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Beltrami-Moreira M, Sharma A, Bussel JB. Immune thrombocytopenia and pregnancy: challenges and opportunities in diagnosis and management. Expert Rev Hematol 2024:1-13. [PMID: 39105265 DOI: 10.1080/17474086.2024.2385481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 06/13/2024] [Accepted: 07/24/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) affecting pregnancy is a diagnostic and often a therapeutic challenge. AREAS COVERED We review the current diagnostic criteria for ITP in pregnancy and the potential utility of laboratory tests. We discuss the impact of ITP on pregnancy outcomes and the effects of pregnancy on patients living with chronic ITP. We describe the criteria for intervention, the evidence supporting first-line treatment approaches and the therapeutic decisions and challenges in cases refractory to steroids and IVIG. We review the evidence supporting the potential use of thrombopoietin receptor agonists for refractory thrombocytopenia. Finally, we describe the diagnostic, prognostic, and treatment approaches to neonatal ITP and considerations regarding breastfeeding. We searched the terms 'immune thrombocytopenia' and 'pregnancy' on PubMed to identify the relevant literature published before 31 December 2023, including within cited references. EXPERT OPINION Decreased platelet production may play a role in pregnancy-related ITP exacerbation. Putative mechanisms include placental hormones, such as inhibin. Although IVIG and prednisone usually suffice to achieve hemostasis for delivery, second-line agents are sometimes required to allow for neuraxial anesthesia. There is growing evidence supporting the use of romiplostim during pregnancy; however, its risk of venous thromboembolism warrants further evaluation.
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Affiliation(s)
- Marina Beltrami-Moreira
- Department of Medicine, Division of Hematology, The Ohio State University Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amy Sharma
- Department of Hematology-Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Division of Hematology, New York, NY, USA
| | - James B Bussel
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, Department of Pediatrics and Department of Medicine, Division of Hematology and Medical Oncology, New York, NY, USA
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Qiu X, Jiang H, Xiao X, Huang L, Xu Y. Recombinant human thrombopoietin improves platelet engraftment after autologous hematopoietic stem cell transplantation in patients with aggressive lymphoma. Transfus Apher Sci 2024; 63:103972. [PMID: 39013350 DOI: 10.1016/j.transci.2024.103972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 06/30/2024] [Accepted: 07/01/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND To explore the efficiency and safety of recombinant human thrombopoietin (TPO) on the platelet engraftment after autologous stem cell transplantation (ASCT) in patients with aggressive lymphoma. PATIENTS AND METHODS Forty patients were enrolled in a single-center, retrospective clinical trial from July 2019 with rhTPO administration when the platelet count ≤ 75 × 109/L after the reinfusion of stem cells. The hematopoietic reconstitution, platelet transfusion dependence, the cost and length of hospitalization, side effects and survival benefit were compared between the rhTPO group and the control group of 25 historic patients without rhTPO. RESULTS The cumulative incidence of platelet engraftment in the rhTPO group was significantly higher since d+ 13 post-transplantation. But no difference of neutrophil engraftment was found. rhTPO was considered to influence the platelet engraftment independently by multivariate analysis. Subgroup analysis demonstrated that when the patients were older than 45 years old, male, at stage-IV as diagnosed and obtained PR after previous treatment, rhTPO was more recommended to facilitate platelet early engraftment after ASCT. Although rhTPO didn't relieve the dependency of platelet transfusion, patients had the shorter length of hospitalization. And better OS was shown in the rhTPO group. CONCLUSION rhTPO improved platelet engraftment after ASCT with aggressive lymphoma, especially the ones older than 45 years old, male, at stage-IV as diagnosed and obtained PR after previous treatment. Although rhTPO didn't lessen platelet transfusion dependence, the length and medical cost of hospitalization were reduced when rhTPO was involved. rhTPO was efficacy and safety which could be recommended after ASCT.
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Affiliation(s)
- Xi Qiu
- The Department of Hematology, Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Huawei Jiang
- The Department of Hematology, Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Xibin Xiao
- The Department of Hematology, Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Liansheng Huang
- The Department of Hematology, Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China
| | - Yang Xu
- The Department of Hematology, Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Hangzhou 310009, China.
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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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Liu X, Bai Y, Wang T, Song Y, Sun F, Xia R, Zhu F, Ma J, Lu Q, Ye X, Zhan X, Li L, Guo X, Cheng S, Li Y, Guo Z, Chen Y, Qian S, Qin L, Zhang Q, Cao S, Yang R. Recombinant human thrombopoietin (rhTPO) of different dosing regimens for refractory/relapsed primary immune thrombocytopenia: a multicenter, randomized controlled trial and pharmacokinetics study. Platelets 2023; 34:2157806. [PMID: 36597010 DOI: 10.1080/09537104.2022.2157806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recombinant human TPO (rhTPO) is effective for refractory/relapsed primary immune thrombocytopenia (ITP), but optimal dosing regimen remains elusive. In this multicenter, randomized, controlled trial, a total of 282 adult ITP patients (mean age 47.3 years; 82 men) with a platelet count ≤30 × 109/L or >30 × 109/L with active bleeding randomly received a once daily (QD) subcutaneous injection of 7500 U (n = 64) or 15000 U rhTPO for 14 injections, or 15000 U or 30000 U rhTPO once every other day (QOD) for 7 injections. The primary outcomes included change from baseline in platelet count and total response rate (TRR) on day 14. On day 14, the median increase of platelet count from baseline was the highest in the 15000-U QD group (167.5 × 109/L, interquartile range [IQR] 23.0-295.0 × 109/L), followed by the 30000-U QOD group (57.5 × 109/L, IQR 9.0-190.0 × 109/L) (ANCOVA P < .001; P = .266 with baseline count as a covariate). The TRR on day 14 was also the highest in the 15000-U QD group (63.2%), followed by the 30000-U QOD group (59.7%). The rate of grade 3 and above adverse events did not differ among the four groups. There were no new safety concerns. All 4 regimens are safe and well-tolerated. The 30000-U QOD regimen is practically indistinguishable in efficacy to the 15000-U QD regimen.
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Affiliation(s)
- Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Yusheng Bai
- Department of Hematology, Traditional Chinese Medical Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, China
| | - Tao Wang
- Department of Hematology, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Yanping Song
- Department of Hematology, Xi'an Central Hospital, Xi'an, Shaanxi, China
| | - Feng Sun
- Department of Hematology, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Ruixiang Xia
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, China
| | - Feiyue Zhu
- Department of Hematology, Loudi Central Hospital, Loudi, Hunan, China
| | - Jun Ma
- Department of Hematology, Harbin Institute of Hematology and Oncology, Harbin, Heilongjiang, China
| | - Quanyi Lu
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China
| | - Xu Ye
- Department of Hematology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xinrong Zhan
- Department of Hematology, Xinxiang Central Hospital, Xinxiang, Henan, China
| | - Linjie Li
- Department of Hematology, Lishui Central Hospital, Lishui, Zhejiang, China
| | - Xinhong Guo
- Department of Hematology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Shuqin Cheng
- Department of Hematology, Guangzhou Panyu Central Hospital, Guangzhou, Guangdong, China
| | - Yan Li
- Department of Hematology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhiqiang Guo
- Department of Hematology, Zhengzhou Central Hospital, Zhengzhou, Henan, China
| | - Youhua Chen
- Department of Hematology, Renmin Hospital of Wuhan University, Hubei General Hospital, Wuhan, Hubei, China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ling Qin
- Department of Hematology, The First Affiliated Hospital of Henan Technology University, Luoyang, Henan, China
| | - Qing Zhang
- Department of Hematology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Sunqiong Cao
- Medical Department, Shenyang Sunshine Pharmaceuticals Co. Ltd, Shenyang, Liaoning, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
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Rottenstreich A, Bussel JB. Treatment of immune thrombocytopenia during pregnancy with thrombopoietin receptor agonists. Br J Haematol 2023; 203:872-885. [PMID: 37830251 DOI: 10.1111/bjh.19161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 09/30/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
The introduction of thrombopoietin receptor agonists (TPO-RAs) led to a paradigm shift in the management of immune thrombocytopenia (ITP). However, TPO-RAs are not approved for use during pregnancy due to the absence of evidence and concerns for possible effects on the fetus due to their expected transplacental transfer. This comprehensive review examines the safety and efficacy of TPO-RA in 45 pregnancies of women with ITP (romiplostim n = 22; eltrombopag n = 21; both in the same pregnancy n = 2). Mothers experienced failure of the median of three treatment lines during pregnancy prior to TPO-RA administration. A platelet response (>30 × 109 /L) was seen in 86.7% of cases (including a complete response >100 × 109 /L in 66.7%) and was similar between eltrombopag and romiplostim (87.0% and 83.3%, p = 0.99). The maternal safety profile was favourable, with no thromboembolic events encountered. Neonatal thrombocytopenia was noted in one third of cases, with one case of ICH grade 3, and neonatal thrombocytosis was observed in three cases. No other neonatal adverse events attributable to TPO-RAs were seen. This review suggests that the use of TPO-RA during pregnancy is associated with a high response rate and appears safe. Nevertheless, TPO-RA should not be routinely used in pregnancy and should be avoided in the first trimester until further evidence is accumulated.
