109/L, an absence of bleeding, and no requirement for any other ITP-specific treatment for 6 consecutive months after achievement of OR during 1 year following enrollment, was achieved by 68 (61%) patients in the combination group and 23 (41%) patients in the monotherapy group (between-group difference, 0.20; 95% CI, 0.04-0.35). The 2 most common adverse events (AEs) for the combination group were dry skin and headache or dizziness. Our findings demonstrated that ATRA plus LD-RTX significantly increased the overall and sustained response, indicating a promising treatment option for corticosteroid-resistant or relapsed adult ITP. This study is registered at www.clinicaltrials.gov as #NCT03304288.
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Affiliation(s)
- Ye-Jun Wu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hui Liu
- Department of Hematology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Qiao-Zhu Zeng
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yi Liu
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wen-Sheng Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Jia-Feng
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China; and
| | - He-Bing Zhou
- Department of Hematology, The Affiliated Beijing Luhe Hospital of Capital Medical University, Beijing, China
| | - Qiu-Sha Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yun He
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hai-Xia Fu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Lu Zhu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qian Jiang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hao Jiang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ying-Jun Chang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lan-Ping Xu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Jun Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
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Youssef MAM, Salah Eldin EM, Osman NS. Revolution of Disturbed Bregs and Bmems Lymphocytes Homeostasis in Children With Chronic ITP After High-dose Dexamethasone Rescue Therapy. J Pediatr Hematol Oncol 2022; 44:e96-e100. [PMID: 33974586 DOI: 10.1097/mph.0000000000002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/04/2021] [Indexed: 11/26/2022]
Abstract
SUMMARY Dexamethasone is approved as second-line therapy in pediatric chronic immune thrombocytopenic purpura (ITP). Several B-cell abnormalities have been described in ITP pathogenesis.This study assessed the effects of high-dose dexamethasone (HD-DXM) on the percentages and absolute counts of CD19+CD24hiCD38hi regulatory (Bregs) and CD19+CD27+ memory B lymphocytes (Bmems) in children with chronic ITP during active bleeding.The study was a prospective case-control, included 20 children with chronic ITP and uncontrolled bleeding. Children received a single daily dose of HD-DXM for 4 days. Blood samples were withdrawn from patients just before HD-DXM therapy and on day 5 to evaluate the platelet counts and flow cytometric analysis of Bregs and Bmem. The patients' platelet counts significantly increased after 5 days of the initiation of therapy (P=0.0001). Bmems percentage and absolute counts were significantly higher in patients before treatment (P=0.0007), and decreased after HD-DXM therapy (P=0.97) compared with the controls. Bregs percentage and absolute counts were significantly lower before treatment (P=0.0003) and increased after HD-DXM (P=0.003). There is a negative correlation between platelet counts and Bregs percentage and absolute count Bmems percentage before and after HD-DXM, whereas a positive correlation between platelets and Bregs before and after dexamethasone has been reported. CONCLUSIONS HD-DXM reestablishes the normal Bregs/Bmems balance. This finding discloses possible involvement of Bregs and Bmems in the pathogenesis of pediatric ITP and provides a novel vision for immune modulation and treatment perspectives.
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Affiliation(s)
| | | | - Naglaa S Osman
- Children's Hospital, Immunology Unit, Faculty of Medicine, Assiut University, Assiut, Egypt
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Ravaiau C, Geoffrey U, Lozac’h P, Christian L, Orvain C, Lacout C. PREDEXIT : PREDnisone versus DEXamethasone in Immune Thrombocytopenia. Rev Med Interne 2021. [DOI: 10.1016/j.revmed.2021.10.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abdallah GEM, Abbas WA, Elbeih EAS, Abdelmenam E, Mohammed Saleh MF. Systemic corticosteroids in the treatment of warm autoimmune hemolytic anemia: A clinical setting perspective. Blood Cells Mol Dis 2021; 92:102621. [PMID: 34808491 DOI: 10.1016/j.bcmd.2021.102621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 10/14/2021] [Accepted: 10/16/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION There are unmet answers about the effect of the different forms of corticosteroids in the treatment of the warm autoimmune hemolytic anemia (WAIHA). We aimed to describe the initial response rate and the safety profile of different regimens and forms of parenteral corticosteroids versus the solo oral prednisolone as first-line strategies for newly diagnosed adult WAIHA. METHODS We recruited 156 patients who treated with either oral prednisolone 1 mg/kg daily for 3 weeks or intravenous corticosteroids like dexamethasone 40 mg daily for 4 days, Methylprednisolone 1 g/day for 3 days, or Methylprednisolone 1 g/day for 5 days then followed by oral prednisolone 1 mg/kg/day for 3 weeks. Full clinical and laboratory evaluations were done every 3 days for 3 weeks. RESULTS The primary outcome was the rate of response at the end of the third-week post treatment. The rate of response was more in the group started the treatment intravenously (81.6% versus 41.7% and p = 0.0001). Multivariate cox regression analysis proved the predictivity of intravenous corticosteroid therapy for initial response. CONCLUSION The safety profile of the different forms and regimens of corticosteroids were comparable. Therefore, parenteral regimens can be used as a rescue treatment in severe cases of WAIHA.