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Affiliation(s)
- Amihai Rottenstreich
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
- Laboratory of Blood and Vascular Biology, Rockefeller University, New York, New York, USA
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
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Lin J, Wang TF, Huang MJ, Huang HB, Chen PF, Zhou Y, Dai WC, Zhou L, Feng XS, Wang HL. Recombinant human thrombopoietin therapy for primary immune thrombocytopenia in pregnancy: a retrospective comparative cohort study. BMC Pregnancy Childbirth 2023; 23:820. [PMID: 38012579 PMCID: PMC10680270 DOI: 10.1186/s12884-023-06134-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Treatment options for pregnant women with immune thrombocytopenia (ITP) who do not respond to first-line treatment are limited. Few studies have reported the use of recombinant human thrombopoietin (rhTPO) for this subset of patients. AIMS To investigate the efficacy and safety of rhTPO in ITP during pregnancy and determine obstetric outcomes and predictors of treatment response. METHODS From July 2013 to October 2022, the data of 81 pregnant women with ITP and a platelet count < 30 × 109/L who did not respond to steroids and/or intravenous immunoglobulin were retrospectively analysed. Of these patients, 33 received rhTPO treatment (rhTPO group) while 48 did not (control group). Baseline characteristics, haematological disease outcomes before delivery, obstetric outcomes, and adverse events were compared between groups. In the rhTPO group, a generalised estimating equation (GEE) was used to investigate the factors influencing the response to rhTPO treatment. RESULTS The baseline characteristics were comparable between both groups (P > 0.05, both). Compared with controls, rhTPO patients had higher platelet counts (median [interquartile range]: 42 [21.5-67.5] vs. 25 [19-29] × 109/L, P = 0.002), lower bleeding rate (6.1% vs. 25%, P = 0.027), and lower platelet transfusion rate before delivery (57.6% vs. 97.9%, P < 0.001). Gestational weeks of delivery (37.6 [37-38.4] vs 37.1 [37-37.2] weeks, P = 0.001) were longer in the rhTPO group than in the control group. The rates of caesarean section, postpartum haemorrhage, foetal or neonatal complications, and complication types in both groups were similar (all P > 0.05). No liver or renal function impairment or thrombosis cases were observed in the rhTPO group. GEE analysis revealed that the baseline mean platelet volume (MPV) (odds ratio [OR]: 0.522, P = 0.002) and platelet-to-lymphocyte ratio (PLR) (OR: 1.214, P = 0.025) were predictors of response to rhTPO treatment. CONCLUSION rhTPO may be an effective and safe treatment option for pregnancies with ITP that do not respond to first-line treatment; it may have slightly prolonged the gestational age of delivery. Patients with a low baseline MPV and high baseline PLR may be more responsive to rhTPO treatment. The present study serves as a foundation for future research.
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Affiliation(s)
- Jing Lin
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Tong-Fei Wang
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Mei-Juan Huang
- Fujian Institute of Haematology, Fujian Provincial Key Laboratory of Haematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hao-Bo Huang
- Department of Blood Transfusion, Fujian Medical University Union Hospital, Fuzhou, China
| | - Pei-Fang Chen
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yu Zhou
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wei-Chao Dai
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ling Zhou
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xiu-Shan Feng
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Hui-Lan Wang
- Department of Ob and Gyn, Fujian Medical University Union Hospital, Fuzhou, China.
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7
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Affiliation(s)
- James B Bussel
- From the Department of Pediatrics, Weill Cornell Medicine, New York (J.B.B.); the Department of Hematology, Qilu Hospital of Shandong University, Shandong University, Jinan, China (M.H.); and the Departments of Pathology and Laboratory Medicine and Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (D.B.C.)
| | - Ming Hou
- From the Department of Pediatrics, Weill Cornell Medicine, New York (J.B.B.); the Department of Hematology, Qilu Hospital of Shandong University, Shandong University, Jinan, China (M.H.); and the Departments of Pathology and Laboratory Medicine and Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (D.B.C.)
| | - Douglas B Cines
- From the Department of Pediatrics, Weill Cornell Medicine, New York (J.B.B.); the Department of Hematology, Qilu Hospital of Shandong University, Shandong University, Jinan, China (M.H.); and the Departments of Pathology and Laboratory Medicine and Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (D.B.C.)
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Yu J, Miao P, Qian S. Application of recombinant human thrombopoietin in pregnant women with immune thrombocytopenia: a single-center experience of four patients and literature review. J Int Med Res 2023; 51:3000605231187950. [PMID: 37548331 PMCID: PMC10408329 DOI: 10.1177/03000605231187950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023] Open
Abstract
The management of pregnant women with immune thrombocytopenia who fail to respond to corticosteroids and intravenous immunoglobulin is an intractable clinical challenge because of the limited availability of evidence-based information. Recombinant human thrombopoietin (rhTPO) is recommended for refractory immune thrombocytopenia (ITP). To date, however, few studies have investigated rhTPO treatment during pregnancy. We retrospectively reviewed four cases who were diagnosed with ITP and treated with rhTPO during pregnancy in our center from January 2015 to June 2020. Of the four cases, two (50%) responded to rhTPO treatment. No adverse events were noted in the newborns. Our findings indicate that rhTPO treatment is safe for patients with refractory gestational ITP, and that subcutaneous injection is a convenient delivery method that does not lead to adverse events. Thus, rhTPO may be a viable alternative treatment option for patients with refractory gestational ITP who do not respond to first-line therapies.
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Affiliation(s)
- Jingdi Yu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Peiwen Miao
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang Chinese Medical University, Hangzhou, China
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[Chinese expert consensus on the clinical application of recombinant human thrombopoiein and thrombopoiein receptor agonist (2023)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:535-542. [PMID: 37749031 PMCID: PMC10509622 DOI: 10.3760/cma.j.issn.0253-2727.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Indexed: 09/27/2023]
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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: 15] [Impact Index Per Article: 15.0] [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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11
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Bussel JB, Cooper N, Lawrence T, Michel M, Vander Haar E, Wang K, Wang H, Saad H. Romiplostim use in pregnant women with immune thrombocytopenia. Am J Hematol 2023; 98:31-40. [PMID: 36156812 PMCID: PMC10091785 DOI: 10.1002/ajh.26743] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 02/04/2023]
Abstract
Treatment for immune thrombocytopenia (ITP) in pregnancy is hampered by the lack of fetal safety evidence of maternally-administered medications. The Pregnancy Surveillance Program (PSP) collected patient information from 2017-2020 for pregnancy, birth outcomes, and adverse events (AEs) for 186 women exposed to romiplostim from 20 days before pregnancy to the end of pregnancy. Timing of exposure was available in 128 women. Seventy-one mothers (38%) had prepregnancy exposure to romiplostim; intrapartum exposure was known for the first (for many mothers when they discovered their pregnancy), second, and third trimesters for 74 (40%), 22 (12%), and 44 (24%) mothers, respectively, with 15 mothers exposed during >1 trimester. Among the 86 mothers with known pregnancy outcomes, 46 (53%) had at least one pregnancy-related serious AE (SAE); approximately 2/3 of SAEs were due to underlying ITP. Of 92 mothers with known birth outcomes, 60 (65%) had a normal pregnancy and 16 (17%) had complications, with both categories including term and preterm births; there were 12 (14%) spontaneous miscarriages/stillbirths, 3 (3%) ectopic pregnancies, and 1 (1%) molar pregnancy. Most abnormal births resulted from abnormal pregnancies. There were five neonatal/postnatal AEs of note: inguinal hernia, cytomegalovirus infection, trisomy 8 (third trimester single-dose romiplostim exposure), single umbilical artery without known anomalies, and development of autism at age 2 years. Seven of 12 infants with neonatal thrombocytopenia had resolution of thrombocytopenia before discharge; all 12 were discharged. Review of pregnancies in women exposed to romiplostim did not reveal any specific safety concerns for mothers, fetuses, or infants.
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Affiliation(s)
| | | | | | - Marc Michel
- Henri Mondor University Hospital, Université Paris-Est Créteil, France
| | | | - Kejia Wang
- Amgen Inc., Thousand Oaks, California, USA
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12
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Chi Y, Hu Q, Yang C, Chen M, Han B. Avatrombopag is effective in patients with chemoradiotherapy-induced aplastic anemia: a single-center, retrospective study. Exp Hematol 2023; 117:62-68. [PMID: 36400314 DOI: 10.1016/j.exphem.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/05/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022]
Abstract
Aplastic anemia (AA) secondary to radiotherapy presents a difficult situation in the treatment of both the malignant tumor and AA itself. We aimed to evaluate the efficacy of avatrombopag (AVA), a thrombopoietin receptor agonist, in patients with AA secondary to chemoradiotherapy. In this retrospective study, patients with malignant tumors who were diagnosed with AA after radiotherapy and chemotherapy and accepted AVA between September 2020 and October 2021 at Peking Union Medical College Hospital were selected. A total of 34 patients were enrolled, including 13 (38.2%) men, with a median age of 60 (20-71) years. At a median of 8 (6-18) months of follow-up, the overall response rates (ORRs) at 1, 3, and 6 months were 32.4%, 55.9%, and 58.8%, respectively, and the complete response rates (CRRs) were 5.9%, 14.7%, and 23.5%, respectively. The median time to respond was 3 (1-6) months. In total, 15.0% of patients relapsed during follow-up, but no clonal evolution was noticed. Mild side effects were observed in 17.6% of patients without drug withdrawal. At the end of follow-up, 17.6% of patients had tumors relapsed. Four patients died, three from tumor relapse and one from cerebral hemorrhage. The ORR and CRR did not correlate with eltrombopag before AVA (p > 0.05) but increased when the total exposure of AVA increased (p = 0.011), and the threshold for AVA response was a cumulative dose > 3,000 mg (p = 0.013). AVA yielded good response and tolerance in patients treated for AA secondary to chemoradiotherapy, and a higher dose may correlate with better response.
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Affiliation(s)
- Yarong Chi
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China
| | - Qinglin Hu
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China
| | - Chen Yang
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China
| | - Miao Chen
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China
| | - Bing Han
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China.
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Thrombocytopenia in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:303-311. [PMID: 36485110 PMCID: PMC9820693 DOI: 10.1182/hematology.2022000375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hematologists are often consulted for thrombocytopenia in pregnancy, especially when there is a concern for a non-pregnancy-specific etiology or an insufficient platelet count for the hemostatic challenges of delivery. The severity of thrombocytopenia and trimester of onset can help guide the differential diagnosis. Hematologists need to be aware of the typical signs of preeclampsia with severe features and other hypertensive disorders of pregnancy to help distinguish these conditions, which typically resolve with delivery, from other thrombotic microangiopathies (TMAs) (eg, thrombotic thrombocytopenic purpura or complement-mediated TMA). Patients with chronic thrombocytopenic conditions, such as immune thrombocytopenia, should receive counseling on the safety and efficacy of various medications during pregnancy. The management of pregnant patients with chronic immune thrombocytopenia who are refractory to first-line treatments is an area that warrants further research. This review uses a case-based approach to discuss recent updates in diagnosing and managing thrombocytopenia in pregnancy.
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Cai X, Fu H, Zhao X, Lu J, Jiang Q, Chang Y, Huang X, Zhang X. Switching between eltrombopag and recombinant human thrombopoietin in patients with immune thrombocytopenia: an observational study. Chin Med J (Engl) 2022; 135:2344-2350. [PMID: 36535011 PMCID: PMC9771238 DOI: 10.1097/cm9.0000000000002346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Recombinant human thrombopoietin (rh-TPO) and eltrombopag are two distinct TPO receptor agonists (TPO-RAs) with different mechanisms. During the pandemic, when immunosuppressive medications are controversial, switching to another TPO-RA may be worth exploring in patients who do not benefit from their first TPO-RA. We investigated the outcomes of switching from rh-TPO to eltrombopag or vice versa in immune thrombocytopenia (ITP) patients. METHODS This prospective, open-label, observational investigation included 96 adult ITP patients who needed to switch between rh-TPO and eltrombopag between January 2020 and January 2021 at Peking University People's Hospital in China. The study evaluated response rates and platelet counts at different time points after the switch, bleeding events, time to response, duration of response, and adverse events. RESULTS At 6 weeks after switching, response was observed in 21/49 patients (43%) who switched for inefficacy and 34/47 patients (72%) who switched for non-efficacy-related issues. In the inefficacy group, 9/27 patients (33%) responded to eltrombopag, and 12/22 patients (55%) responded to rh-TPO. In the non-efficacy-related group, 21/26 (81%) and 13/21 (62%) patients in the eltrombopag and rh-TPO groups maintained their response rates at 6 weeks after switching, respectively. Response at 6 months was achieved in 24/49 patients (49%) switching for inefficacy and 37/47 patients (79%) switching for non-efficacy issues. In the inefficacy group, 13/27 patients (48%) responded to eltrombopag, and 11/22 patients (50%) responded to rh-TPO. In the non-efficacy-related group, 22/26 patients (85%) and 15/21 patients (71%) in the eltrombopag and rh-TPO groups maintained their response rates at 6 months after switching, respectively. Both eltrombopag and rh-TPO were well tolerated. CONCLUSIONS Our study confirmed the safety and effectiveness of switching between rh-TPO and eltrombopag for ITP patients who had no response to or experienced adverse events with their first TPO-RA. When the switch was motivated by other reasons, including patient preference and platelet count fluctuations, the probability of response was high. REGISTRATION ClinicalTrials.gov, NCT04214951.
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Affiliation(s)
- Xuan Cai
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Haixia Fu
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiangyu Zhao
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Jin Lu
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Qian Jiang
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yingjun Chang
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiaojun Huang
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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15
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Jiang D, Al-Samkari H, Panch SR. Changing Paradigms in ITP Management: Newer Tools for an Old Disease. Transfus Med Rev 2022; 36:188-194. [PMID: 36273934 PMCID: PMC10044485 DOI: 10.1016/j.tmrv.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by isolated thrombocytopenia that may be accompanied clinically by bleeding and reduced health-related quality of life (HRQoL). While corticosteroids, splenectomy, and various immunosuppressants (used off-label) have served as historical mainstays of ITP treatment, their use is associated with adverse effects and morbidity. Over the last 15 years, the advent of the thrombopoietin receptor agonists has revolutionized the management of chronic ITP with high response rates, durable responses, and minimal adverse effects in most patients. With four agents now FDA-approved to manage chronic ITP, there is a renewed emphasis on improving HRQoL and minimizing the toxicities associated with traditional therapies. Promising agents with diverse mechanisms of action, ranging from those targeting Bruton's Tyrosine Kinase to the neonatal Fc receptor, are currently under investigation. This review highlights recent landmark clinical trials which have made significant impacts on ITP management and ongoing drug development. In critically analyzing studies of relevance, we illustrate the changing paradigms of ITP management and how the field is advancing beyond traditional therapies.
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Affiliation(s)
- Debbie Jiang
- Division of Hematology, University of Washington, Seattle, WA, USA
| | - Hanny Al-Samkari
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA; Division of Hematology, Harvard Medical School, Boston, MA, USA
| | - Sandhya R Panch
- Division of Hematology, University of Washington, Seattle, WA, USA; Transfusion Services, Seattle Cancer Care Alliance, Seattle, WA, USA.
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16
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Li Y, Sun L, Li F, Li Y, Hou Y, Meng Y, Fan X, Cheng Y, Hua F. Recombinant Thrombopoietin Effectively Shortens the Time to Response and Increases Platelet Counts in Elderly Patients with Severe Immune Thrombocytopenia. J Clin Med 2022; 11:jcm11195763. [PMID: 36233631 PMCID: PMC9573713 DOI: 10.3390/jcm11195763] [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: 08/13/2022] [Revised: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This study was conducted to investigate the short-term efficacy and safety of rhTPO for the management of severe ITP in the elderly as first-line treatment. Methods: A total of 54 elderly patients with severe ITP were studied, including 39 patients treated with a combination regimen of rhTPO plus standard treatment (glucocorticoid; rhTPO group) and 15 patients treated with glucocorticoid treatment alone (control group). The response rate, time to initial response, peak platelet counts, and time to peak platelet counts were compared, and clinical characteristics correlated with the efficacy of rhTPO were analyzed. The efficacy of rhTPO in the elderly is comparable to the non-elderly in terms of the OR, CR, time to initial response, and peak platelet counts. Results: There were no differences in the overall response (OR) and the complete response (CR) in the rhTPO group compared to the control group. The time to initial response in the rhTPO group was shorter than that in the control group (p = 0.032). In patients without intravenous immunoglobulin (IVIg) and platelet transfusion, the peak platelet counts in the rhTPO group were higher than those in the control group (p = 0.003). Conclusions: Standard glucocorticoid treatment plus rhTPO effectively shortens the time to response and increases platelet counts in the elderly with severe ITP.
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Affiliation(s)
- Yang Li
- Department of Hematology, Zhongshan Hospital, Qingpu Branch, Fudan University, 1158 Gong Yuan Dong Road, Shanghai 201700, China
| | - Lihua Sun
- Department of Hematology, Zhongshan Hospital, Qingpu Branch, Fudan University, 1158 Gong Yuan Dong Road, Shanghai 201700, China
| | - Feng Li
- Department of Hematology, Zhongshan Hospital, Qingpu Branch, Fudan University, 1158 Gong Yuan Dong Road, Shanghai 201700, China
- Department of Hematology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
| | - Ying Li
- Center for Tumor Diagnosis & Therapy, Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Yunhua Hou
- Department of Hematology, Minhang Hospital, Fudan University, Shanghai 201199, China
| | - Yahong Meng
- Department of Hematology, Zhongshan Hospital, Qingpu Branch, Fudan University, 1158 Gong Yuan Dong Road, Shanghai 201700, China
| | - Xiaohong Fan
- Department of Hematology, Zhongshan Hospital, Qingpu Branch, Fudan University, 1158 Gong Yuan Dong Road, Shanghai 201700, China
| | - Yunfeng Cheng
- Department of Hematology, Zhongshan Hospital, Qingpu Branch, Fudan University, 1158 Gong Yuan Dong Road, Shanghai 201700, China
- Department of Hematology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China
- Center for Tumor Diagnosis & Therapy, Jinshan Hospital, Fudan University, Shanghai 201508, China
- Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai 200032, China
- Correspondence: (Y.C.); (F.H.)
| | - Fanli Hua
- Department of Hematology, Zhongshan Hospital, Qingpu Branch, Fudan University, 1158 Gong Yuan Dong Road, Shanghai 201700, China
- Correspondence: (Y.C.); (F.H.)