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Affiliation(s)
- Ghada E M Abdallah
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Wael A Abbas
- Department of Internal Medicine, Faculty of Medicine, Assiut University Assiut, Egypt
| | - Esam A S Elbeih
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ehab Abdelmenam
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mostafa F Mohammed Saleh
- Clinical Hematology Unit, Department of Internal Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
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Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a low platelet count (<100 × 109/L) with an increased risk of bleeding. Recent (2019) guidelines from the International Consensus Report (ICR) expert panel and the American Society of Hematology (ASH) provide updated recommendations for the diagnosis and management of ITP. AREAS COVERED The 2019 ICR and ASH guidelines are reviewed, and differences and similarities highlighted. Clinical approaches to the treatment of ITP are discussed, including the role of fostamatinib which is an approved treatment option in adult patients who are refractory to other treatments. EXPERT OPINION The 2019 ICR and ASH guidelines reflect recent changes in the management of ITP. Current treatment approaches for ITP are more rational and evidence-based than in the past. Patients should be treated based on their needs rather than on disease stage, and patient-specific outcomes, (e.g. quality of life) should be considered. Whilst corticosteroids are the mainstay of initial ITP treatment their use should be limited. For subsequent treatment, the use of thrombopoietin receptor agonist (TPO-RA) agents, fostamatinib and rituximab in adults is supported by robust evidence. Rituximab and recently approved fostamatinib offer viable alternatives to splenectomy.
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Affiliation(s)
- James Bussel
- Professor Emeritus, Weill Cornell Medicine, New York, USA
| | - Nichola Cooper
- Senior Lecturer and Honorary Consultant Haematologist, Imperial College, London, UK
| | - Ralph Boccia
- Clinical Associate Professor of Medicine, Georgetown University, Washington DC and Medical Director, Center for Cancer and Blood Disorders, Bethesda, USA
| | - Francesco Zaja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Sc Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Adrian Newland
- Professor of Haematology, Barts and the London School of Medicine and Dentistry, London, UK
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Ishiyama M, Shiseki M, Yoshinaga K, Ryuzaki M, Izuka Y, Watanabe A, Tanaka N, Shinohara A, Hagiwara S, Tanaka J. Very Early Increased Platelet Count within a Week after Initiation of High-Dose Dexamethasone Treatment Is Associated with Long-Term Response in Newly Diagnosed Immune Thrombocytopenia Patients. Acta Haematol 2021; 145:193-200. [PMID: 34818223 DOI: 10.1159/000518744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/28/2021] [Indexed: 11/19/2022]
Abstract
To evaluate the long-term efficacy of high-dose dexamethasone (HD-DXM) treatment for immune thrombocytopenia (ITP), we retrospectively analysed 36 newly diagnosed ITP patients treated with HD-DXM as a first-line treatment. An initial response was obtained in 23 (63.9%) patients, including 11 with a complete response (CR) and 12 with a partial response (PR). Six months after HD-DXM treatment, 26 of 33 (78.8%) evaluable patients achieved objective responses, including 18 CR and 8 PR. Among 13 patients without initial response, very early increased platelet count within a week (VEIP) was observed in 7 patients, 5 (71.4%) of whom achieved a response at 6 months. In 29 patients who had available platelet count within a week, patients showing VEIP revealed longer survival than those who did not (p = 0.026). HD-DXM was an effective treatment for newly diagnosed ITP patients. VEIP after HD-DXM treatment initiation was associated with a long-term objective response in newly diagnosed ITP patients.