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17
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Marini I, Uzun G, Jamal K, Bakchoul T. Treatment of drug-induced immune thrombocytopenias. Haematologica 2022; 107:1264-1277. [PMID: 35642486 PMCID: PMC9152960 DOI: 10.3324/haematol.2021.279484] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Several therapeutic agents can cause thrombocytopenia by either immune-mediated or non-immune-mediated mechanisms. Non-immune-mediated thrombocytopenia is due to direct toxicity of drug molecules to platelets or megakaryocytes. Immune-mediated thrombocytopenia, on the other hand, involves the formation of antibodies that react to platelet-specific glycoprotein complexes, as in classic drug-induced immune thrombocytopenia (DITP), or to platelet factor 4, as in heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombotic thrombocytopenia (VITT). Clinical signs include a rapid drop in platelet count, bleeding or thrombosis. Since the patient's condition can deteriorate rapidly, prompt diagnosis and management are critical. However, the necessary diagnostic tests are only available in specialized laboratories. Therefore, the most demanding step in treatment is to identify the agent responsible for thrombocytopenia, which often proves difficult because many patients are taking multiple medications and have comorbidities that can themselves also cause thrombocytopenia. While DITP is commonly associated with an increased risk of bleeding, HIT and VITT have a high mortality rate due to the high incidence of thromboembolic complications. A structured approach to drug-associated thrombocytopenia/thrombosis can lead to successful treatment and a lower mortality rate. In addition to describing the treatment of DITP, HIT, VITT, and vaccine-associated immune thrombocytopenia, this review also provides the pathophysiological and clinical information necessary for correct patient management.
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Affiliation(s)
- Irene Marini
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Gunalp Uzun
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Kinan Jamal
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen.
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18
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Kuter DJ. Treatment of chemotherapy-induced thrombocytopenia in patients with non-hematologic malignancies. Haematologica 2022; 107:1243-1263. [PMID: 35642485 PMCID: PMC9152964 DOI: 10.3324/haematol.2021.279512] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of the treatment of non-hematologic malignancies. Many patient-related variables (e.g., age, tumor type, number of prior chemotherapy cycles, amount of bone marrow tumor involvement) determine the extent of CIT. CIT is related to the type and dose of chemotherapy, with regimens containing gemcitabine, platinum, or temozolomide producing it most commonly. Bleeding and the need for platelet transfusions in CIT are rather uncommon except in patients with platelet counts below 25x109/L in whom bleeding rates increase significantly and platelet transfusions are the only treatment. Nonetheless, platelet counts below 70x109/L present a challenge. In patients with such counts, it is important to exclude other causes of thrombocytopenia (medications, infection, thrombotic microangiopathy, post-transfusion purpura, coagulopathy and immune thrombocytopenia). If these are not present, the common approach is to reduce chemotherapy dose intensity or switch to other agents. Unfortunately decreasing relative dose intensity is associated with reduced tumor response and remission rates. Thrombopoietic growth factors (recombinant human thrombopoietin, pegylated human megakaryocyte growth and development factor, romiplostim, eltrombopag, avatrombopag and hetrombopag) improve pretreatment and nadir platelet counts, reduce the need for platelet transfusions, and enable chemotherapy dose intensity to be maintained. National Comprehensive Cancer Network guidelines permit their use but their widespread adoption awaits adequate phase III randomized, placebo-controlled studies demonstrating maintenance of relative dose intensity, reduction of platelet transfusions and bleeding, and possibly improved survival. Their potential appropriate use also depends on consensus by the oncology community as to what constitutes an appropriate pretreatment platelet count as well as identification of patient-related and treatment variables that might predict bleeding.
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Affiliation(s)
- David J Kuter
- Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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19
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Abstract
The new techniques of genetic analysis have made it possible to identify many new forms of inherited thrombocytopenias (IT) and study large series of patients. In recent years, this has changed the view of IT, highlighting the fact that, in contrast to previous belief, most patients have a modest bleeding diathesis. On the other hand, it has become evident that some of the mutations responsible for platelet deficiency predispose the patient to serious, potentially life-threatening diseases. Today's vision of IT is, therefore, very different from that of the past and the therapeutic approach must take these changes into account while also making use of the new therapies that have become available in the meantime. This review, the first devoted entirely to IT therapy, discusses how to prevent bleeding in those patients who are exposed to this risk, how to treat it if it occurs, and how to manage the serious illnesses to which patients with IT may be predisposed.
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20
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Feng R, Liu Y, Zhu XL, Zhai WY, He Y, Fu HX, Jiang Q, Jiang H, Lu J, Liu H, Wang JW, Wang H, Xie YD, Ma H, Huang XJ, Zhang XH. Recombinant human thrombopoietin increases platelet count in severe thrombocytopenic patients with hepatitis B-related cirrhosis: Multicentre real-world observational study. J Viral Hepat 2022; 29:306-316. [PMID: 35152507 DOI: 10.1111/jvh.13655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 11/25/2021] [Accepted: 02/03/2022] [Indexed: 12/23/2022]
Abstract
Patients with hepatitis B-related cirrhosis complicated with thrombocytopenia have a higher risk of bleeding, which may lead to higher mortality. We aimed to explore the efficacy and safety of recombinant human thrombopoietin (rhTPO) in the treatment of hepatitis B-related cirrhosis complicated with severe thrombocytopenia. Patients with hepatitis B-related compensated liver cirrhosis complicated with severe thrombocytopenia were divided into four groups according to the treatment method for thrombocytopenia. Platelet counts, the appearance of bleeding symptoms and adverse events were evaluated during the observation period. Also during the observational period, the platelet counts in the prednisone group, rhTPO group and prednisone plus rhTPO group were higher than those in the no treatment group. Patients without splenomegaly reacted better to rhTPO. Fewer bleeding events of grade 2 or worse were observed in the three treatment groups compared to the no treatment group. The platelet counts at baseline and treatment with rhTPO and/or prednisone were factors associated with bleeding events of grade 2 or worse in multivariate analysis. There could be a potential advantage for the use of rhTPO plus prednisone based on higher platelet counts and fewer bleeding events. Treatment with rhTPO was more effective in patients without splenomegaly.
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Affiliation(s)
- Ru Feng
- Department of Hematology, National Center of Gerontology, Beijing Hospital, Beijing, China.,Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Liu
- Department of Hematology, the Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Xiao-Lu Zhu
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Wan-Yi Zhai
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Yun He
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Hai-Xia Fu
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Qian Jiang
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Hao Jiang
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Jin Lu
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Hui Liu
- Department of Hematology, National Center of Gerontology, Beijing Hospital, Beijing, China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Beijing, China
| | - Hao Wang
- Institute of Hepatic Diseases, Peking University People's Hospital, Beijing, China
| | - Yan-Di Xie
- Institute of Hepatic Diseases, Peking University People's Hospital, Beijing, China
| | - Hui Ma
- Institute of Hepatic Diseases, Peking University People's Hospital, Beijing, China
| | - Xiao-Jun Huang
- Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Xiao-Hui Zhang
- Institute of Hematology, Peking University People's Hospital, Beijing, China
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21
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Zhu XL, Feng R, Huang QS, Liang MY, Jiang M, Liu H, Liu Y, Yao HX, Zhang L, Qian SX, Yang TH, Zhang JY, Shen XL, Yang LH, Hu JD, Huang RW, Jiang ZX, Wang JW, Zhang HY, Xiao Z, Zhan SY, Liu HX, Wang XL, Chang YJ, Wang Y, Kong Y, Xu LP, Liu KY, Zhang XH, Yin CH, Li YY, Wang QF, Wang JL, Huang XJ, Zhang XH. Prednisone plus IVIg compared with prednisone or IVIg for immune thrombocytopenia in pregnancy: a national retrospective cohort study. Ther Adv Hematol 2022; 13:20406207221095226. [PMID: 35510211 PMCID: PMC9058461 DOI: 10.1177/20406207221095226] [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: 12/04/2021] [Accepted: 03/16/2022] [Indexed: 01/05/2023] Open
Abstract
Background: The responses of intravenous immunoglobulin (IVIg) or corticosteroids as the initial treatment on pregnancy with ITP were unsatisfactory. This study aimed to assess the safety and effectiveness of prednisone plus IVIg versus prednisone or IVIg in pregnant patients with immune thrombocytopenia (ITP). Methods: Between 1 January 2010 and 31 December 2020, 970 pregnancies diagnosed with ITP at 19 collaborative centers in China were reviewed in this observational study. A total of 513 pregnancies (52.89%) received no intervention. Concerning the remaining pregnancies, 151 (33.04%) pregnancies received an initial treatment of prednisone plus IVIg, 105 (22.98%) pregnancies received IVIg alone, and 172 (37.64%) pregnancies only received prednisone. Results: Regarding the maternal response to the initial treatment, no differences were found among the three treatment groups (41.1% for prednisone plus IVIg, 33.1% for prednisone, and 38.1% for IVIg). However, a significant difference was observed in the time to response between the prednisone plus IVIg group (4.39 ± 2.54 days) and prednisone group (7.29 ± 5.01 days; p < 0.001), and between the IVIg group (6.71 ± 4.85 days) and prednisone group (p < 0.001). The median prednisone duration in the monotherapy group was 27 days (range, 8–195 days), whereas that in the combination group was 14 days (range, 6–85 days). No significant differences were found among these three treatment groups in neonatal outcomes, particularly concerning the neonatal platelet counts. The time to response in the combination treatment group was shorter than prednisone monotherapy. The duration of prednisone application in combination group was shorter than prednisone monotherapy. The combined therapy showed a lower predelivery platelet transfusion rate than IVIg alone. Conclusion: These findings suggest that prednisone plus IVIg may represent a potential combination therapy for pregnant patients with ITP.