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Affiliation(s)
- Midori Ishiyama
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan,
| | - Masayuki Shiseki
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kentaro Yoshinaga
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Michiko Ryuzaki
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuki Izuka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Aya Watanabe
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Norina Tanaka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Akihito Shinohara
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shotaro Hagiwara
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Junji Tanaka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
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All-trans retinoic acid plus low-dose rituximab vs low-dose rituximab in corticosteroid-resistant or relapsed ITP. Blood 2021; 139:333-342. [PMID: 34665865 DOI: 10.1182/blood.2021013393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
The study aimed to compare the efficacy and safety of all-trans retinoic acid (ATRA) plus low-dose rituximab (LD-RTX) with LD-RTX monotherapy in corticosteroid-resistant or relapsed immune thrombocytopenia (ITP) patients. Recruited patients were randomized at a ratio of 2:1 into 2 groups: 112 patients received LD-RTX plus ATRA and 56 patients received LD-RTX monotherapy. Overall response (OR), defined as achieving a platelet count of ≥ 30 × 109/L confirmed on at least two separate occasions (at least 7 days apart), at least a doubling of the baseline platelet count without any other ITP-specific treatment and the absence of bleeding within 1 year after enrollment, was observed in more patients in the LD-RTX plus ATRA group (80%) than in the LD-RTX monotherapy group (59%) (between-group difference, 0.22; 95% CI, 0.07 to 0.36). Sustained response (SR), defined as maintenance of a platelet count > 30 x 109/L, an absence of bleeding, and no requirement for any other ITP-specific treatment for 6 consecutive months after achievement of OR during 1 year following enrollment, was achieved by 68 (61%) patients in the combination group and 23 (41%) patients in the monotherapy group (between-group difference, 0.20; 95% CI, 0.04 to 0.35). The 2 most common AEs for the combination group were dry skin and headache or dizziness. Our findings demonstrated that ATRA plus LD-RTX significantly increased the overall and sustained response, indicating a promising treatment option for corticosteroid-resistant or relapsed adult ITP. This study is registered at www.clinicaltrials.gov as #NCT03304288.
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43
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Choi PY, Merriman E, Bennett A, Enjeti AK, Tan CW, Goncalves I, Hsu D, Bird R. Consensus guidelines for the management of adult immune thrombocytopenia in Australia and New Zealand. Med J Aust 2021; 216:43-52. [PMID: 34628650 PMCID: PMC9293212 DOI: 10.5694/mja2.51284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 01/21/2023]
Abstract
Introduction The absence of high quality evidence for basic clinical dilemmas in immune thrombocytopenic purpura (ITP) underlines the need for contemporary guidelines relevant to the local treatment context. ITP is diagnosed by exclusions, with a hallmark laboratory finding of isolated thrombocytopenia. Main recommendations Bleeding, family and medication histories and a review of historical investigations are required to gauge the bleeding risk and possible hereditary syndromes. Beyond the platelet count, the decision to treat is affected by individual bleeding risk, disease stage, side effects of treatment, concomitant medications, and patient preference. Treatment is aimed at achieving a platelet count > 20 × 109/L, and avoidance of severe bleeding. Steroids are the standard first line treatment, with either 6‐week courses of tapering prednisone or repeated courses of high dose dexamethasone providing equivalent efficacy. Intravenous immunoglobulin can be used periprocedurally or as first line therapy in combination with steroids. Changes in management as a result of this statement There is no consensus on choice of second line treatments. Options with the most robust evidence include splenectomy, rituximab and thrombopoietin receptor agonists. Other therapies include azathioprine, mycophenolate mofetil, dapsone and vinca alkaloids. Given that up to one‐third of patients achieve a satisfactory haemostatic response, splenectomy should be delayed for at least 12 months if possible. In life‐threatening bleeding, we recommend platelet transfusions to achieve haemostasis, along with intravenous immunoglobulin and high dose steroids.
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Affiliation(s)
- Philip Yi Choi
- Canberra Hospital, Canberra, ACT.,Australian National University, Canberra, ACT
| | | | - Ashwini Bennett
- Monash Medical Centre, Melbourne, VIC.,Monash University, Melbourne, VIC
| | - Anoop K Enjeti
- Calvary Mater Hospital, Newcastle, NSW.,University of Newcastle, Newcastle, NSW
| | - Chee Wee Tan
- Royal Adelaide Hospital, Adelaide, SA.,SA Pathology, Adelaide, SA
| | - Isaac Goncalves
- Peter MacCallum Cancer Centre, Melbourne, VIC.,Royal Melbourne Hospital, Melbourne, VIC
| | - Danny Hsu
- South Western Sydney Local Health District, Sydney, NSW.,University of New South Wales, Sydney, NSW
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Huang QS, Liu Y, Wang JB, Peng J, Hou M, Liu H, Feng R, Wang JW, Xu LP, Wang Y, Huang XJ, Zhang XH. All-trans retinoic acid plus high-dose dexamethasone as first-line treatment for patients with newly diagnosed immune thrombocytopenia: a multicentre, open-label, randomised, controlled, phase 2 trial. Lancet Haematol 2021; 8:e688-e699. [PMID: 34560012 DOI: 10.1016/s2352-3026(21)00240-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/26/2021] [Accepted: 07/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND High-dose dexamethasone is the standard initial treatment for patients with immune thrombocytopenia, but many patients still relapse and require further treatments. All-trans retinoic acid has been shown to exert immunomodulatory effects and promote thrombopoiesis, and so we aimed to assess the activity and safety of all-trans retinoic acid plus high-dose dexamethasone as a first-line treatment for newly diagnosed patients with immune thrombocytopenia. METHODS This multicentre, open-label, randomised, controlled, phase 2 trial was done at six different tertiary medical centres in China. Eligible participants were adults (aged >18 years) with treatment-naive, newly diagnosed, primary immune thrombocytopenia who had either a platelet count of less than 30 × 109 platelets per L or a platelet count of less than 50 × 109 platelets per L and clinically significant bleeding. We randomly assigned (1:1) participants to receive either all-trans retinoic acid (10 mg orally twice daily for 12 weeks) plus high-dose dexamethasone (40 mg/day intravenously for 4 consecutive days) or high-dose dexamethasone alone using a central, web-based randomisation system. If patients did not respond by day 14, the 4-day course of dexamethasone was repeated. The primary endpoint was 6-month sustained response, defined as the maintenance of a platelet count of at least 30 × 109 platelets per L and at least 2-times higher than the baseline count and the absence of bleeding, with no need for rescue medication at this time. The primary endpoint was analysed by intention-to-treat and safety was assessed in all participants who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov, NCT04217148, and is now completed. FINDINGS Between Jan 1, 2020, and June 30, 2020, 132 patients were randomly assigned to either all-trans retinoic acid plus high-dose dexamethasone (n=66) or high-dose dexamethasone alone (n=66). Three patients did not receive their allocated treatment, leaving 129 in the safety analysis set. At 6 months, a significantly higher proportion of participants in the all-trans retinoic acid plus high-dose dexamethasone group (45 [68%] of 66) than in the high-dose dexamethasone monotherapy group (27 [41%] of 66) had a sustained response (OR 3·095, 95% CI 1·516-6·318; p=0·0017). The most common adverse events were dry skin (31 [48%] of 64 patients), headaches (12 [19%]), and insomnia (12 [19%]) in the combination group, and insomnia (ten [15%] of 65 patients) and anxiety or mood disorders (eight [12%]) in the monotherapy group. Both treatments were well tolerated and no grade 4 or worse adverse events occurred. There were no treatment-related deaths. INTERPRETATION The combination of all-trans retinoic acid and high-dose dexamethasone was safe and active in newly diagnosed patients with primary immune thrombocytopenia, providing a sustained response. This regimen represents a potential first-line treatment in this setting, but further studies are needed to validate its efficacy and safety. FUNDING The Beijing Municipal Science and Technology Commission, the National Natural Science Foundation of China, the Beijing Natural Science Foundation, the National Key Research and Development Program of China, and the Foundation for Innovative Research Groups of the National Natural Science Foundation of China.
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Affiliation(s)
- Qiu-Sha Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yi Liu
- Department of Hematology, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Jing-Bo Wang
- Department of Hematology, Beijing Aerospace General Hospital, Beijing, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Hui Liu
- Department of Hematology, National Centre of Gerontology, Beijing Hospital, Beijing, China
| | - Ru Feng
- Department of Hematology, National Centre of Gerontology, Beijing Hospital, Beijing, China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Beijing, China
| | - Lan-Ping Xu
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yang Wang
- Biological Information and Statistics Center, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Jun Huang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China; National Clinical Research Center for Hematologic Disease, Beijing, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Collaborative Innovation Center of Hematology, Peking University, Beijing, China.