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Affiliation(s)
- Xiao-Lu Zhu
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Ru Feng
- Departments of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Qiu-Sha Huang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Mei-Ying Liang
- Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, P.R. China
| | - Ming Jiang
- Center of Hematologic Diseases, First Affiliated Hospital of Xinjiang Medical University, Ürümqi, P.R. China
| | - Hui Liu
- Departments of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China
| | - Yi Liu
- Department of Hematology, Navy General Hospital, Beijing, P.R. China
| | - Hong-Xia Yao
- Department of Hematology, People’s Hospital of Hainan Province, Haikou, P.R. China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Shen-Xian Qian
- Department of Hematology, First People’s Hospital of Hangzhou, Hangzhou, P.R. China
| | - Tong-Hua Yang
- Department of Hematology, First People’s Hospital of Yunnan Province, Kunming, P.R. China
| | - Jing-Yu Zhang
- Department of Hematology, Hebei Institute of Hematology, The Second Hospital of Hebei Medical University, Shijiazhuang, P.R. China
| | - Xu-Liang Shen
- Department of Hematology, He Ping Central Hospital of the Changzhi Medical College, Changzhi, P.R. China
| | - Lin-Hua Yang
- Department of Hematology, Second Hospital of Shanxi Medical University, Taiyuan, P.R. China
| | - Jian-Da Hu
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, P.R. China
| | - Ren-Wei Huang
- Department of Hematology, Third Affiliated Hospital of Southern Medical University, Guangzhou, P.R. China
| | - Zhong-Xing Jiang
- Department of Hematology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, P.R. China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Beijing, P.R. China
| | - Hong-Yu Zhang
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, P.R. China
| | - Zhen Xiao
- Department of Hematology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, P.R. China
| | - Si-Yan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, P.R. China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology, Peking University People’s Hospital, Beijing, P.R. China
| | - Xing-Lin Wang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Ying-Jun Chang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Yu Wang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Yuan Kong
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Lan-Ping Xu
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Kai-Yan Liu
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Xiao-Hong Zhang
- Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, P.R. China
| | - Cheng-Hong Yin
- Department of Internal Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, P.R. China
| | - Yue-Ying Li
- CAS Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, China National Center for Bioinformation, Beijing, P.R. China
| | - Qian-Fei Wang
- CAS Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, China National Center for Bioinformation, Beijing, P.R. China
| | - Jian-Liu Wang
- Department of Obstetrics and Gynecology, Peking University People’s Hospital, Beijing, P.R. China
| | - Xiao-Jun Huang
- Peking University People’s Hospital, Beijing, P.R. China
- Peking University Institute of Hematology, Beijing, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People’s Hospital, Beijing, P.R. China
| | - Xiao-Hui Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, No. 11 Xizhimen South Street, Xicheng District, Beijing 100044, P.R. China
- National Clinical Research Center for Hematologic Disease, Beijing, P.R. China
- Collaborative Innovation Center of Hematology, Beijing, P.R. China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, P.R. China
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Gonzalez-Porras JR, Palomino D, Vaquero-Roncero LM, Bastida JM. Bleeding complications associated with pregnancy with primary immune thrombocytopenia: a meta-analysis. TH OPEN 2022; 6:e230-e237. [PMID: 36046200 PMCID: PMC9423940 DOI: 10.1055/a-1837-7581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 04/21/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction
Immune thrombocytopenia (ITP) during pregnancy has received little attention from researchers. Reliable information about the outcome of mothers and newborns is required to properly counsel women who are pregnant or planning to become pregnant. Our primary outcomes were the frequency and severity of maternal and neonatal bleeding events in the setting of ITP in pregnancy. Mode of delivery, neonatal thrombocytopenia, and maternal/infant mortality were secondary outcomes.
Material and Methods
We comprehensively reviewed the prospective studies that enrolled ≥20 pregnant women with primary ITP. Two reviewers, blinded to each other, searched Medline and Embase up to February 2021. Meta-analyses of the maternal and newborn outcomes were performed. Weighted proportions were estimated by a random-effects model.
Results
From an initial screening of 163 articles, 15 were included, encompassing 1,043 pregnancies. The weighted event rate for bleeding during pregnancy was 0.181 (95% confidence interval [CI], 0.048–0.494). Most of these were nonsevere cases. The weighted event rates were 0.053 (95% CI, 0.020–0.134) for severe postpartum hemorrhage, 0.014 (95% CI, 0.008–0.025) for intracerebral hemorrhage, and 0.122 (0.095–0.157) for severe thrombocytopenia events in neonates (platelet count <50,000/μL). There were no reliable predictors of severe neonatal thrombocytopenia. The incidence of neonatal mortality was 1.06%. There were no maternal deaths.
Conclusion
Primary ITP in pregnant women is rarely associated with poor outcomes.
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Favier R, De Carne C, Elefant E, Rigouzzo A. A promising treatment to optimize delivery management in a pregnant woman with inherited thrombocytopenias: a new report of thrombopoietin receptor agonist administration. Int J Obstet Anesth 2022; 50:103541. [DOI: 10.1016/j.ijoa.2022.103541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 11/26/2022]
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24
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Hofmann A, Aapro M, Fedorova TA, Zhiburt YB, Snegovoy AV, Kaganov OI, Ognerubov NA, Lyadov VK, Moiseenko VM, Trofimova OP, Ashrafyan LA, Khasanov RS, Poddubnaya IV. Patient blood management in oncology in the Russian Federation: Resolution to improve oncology care. J Cancer Policy 2022; 31:100315. [DOI: 10.1016/j.jcpo.2021.100315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/31/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022]
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Aplastic Anemia Treated with Eltrombopag during Pregnancy. Case Rep Obstet Gynecol 2022; 2022:5889427. [PMID: 35251724 PMCID: PMC8896932 DOI: 10.1155/2022/5889427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 02/18/2022] [Indexed: 11/17/2022] Open
Abstract
Aplastic anemia is a rare blood disorder characterized by pancytopenia and hypocellular bone marrow. In patients with aplastic anemia, pancytopenia sometimes worsens during pregnancy, and relapse of aplastic anemia in pregnancy is common. Nevertheless, only supportive care with blood products is the mainstay of treatment of aplastic anemia in pregnancy. Thus, the obstetric management and treatment of aplastic anemia in pregnancy is extremely challenging. We herein report the first case of a pregnant woman complicated with aplastic anemia who was successfully treated with eltrombopag, a thrombopoietin receptor agonist. A 27-year-old primigravida woman who had a history of aplastic anemia refractory to immunosuppressive therapy and was treated with eltrombopag became pregnant. Eltrombopag treatment was continued after weighing the benefits and potential risks. Throughout pregnancy, the woman's pancytopenia did not progress, and she delivered a 2336 g baby vaginally at 38 weeks of gestation. Her postpartum outcome was uneventful, and the neonate did not develop thrombocytosis. Since the efficacy and safety of eltrombopag in pregnancy has not yet been established, its routine use should be avoided. However, if limited to refractory cases and with adequate maternal and fetal monitoring, including neonatal blood examinations, the use of eltrombopag for patients with aplastic anemia during pregnancy may be acceptable and result in favorable maternal and fetal outcomes.
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26
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Cao Y, Wang M, Shen B, Zhao F, Zhang R, Chen X, He Y, Zhai W, Ma Q, Wei J, Huang Y, Yang D, Pang A, Feng S, Jiang E, Han M. Efficacy of Recombinant Human Thrombopoietin for the Treatment of Secondary Failure of Platelet Recovery After Allogeneic HSCT. Clin Appl Thromb Hemost 2022; 28:10760296211068037. [PMID: 35019756 PMCID: PMC8761877 DOI: 10.1177/10760296211068037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Secondary failure of platelet recovery (SFPR) is a life-threatening complication that may affect up to 20% of patients after allogeneic hematopoietic stem cell transplantation (HSCT). In this study, to evaluate the efficacy of recombinant human thrombopoietin (rhTPO), we retrospectively analyzed 29 patients who received continuous rhTPO for the treatment of SFPR. Overall response and complete response were observed in 24 (82.8%) patients and 10 (34.5%) patients, at a median time of 21.5 days (range, 3-41 days) and 39.5 days (range, 7-53 days) after initiation of rhTPO treatment, respectively. Among the responders, the probability of keeping overall response and complete response at 1 year after response was 77.3% and 80.0%, respectively. In multivariate analysis, higher CD34+ cells (≥3 × 106/kg) infused during HSCT (HR: 7.22, 95% CI: 1.53-34.04, P = 0.01) and decreased ferritin after rhTPO treatment (HR: 6.16, 95% CI: 1.18-32.15, P = 0.03) were indicated to associate with complete response to rhTPO. Importantly, rhTPO was well tolerated in all patients without side effects urging withdrawal and clinical intervention. The results of this study suggest that rhTPO may be a safe and effective treatment for SFPR.