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Sandvad M, Pedersen EA, Frederiksen H, Mannering N. Risk of infection in adult patients with primary immune thrombocytopenia (ITP): a systematic review. Expert Rev Hematol 2021; 14:961-974. [PMID: 34487679 DOI: 10.1080/17474086.2021.1976635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is a bleeding disorder characterized by autoimmune destruction and impaired production of platelets. Immunosuppressive drugs are the main treatment and may increase risk of infection. AREAS COVERED This systematic review included studies incorporating adult patients with primary ITP and infectious outcomes. Studies comparing risk of infection with the general population were included as primary and studies without this comparison were considered secondary. Three primary and 10 secondary studies were included. The main findings: 1-year adjusted relative-risk of infection was 4.5 (95% CI, 3.3-6.1) fold elevated compared to the general population. When comparing splenectomized with non-splenectomized ITP patients, the +1-year adjusted relative-risk of infection was 4.0 (95% CI, 2.8-5.6). The unadjusted 5-year mortality rate-ratio for infection-related deaths was 6.0 (95% CI, 3.0-11.8) in one study, and the hazard ratio was 2.4 (95% CI, 1.0-5.7) for fatal infections in another. EXPERT OPINION This review emphasizes that patients with ITP have increased risk of infection. Since ITP is a benign hematologic disease, it is important to assess the extent and causes of infection in the clinical care and considerations before initiating treatment. More homogeneous studies are needed on this topic.
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Affiliation(s)
- Melanie Sandvad
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Nikolaj Mannering
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Hematology, Odense University Hospital, Odense, Denmark
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Bradbury CA, Pell J, Hill Q, Bagot C, Cooper N, Ingram J, Breheny K, Kandiyali R, Rayment R, Evans G, Talks K, Thomas I, Greenwood R. Mycophenolate Mofetil for First-Line Treatment of Immune Thrombocytopenia. N Engl J Med 2021; 385:885-895. [PMID: 34469646 DOI: 10.1056/nejmoa2100596] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Immune thrombocytopenia is a rare autoimmune disorder with associated bleeding risk and fatigue. Recommended first-line treatment for immune thrombocytopenia is high-dose glucocorticoids, but side effects, variable responses, and high relapse rates are serious drawbacks. METHODS In this multicenter, open-label, randomized, controlled trial conducted in the United Kingdom, we assigned adult patients with immune thrombocytopenia, in a 1:1 ratio, to first-line treatment with a glucocorticoid only (standard care) or combined glucocorticoid and mycophenolate mofetil. The primary efficacy outcome was treatment failure, defined as a platelet count of less than 30×109 per liter and initiation of a second-line treatment, assessed in a time-to-event analysis. Secondary outcomes were response rates, side effects, occurrence of bleeding, patient-reported quality-of-life measures, and serious adverse events. RESULTS A total of 120 patients with immune thrombocytopenia underwent randomization (52.4% male; mean age, 54 years [range 17 to 87]; mean platelet level, 7×109 per liter) and were followed for up to 2 years after beginning trial treatment. The mycophenolate mofetil group had fewer treatment failures than the glucocorticoid-only group (22% [13 of 59 patients] vs. 44% [27 of 61 patients]; hazard ratio, 0.41; range, 0.21 to 0.80; P = 0.008) and greater response (91.5% of patients having platelet counts greater than 100×109 per liter vs. 63.9%; P<0.001). We found no evidence of a difference between the groups in the occurrence of bleeding, rescue treatments, or treatment side effects, including infection. However, patients in the mycophenolate mofetil group reported worse quality-of-life outcomes regarding physical function and fatigue than those in the glucocorticoid-only group. CONCLUSIONS The addition of mycophenolate mofetil to a glucocorticoid for first-line treatment of immune thrombocytopenia resulted in greater response and a lower risk of refractory or relapsed immune thrombocytopenia, but with somewhat decreased quality of life. (Funded by the U.K. National Institute for Health Research; FLIGHT ClinicalTrials.gov number, NCT03156452; EudraCT number, 2017-001171-23.).