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Affiliation(s)
- Yigeng Cao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Mingyang Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Biao Shen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Fei Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Rongli Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xin Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yi He
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Weihua Zhai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Qiaoling Ma
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yong Huang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Donglin Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Aiming Pang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, 70585Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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27
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Chen B, Xuan J, Wu F, Shi N, Dai J, Cai S, An S, Huang Q, Huang X, Chen Z, Zeng Z. Administration of recombinant human thrombopoietin is associated with alleviated thrombocytopenia in adult intensive care unit patients with pneumonia: A single-center retrospective study. Front Pharmacol 2022; 13:1007719. [PMID: 36299903 PMCID: PMC9589100 DOI: 10.3389/fphar.2022.1007719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/22/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Recombinant human thrombopoietin (rhTPO) is reported to stimulate platelet production and increase peripheral platelet counts; it is primarily used to manage chemotherapy-induced thrombocytopenia and idiopathic thrombocytopenic purpura. However, the effect of rhTPO in patients with pneumonia and thrombocytopenia remains uncertain. Objective: To assess the association of rhTPO and platelet counts in ICU patients with pneumonia and thrombocytopenia. Materials and Methods: A retrospective cohort study was performed in the ICU department, Nanfang Hospital, Southern Medical University, Guangzhou, China. From January 2016 to April 2021, patients with pneumonia and thrombocytopenia were allocated to two groups-the rhTPO and no-rhTPO groups-according to whether they received rhTPO treatment or not during their ICU stay. Demographical and clinical data were collected and analyzed using statistical software; p < 0.05 was considered statistically significant. Results: Out of 327 patients, 149 were in the rhTPO group and 178 were in the no-rhTPO group. Within the first 7 days, platelet counts increased more for patients in the rhTPO group compared with those in the no-rhTPO group (99.21 ± 102.613 vs. 2.08 ± 43.877, p = 0.000). The clinical recovery rate of platelets increased within 7 days (65.8 vs. 18.5%, p = 0.000) and, after 7 days of enrollment, hemorrhagic scores decreased more apparently in the rhTPO group (2.81 ± 2.856 vs. 1.16 ± 2.123, p = 0.000). Further, bleeding events ceased in 66.7% of the patients in the rhTPO group compared with 37.3% of the patients in the no-rhTPO group (p = 0.000). Less red-blood-cells transfusions were needed in the rhTPO group (3.639 ± 4.630 vs. 5.818 ± 6.858, p = 0.009). Furthermore, through logistic regression, rhTPO administration was found to be an independent indicator that affected the platelet recovery rate within 7 days. Conclusion: This study finds that rhTPO administration is associated with increased platelet counts, alleviated bleeding, and reduced blood transfusion. For patients with pneumonia and thrombocytopenia, rhTPO may be an effective therapeutic drug; however, more RCT trails are needed to confirm our observation.
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Affiliation(s)
- Bailiang Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Critical Care Medicine, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Jiabin Xuan
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Feng Wu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Nengxian Shi
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianwei Dai
- Department of Critical Care Medicine, The Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Shumin Cai
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengli An
- Department of Biostatistics, School of Public Health (Guangdong Provincial Key Laboratory of Tropical Disease Research), Southern Medical University, Guangzhou, Guangdong, China
| | - Qiaobing Huang
- Guangdong Provincial Key Lab of Shock and Microcirculation, Department of Pathophysiology, Southern Medical University, Guangzhou, China
| | - Xiaoling Huang
- Department of Pediatrics, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Zhongqing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- *Correspondence: Zhongqing Chen, ; Zhenhua Zeng,
| | - Zhenhua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
- *Correspondence: Zhongqing Chen, ; Zhenhua Zeng,
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28
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Chen D, Hou Y, Wei C, Cai X. A Network Meta-Analysis of Two Doses of Recombinant Human Thrombopoietin for Treating Sepsis-Related Thrombocytopenia. Int J Clin Pract 2022; 2022:2124019. [PMID: 36683598 PMCID: PMC9822753 DOI: 10.1155/2022/2124019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/22/2022] [Indexed: 01/01/2023] Open
Abstract
Previous studies suggest that sepsis remains a common critical illness with a global incidence of 31.5 million. The aim of this study was to evaluate the comparative therapeutic value of recombinant human thrombopoietin (rhTPO) in treating sepsis patients with thrombocytopenia. We conducted a comprehensive electronic search of PubMed, EMBASE, the Cochrane Library, and CNKI from its inception through December 31, 2021. Thirteen randomized controlled trials (RCTs) involving 963 patients were included. Network meta-analyses showed that rhTPO 300 U/kg/day and rhTPO 15000 U/day significantly increased the platelet (PLT) levels on the 7th day and decreased the requirement of transfusion of red blood cells (RBCs), plasma, and PLT compared with IVIG and NAT. SUCRA showed that rhTPO 300 U/kg/day ranked first in terms of 28-day mortality (85.5%) and transfusion, including RBC (88.7%), plasma (89.6%), and PLT (95.2%), while rhTPO 15000 U/day ranked first for the length of the intensive care unit (ICU) stay (95.9%) and PLT level at day 7 (91.6%). rhTPO 300 U/kg/day may be the optimal dose to reduce 28-day mortality and transfusion requirements. However, rhTPO 15000 U/day may be the optimal dose for shortening the ICU stay and increasing the PLT level on the 7th day. However, additional studies to further validate our findings are needed.
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Affiliation(s)
- Dandan Chen
- Department of Critical Care Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
| | - Yu Hou
- Department of Critical Care Medicine, Affiliated Haikou Hospital of Xiangya Medical College, Central South University, Haikou, China
| | - Chaochao Wei
- Department of Pulmonary and Critical Care Medicine, Hainan General Hospital, Haikou, China
| | - Xingjun Cai
- Department of Pulmonary and Critical Care Medicine, Hainan General Hospital, Haikou, China
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29
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Kuter DJ. The structure, function, and clinical use of the thrombopoietin receptor agonist avatrombopag. Blood Rev 2021; 53:100909. [PMID: 34815110 DOI: 10.1016/j.blre.2021.100909] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 01/14/2023]
Abstract
Thrombopoietin regulates platelet production through activation of the thrombopoietin receptor (TPO-R). TPO-R agonists (TPO-RAs) are available to treat thrombocytopenia in chronic immune thrombocytopenia (ITP), chronic liver disease (CLD) patients who are undergoing a procedure, severe aplastic anemia (SAA), and hepatitis C virus (HCV) infection. There are four TPO-RAs approved in the US and Europe: romiplostim (ITP), eltrombopag (ITP, SAA, HCV), avatrombopag (ITP, CLD), and lusutrombopag (CLD). It is important to understand pharmacological characteristics of these agents when evaluating treatment options. Avatrombopag interacts with the transmembrane domain of the TPO-RA and does not compete with endogenous thrombopoietin for TPO-R binding. Structural differences between avatrombopag and other TPO-RAs may impart differential downstream effects on cell signaling pathways, potentially resulting in clinically relevant differences in outcome. Avatrombopag has a favorable pharmacological profile with similar exposure in Japanese, Chinese, or Caucasian patients and no drug-drug interactions, food interactions, or potential for chelation.
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Affiliation(s)
- David J Kuter
- Center for Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
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30
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Heenan JM. Management of refractory immune thrombocytopaenia in pregnancy. BMJ Case Rep 2021; 14:e244656. [PMID: 34711622 PMCID: PMC8557288 DOI: 10.1136/bcr-2021-244656] [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] [Accepted: 09/19/2021] [Indexed: 11/04/2022] Open
Abstract
A 25-year-old woman with a history of immune thrombocytopaenia (ITP) in childhood was referred to haematology clinic for review with a platelet count of 50 μ/L at 9 weeks gestation, gravida 2, para 0. She developed progressive severe thrombocytopaenia as the pregnancy progressed, with associated bleeding complications. The thrombocytopaenia was refractory to standard therapies. This led to a need for a planned delivery, which was performed via caesarean section under general anaesthetic with platelet transfusion support, Intravenous Immune Globulin (IVIG), high-dose corticosteroid and the thrombopoietin (TPO) mimetic romiplostim. Both the mother and the neonate survived; however, the neonate required treatment for severe prolonged neonatal thrombocytopaenia. The patient subsequently re-presented 15 months later with recurrent ITP complicating another pregnancy, refractory to rituximab but responsive to romiplostim. She had a successful elective caesarean section under epidural anaesthesia, but the neonate once again suffered severe thrombocytopaenia, which was responsive to IVIG.
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Affiliation(s)
- Jessica M Heenan
- Haematology, Launceston General Hospital, Launceston, Tasmania, Australia
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31
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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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Gu J, Liu J, Li X, Zou W, Huang B, Chen M, Li J. Recombinant human thrombopoietin improved platelet engraftment after autologous hematopoietic stem cell transplantation in patients with newly diagnosed multiple myeloma. Cancer Med 2021; 10:7641-7649. [PMID: 34569193 PMCID: PMC8559510 DOI: 10.1002/cam4.4294] [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: 03/20/2021] [Revised: 08/05/2021] [Accepted: 09/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background To evaluate the efficacy and safety of recombinant human thrombopoietin (rhTPO) for hematopoietic reconstitution after autologous stem cell transplant (ASCT) in patients with newly diagnosed multiple myeloma (NDMM). Method Thirty‐five cases with NDMM had been enrolled into a prospective clinical trial from March 2014. The hematopoietic reconstitution was compared between these 35 cases (rhTPO group) and 98 historic cases not receiving rhTPO (control group) after stem cell reinfusion. Results Thirty‐five (100%) cases receiving rhTPO achieved both neutrophil and platelet engraftment within 30 days post‐transplant. The median time to neutrophil and platelet engraftment was the 10th day and 11th day after stem cell reinfusion, respectively. Multivariate analysis showed that rhTPO administration was an independent factor for accelerating platelet engraftment (HR 2.013, 95% CI 1.336–3.034, p = 0.001). Subgroup analysis showed that rhTPO improved platelet engraftment and alleviated platelet transfusion needs in patients with inadequate re‐infused CD34+ cell counts of <2 × 109/L. All the 35 patients tolerated rhTPO well. Survival analysis showed no decrease in time to progression (TTP) or overall survival (OS) by rhTPO administration. Conclusion rhTPO accelerated the platelet engraftment after ASCT in patients with NDMM with good tolerability and long‐term safety, especially for those patients with poor CD34+ cell reinfusion. rhTPO might be recommended to be used early after ASCT for patients with NDMM.
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Affiliation(s)
- Jingli Gu
- Division of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Junru Liu
- Division of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaozhe Li
- Division of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Waiyi Zou
- Division of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Beihui Huang
- Division of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Meilan Chen
- Division of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Juan Li
- Division of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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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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Semple JW, Rebetz J, Maouia A, Kapur R. An update on the pathophysiology of immune thrombocytopenia. Curr Opin Hematol 2021; 27:423-429. [PMID: 32868673 DOI: 10.1097/moh.0000000000000612] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
: Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder mediated by antiplatelet autoantibodies and antigen-specific T cells that either destroy platelets peripherally in the spleen or impair platelet production in the bone marrow. There have been a plethora of publications relating to the pathophysiology of ITP and since January of 2019, at least 50 papers have been published on ITP pathophysiology. PURPOSE OF REVIEW To summarize the literature relating to the pathophysiology of ITP including the working mechanisms of therapies, T-cell and B-cell physiology, protein/RNA/DNA biochemistry, and animal models in an attempt to unify the perceived abnormal immune processes. RECENT FINDINGS The most recent pathophysiologic irregularities associated with ITP relate to abnormal T-cell responses, particularly, defective T regulatory cell activity and how therapeutics can restore these responses. The robust literature on T cells in ITP points to the notion that ITP is a disease initiated by faulty self-tolerance mechanisms very much like that of other organ-specific autoimmune diseases. There is also a large literature on new and existing animal models of ITP and these will be discussed. It appears that understanding how to specifically modulate T cells in patients with ITP will undoubtedly lead to effective antigen-specific therapeutics. CONCLUSIONS ITP is predominately a T cell disorder which leads to a breakdown in self tolerance mechanisms and allows for the generation of anti-platelet autoantibodies and T cells. Novel therapeutics that target T cells may be the most effective way to perhaps cure this disorder.
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Affiliation(s)
- John W Semple
- Division of Hematology and Transfusion Medicine, Lund University.,Clinical Immunology and Transfusion Medicine, Office of Medical Services, Region Skåne, Lund, Sweden
| | - Johan Rebetz
- Division of Hematology and Transfusion Medicine, Lund University
| | - Amal Maouia
- Division of Hematology and Transfusion Medicine, Lund University
| | - Rick Kapur
- Sanquin Research, Department of Experimental Immunohematology, Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Recombinant human thrombopoietin promotes platelet engraftment after umbilical cord blood transplantation. Blood Adv 2021; 4:3829-3839. [PMID: 32790845 DOI: 10.1182/bloodadvances.2020002257] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/08/2020] [Indexed: 01/01/2023] Open
Abstract
Delayed platelet engraftment is a common complication after umbilical cord blood transplantation (UCBT) accompanied by increased transplant-related complications or death. This study was designed to determine the safety and efficacy of recombinant human thrombopoietin (rhTPO) in promoting platelet engraftment after UCBT. A total of 120 patients scheduled to receive UCBT were randomly assigned to the rhTPO group (300 U/kg once daily from days 14 to 28 after UCBT, n = 60) or the control group (n = 60). The primary outcome was the 60-day cumulative incidence of platelet engraftment after single-unit cord blood transplantation. The 60-day cumulative incidence of platelet engraftment (platelet count ≥20 × 109/L) and the 120-day cumulative incidence of platelet recovery (platelet count ≥50 × 109/L) were both significantly higher in the rhTPO group than in the control group (83.1% vs 66.7%, P = .020; and 81.4% vs 65.0%, P = .032, respectively). In addition, the number of required platelet infusions was significantly lower in the rhTPO group than in the control group (6 vs 8 units, respectively; P = .026). The cumulative incidence of neutrophil engraftment and the probability of 2-year overall survival, disease-free survival, and graft-versus-host disease-free relapse-free survival did not differ between the 2 groups. Other transplant-related outcomes and complications did not differ between the 2 groups, and no severe adverse effects were observed in patients receiving rhTPO. This study demonstrated that rhTPO is well tolerated in patients and could effectively promote platelet engraftment after UCBT. This study was registered on the Chinese Clinical Trial Registry (http://www.chictr.org.cn/index.aspx) as ChiCTR-IPR-16009357.
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Huang Q, Zhu X, Qu Q, Liu X, Zhang G, Su Y, Chen Q, Liu F, Sun X, Liang M, Liu Y, Jiang M, Liu H, Feng R, Yao H, Zhang L, Qian S, Yang T, Zhang J, Shen X, Yang L, Hu J, Huang R, Jiang Z, Wang J, Zhang H, Xiao Z, Zhan S, Liu H, Chang Y, Jiang Q, Jiang H, Lu J, Xu L, Zhang X, Yin C, Wang J, Huang X, Zhang X. Prediction of postpartum hemorrhage in pregnant women with immune thrombocytopenia: Development and validation of the MONITOR model in a nationwide multicenter study. Am J Hematol 2021; 96:561-570. [PMID: 33606900 DOI: 10.1002/ajh.26134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 01/06/2023]
Abstract
Globally, postpartum hemorrhage (PPH) is the leading cause of maternal death. Women with immune thrombocytopenia (ITP) are at increased risk of developing PPH. Early identification of PPH helps to prevent adverse outcomes, but is underused because clinicians do not have a tool to predict PPH for women with ITP. We therefore conducted a nationwide multicenter retrospective study to develop and validate a prediction model of PPH in patients with ITP. We included 432 pregnant women (677 pregnancies) with primary ITP from 18 academic tertiary centers in China from January 2008 to August 2018. A total of 157 (23.2%) pregnancies experienced PPH. The derivation cohort included 450 pregnancies. For the validation cohort, we included 117 pregnancies in the temporal validation cohort and 110 pregnancies in the geographical validation cohort. We assessed 25 clinical parameters as candidate predictors and used multivariable logistic regression to develop our prediction model. The final model included seven variables and was named MONITOR (maternal complication, WHO bleeding score, antepartum platelet transfusion, placental abnormalities, platelet count, previous uterine surgery, and primiparity). We established an easy-to-use risk heatmap and risk score of PPH based on the seven risk factors. We externally validated this model using both a temporal validation cohort and a geographical validation cohort. The MONITOR model had an AUC of 0.868 (95% CI 0.828-0.909) in internal validation, 0.869 (95% CI 0.802-0.937) in the temporal validation, and 0.811 (95% CI 0.713-0.908) in the geographical validation. Calibration plots demonstrated good agreement between MONITOR-predicted probability and actual observation in both internal validation and external validation. Therefore, we developed and validated a very accurate prediction model for PPH. We hope that the model will contribute to more precise clinical care, decreased adverse outcomes, and better health care resource allocation.