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Affiliation(s)
- Charlotte A Bradbury
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Julie Pell
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Quentin Hill
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Catherine Bagot
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Nichola Cooper
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Jenny Ingram
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Katie Breheny
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Rebecca Kandiyali
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Rachel Rayment
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Gillian Evans
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Kate Talks
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Ian Thomas
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Rosemary Greenwood
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
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Yuan B, Yin C, Ye X, Bai Z, Lu Z, Li X, Al-Azab M, Mu L, Li W. Differential effects of Huaier aqueous extract on human CD4 +T lymphocytes from patients with primary immune thrombocytopenia. Exp Hematol 2021; 101-102:58-67. [PMID: 34450221 DOI: 10.1016/j.exphem.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 08/05/2021] [Accepted: 08/11/2021] [Indexed: 02/07/2023]
Abstract
Huaier, a traditional Chinese medicine, is currently used to treat certain types of cancer in the clinic and is also regarded as an immune-modulating and immune-enhancing agent that regulates immune cells. Emerging evidence indicates that an imbalance of immune cells, such as CD4+ T helper (Th) lymphocytes, contributes to the progression of immune thrombocytopenia (ITP), but the effects of Huaier on the regulation of CD4+ T cells are not yet fully elucidated. In the present study, Jurkat cells and peripheral blood mononuclear cells (PBMCs) from patients with ITP and healthy volunteers were treated with Huaier aqueous extract (HR). The CCK-8 assay revealed that HR suppressed the proliferation of Jurkat cells in a dose-dependent manner, whereas 3 mg/mL could decrease cell viability by 50%. At the latter concentration, the activation of CD4+ T cells from patients with ITP was partially attenuated. In addition, HR could correct the unbalanced Th1/Th2 polarization and inhibit the secretion of pro-inflammatory factors interleukin (IL)-2, tumor necrosis factor-α, and interferon-γ. It also suppressed Treg and facilitated Th17 differentiation, but did not change the levels of IL-10 and transforming growth factor-β. Thus, this study provides more information on how Huaier regulates cellular immunity and improves our understanding of the use of Huaier in ITP.
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Affiliation(s)
- Bo Yuan
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Chunlai Yin
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Xiaokang Ye
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Ziran Bai
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Zhimin Lu
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Xia Li
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Mahmoud Al-Azab
- Department of Immunology, Dalian Medical University, Dalian, Liaoning, China
| | - Lijun Mu
- Department of Hematology, Second Hospital of Dalian Medical University, Dalian, Liaoning, China.
| | - Weiping Li
- Department of Hematology, Second Hospital of Dalian Medical University, Dalian, Liaoning, China; Department of Immunology, Dalian Medical University, Dalian, Liaoning, China.
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48
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Cuker A, Liebman HA. Corticosteroid overuse in adults with immune thrombocytopenia: Cause for concern. Res Pract Thromb Haemost 2021; 5:e12592. [PMID: 34466771 PMCID: PMC8387601 DOI: 10.1002/rth2.12592] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/20/2021] [Accepted: 08/02/2021] [Indexed: 01/20/2023] Open
Abstract
Corticosteroids remain a crucial component of first-line therapy for immune thrombocytopenia (ITP) due to low cost, high initial response rates, and acceptable short-term tolerability. However, extended and recurrent use of corticosteroids is associated with substantial toxicity. Survey studies indicate that >95% of patients with ITP treated with corticosteroids report adverse effects, more than one-third of whom require reduction or discontinuation of treatment. In light of the heavy treatment burden of prolonged corticosteroid exposure, clinical practice guidelines recommend limiting corticosteroid treatment to no more than 6 weeks in adults with ITP receiving initial therapy. For patients who require subsequent therapy, clinical practice guidelines recommend treatments more suitable for long-term disease control such as thrombopoietin receptor agonists, rituximab, other immune-modulating medications, or splenectomy, rather than repeated courses of corticosteroids. Despite these recommendations, real-world evidence suggests that corticosteroids remain the most frequently used treatment for adults with ITP, not only in the first line, but also in the second and third line. In this review, we summarize evidence on the efficacy, safety, and tolerability of corticosteroids; discuss the problem of overuse; and suggest strategies for curtailing the excessive use of corticosteroids in adults with ITP.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Howard A. Liebman
- Jane Anne Nohl Division of HematologyDepartment of MedicineNorris Cancer CenterUniversity of Southern California‐Keck School of MedicineLos AngelesCAUSA
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Wang S, Zhang X, Leng S, Zhang Y, Li J, Peng J, Zhou Z, Feng Q, Hu X. SIRT1 single-nucleotide polymorphisms are associated with corticosteroid sensitivity in primary immune thrombocytopenia patients. Ann Hematol 2021; 100:2453-2462. [PMID: 34269838 DOI: 10.1007/s00277-021-04583-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/22/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by decreased platelet count. While corticosteroids are a useful first-line therapy for ITP patients, their long-term effectiveness is limited, and the determinants of corticosteroid sensitivity in ITP patients remain largely unknown. Sirtuin 1 (SIRT1), a member of the mammalian sirtuin family, is related to the anti-inflammatory effects of corticosteroids. Here, we investigate the contribution of the SIRT1 single-nucleotide polymorphisms (SNPs) rs12778366 and rs4746720 to ITP susceptibility. METHODS We recruited 330 ITP patients and 309 healthy controls from Han population, and performed genotyping of SIRT1 rs12778366 and rs4746720 using a MassARRAY system. The results were validated in another 55 ITP patients from ethnic minorities. RESULTS Using clinical data of patients and controls from Han polulation, including corticosteroid sensitivity, susceptibility, refractoriness, and severity, our results revealed that the CC/TC genotypes of SIRT1 rs12778366 were associated with a 2.034-fold increased risk of corticosteroid resistance compared to the homozygous major TT genotype (dominant, CC/TC vs. TT, OR = 2.034, 95% CI = 1.039-3.984, p = 0.038). In contrast, the CC/CT genotype of SIRT1 rs4746720 showed a 0.560-fold decreased risk of corticosteroid resistance (dominant, 95% CI = 0.321-0.976, OR = 0.560, p = 0.041). The C allele substitute in SIRT1 rs12778366 was significantly associated with the corticosteroid sensitivity of ITP patients (p = 0.021). The similar results were obtained in minority ITP patients. CONCLUSION This study indicates that SIRT1 rs12778366 and rs4746720 may be genetic factors related to corticosteroid sensitivity in ITP patients.
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Affiliation(s)
- Shuwen Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyu Zhang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shaoqiu Leng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yanqi Zhang
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ju Li
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Zeping Zhou
- Department of Hematology, the Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China.
| | - Qi Feng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
| | - Xiang Hu
- Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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50
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Li C, Li L, Sun M, Sun J, Shao L, Xu M, Hou Y, Peng J, Wang L, Hou M. Predictive Value of High ICAM-1 Level for Poor Treatment Response to Low-Dose Decitabine in Adult Corticosteroid Resistant ITP Patients. Front Immunol 2021; 12:689663. [PMID: 34326842 PMCID: PMC8313967 DOI: 10.3389/fimmu.2021.689663] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/15/2021] [Indexed: 11/13/2022] Open
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune hemorrhagic disease. Endothelial cell activation/injury has been found in some autoimmune diseases including SLE, systemic sclerosis, and rheumatoid arthritis, but its role in ITP pathogenesis remains unclear. This study attempted to elucidate the correlation between endothelial dysfunction and disease severity of ITP and find related markers to predict response to low-dose decitabine treatment. Compared with healthy volunteers, higher plasma levels of soluble intercellular adhesion molecule-1 (ICAM-1), vascular endothelial growth factor (VEGF), and Angiopoietin-2 were found in adult corticosteroid resistant ITP patients. Notably, ICAM-1 levels were negatively correlated with the platelet count, and positively associated with the bleeding score. Recently, we have reported the efficacy and safety of low-dose decitabine in adult patients with ITP who failed for the first line therapies. Here, we evaluated the correlation of plasma ICAM-1 level with the efficacy of low-dose decitabine therapy for corticosteroid resistant ITP. A total of 29 adult corticosteroid resistant ITP patients who received consecutive treatments of low-dose decitabine were enrolled in this study. Fourteen patients showed response (nine showed complete response and five showed partial response). The levels of ICAM-1 before and after treatment were significantly higher in the non-responsive ITP patients than in the responsive patients. As shown in the multivariable logistic regression model, the odds of developing no-response to low-dose decitabine increased by 36.8% for per 5 ng/ml increase in plasma ICAM-1 level [odds ratio (OR) 1.368, 95% confidence interval (CI): 1.060 to 1.764]. In summary, this was the first study to elucidate the relationship between endothelial dysfunction and corticosteroid resistant ITP and identify the potential predictive value of ICAM-1 level for response to low-dose decitabine.
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Affiliation(s)
- Chaoyang Li
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Lizhen Li
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Meng Sun
- Jinan Vocational College of Nursing, Jinan, China
| | - Jianzhi Sun
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Linlin Shao
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Miao Xu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Lin Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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