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Affiliation(s)
- Qiu‐Sha Huang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xiao‐Lu Zhu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Qing‐Yuan Qu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xiao Liu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Gao‐Chao Zhang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Yan Su
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Qi Chen
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Feng‐Qi Liu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xue‐Yan Sun
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Mei‐Ying Liang
- Department of Obstetrics and Gynecology Peking University People's Hospital Beijing China
| | - Yi Liu
- Department of Hematology Navy General Hospital Beijing China
| | - Ming Jiang
- Center of Hematologic Diseases First Affiliated Hospital of Xinjiang Medical University Urumqi China
| | - Hui Liu
- Department of Hematology Beijing Hospital Beijing China
| | - Ru Feng
- Department of Hematology Beijing Hospital Beijing China
| | - Hong‐Xia Yao
- Department of Hematology People's Hospital of Hainan Province Haikou China
| | - Lei Zhang
- 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
| | - Shen‐Xian Qian
- Department of Hematology First People's Hospital of Hangzhou Hangzhou China
| | - Tong‐Hua Yang
- Department of Hematology First People's Hospital of Yunnan Province Kunming China
| | - Jing‐Yu Zhang
- Department of Hematology Hebei Institute of Hematology, The Second Hospital of Hebei Medical University Shijiazhuang China
| | - Xu‐Liang Shen
- Department of Hematology He Ping Central Hospital of the Changzhi Medical College Changzhi China
| | - Lin‐Hua Yang
- Department of Hematology Second Hospital of Shanxi Medical University Taiyuan China
| | - Jian‐Da Hu
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital Fuzhou China
| | - Ren‐Wei Huang
- Department of Hematology Third Affiliated Hospital of Southern Medical University Guangzhou China
| | - Zhong‐Xing Jiang
- Department of Hematology First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Jing‐Wen Wang
- Department of Hematology Beijing Tongren Hospital Beijing China
| | - Hong‐Yu Zhang
- Department of Hematology Peking University Shenzhen Hospital Shenzhen China
| | - Zhen Xiao
- Department of Hematology Affiliated Hospital of Inner Mongolia Medical University Hohhot China
| | - Si‐Yan Zhan
- Department of Epidemiology and Biostatistics School of Public Health, Peking University Health Science Center Beijing China
| | - Hui‐Xin Liu
- Department of Clinical Epidemiology Peking University People's Hospital Beijing China
| | - Ying‐Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Hao Jiang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Lan‐Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xiao‐Hong Zhang
- Department of Obstetrics and Gynecology Peking University People's Hospital Beijing China
| | - Cheng‐Hong Yin
- Department of Internal Medicine Beijing Obstetrics and Gynecology Hospital, Capital Medical University Beijing China
| | - Jian‐Liu Wang
- Department of Obstetrics and Gynecology Peking University People's Hospital Beijing China
| | - Xiao‐Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
| | - Xiao‐Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology; National Clinical Research Center for Hematologic Disease; Collaborative Innovation Center of Hematology; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation Beijing China
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Use of thrombopoietin receptor agonists for immune thrombocytopenia in pregnancy: results from a multicenter study. Blood 2021; 136:3056-3061. [PMID: 32814348 DOI: 10.1182/blood.2020007594] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/04/2020] [Indexed: 01/14/2023] Open
Abstract
Management of immune thrombocytopenia (ITP) during pregnancy can be challenging because treatment choices are limited. Thrombopoietin receptor agonists (Tpo-RAs), which likely cross the placenta, are not recommended during pregnancy. To better assess the safety and efficacy of off-label use of Tpo-RAs during pregnancy, a multicenter observational and retrospective study was conducted. Results from 15 pregnant women with ITP (pregnancies, n = 17; neonates, n = 18) treated with either eltrombopag (n = 8) or romiplostim (n = 7) during pregnancy, including 2 patients with secondary ITP, were analyzed. Median time of Tpo-RA exposure during pregnancy was 4.4 weeks (range, 1-39 weeks); the indication for starting Tpo-RAs was preparation for delivery in 10 (58%) of 17 pregnancies, whereas 4 had chronic refractory symptomatic ITP and 3 were receiving eltrombopag when pregnancy started. Regarding safety, neither thromboembolic events among mothers nor Tpo-RA-related fetal or neonatal complications were observed, except for 1 case of neonatal thrombocytosis. Response to Tpo-RAs was achieved in 77% of cases, mostly in combination with concomitant ITP therapy (70% of responders). On the basis of these preliminary findings, temporary off-label use of Tpo-RAs for severe and/or refractory ITP during pregnancy seems safe for both mother and neonate and is likely to be helpful, especially before delivery.
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38
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Are Tpo agonists an option for ITP in pregnancy? Blood 2021; 136:2971-2972. [PMID: 33367548 DOI: 10.1182/blood.2020008637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Agarwal N, Mangla A. Thrombopoietin receptor agonist for treatment of immune thrombocytopenia in pregnancy: a narrative review. Ther Adv Hematol 2021; 12:20406207211001139. [PMID: 33796239 PMCID: PMC7983475 DOI: 10.1177/20406207211001139] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/09/2021] [Indexed: 12/26/2022] Open
Abstract
The treatment of immune thrombocytopenia (ITP) in adults has evolved rapidly over the past decade. The second-generation thrombopoietin receptor agonists (TPO-RAs), romiplostim, eltrombopag, and avatrombopag are approved for the treatment of chronic ITP in adults. However, their use in pregnancy is labeled as category C by the United States Food and Drug Administration (FDA) due to the lack of clinical data on human subjects. ITP is a common cause of thrombocytopenia in the first and second trimester of pregnancy, which not only affects the mother but can also lead to thrombocytopenia in the neonatal thrombocytopenia secondary to maternal immune thrombocytopenia (NMITP). Corticosteroids, intravenous immunoglobulins (IVIGs) are commonly used for treating acute ITP in pregnant patients. Drugs such as rituximab, anti-D, and azathioprine that are used to treat ITP in adults, are labeled category C and seldom used in pregnant patients. Cytotoxic chemotherapy (vincristine, cyclophosphamide), danazol, and mycophenolate are contraindicated in pregnant women. In such a scenario, TPO-RAs present an attractive option to treat ITP in pregnant patients. Current evidence on the use of TPO-RAs in pregnant women with ITP is limited. In this narrative review, we will examine the preclinical and the clinical literature regarding the use of TPO-RAs in the management of ITP in pregnancy and their effect on neonates with NMITP.
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Affiliation(s)
- Nikki Agarwal
- Division of Pediatric Hematology and Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ankit Mangla
- Division of Hematology and Oncology, Seidman Cancer Center, University Hospitals, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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40
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Emerging Therapies in Immune Thrombocytopenia. J Clin Med 2021; 10:jcm10051004. [PMID: 33801294 PMCID: PMC7958340 DOI: 10.3390/jcm10051004] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disorder caused by peripheral platelet destruction and inappropriate bone marrow production. The management of ITP is based on the utilization of steroids, intravenous immunoglobulins, rituximab, thrombopoietin receptor agonists (TPO-RAs), immunosuppressants and splenectomy. Recent advances in the understanding of its pathogenesis have opened new fields of therapeutic interventions. The phagocytosis of platelets by splenic macrophages could be inhibited by spleen tyrosine kinase (Syk) or Bruton tyrosine kinase (BTK) inhibitors. The clearance of antiplatelet antibodies could be accelerated by blocking the neonatal Fc receptor (FcRn), while new strategies targeting B cells and/or plasma cells could improve the reduction of pathogenic autoantibodies. The inhibition of the classical complement pathway that participates in platelet destruction also represents a new target. Platelet desialylation has emerged as a new mechanism of platelet destruction in ITP, and the inhibition of neuraminidase could dampen this phenomenon. T cells that support the autoimmune B cell response also represent an interesting target. Beyond the inhibition of the autoimmune response, new TPO-RAs that stimulate platelet production have been developed. The upcoming challenges will be the determination of predictive factors of response to treatments at a patient scale to optimize their management.
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Cooper N, Bird R, Chinthammitr Y, George B, Stentoft J, Tomiyama Y, Zaja F, Hokland P. How I treat immune thrombocytopenia - a global view. Br J Haematol 2021; 193:1076-1086. [PMID: 33570179 DOI: 10.1111/bjh.17324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/21/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Nichola Cooper
- Department of Haematology. Division of Immunology and Inflammation, Imperial College London, London, UK
| | - Robert Bird
- Division of Cancer Services, Princess Alexandra Hospital, Brisbane, Australia
| | - Yingyong Chinthammitr
- Department of Medicine, Division of Hematology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, India
| | - Jesper Stentoft
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Peter Hokland
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Brand A, De Angelis V, Vuk T, Garraud O, Lozano M, Politis D. Review of indications for immunoglobulin (IG) use: Narrowing the gap between supply and demand. Transfus Clin Biol 2021; 28:96-122. [DOI: 10.1016/j.tracli.2020.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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43
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Bussel JB. Early combination treatment of immune thrombocytopenia: Is this the way? Am J Hematol 2020; 95:1452-1453. [PMID: 33068015 DOI: 10.1002/ajh.26024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 11/10/2022]
Affiliation(s)
- James B. Bussel
- Division of Hematology/Oncology Weill Cornell Medicine New York New York USA
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Yu Y, Wang M, Hou Y, Qin P, Zeng Q, Yu W, Guo X, Wang J, Wang X, Liu G, Chu X, Yang L, Feng Y, Zhou F, Sun Z, Zhang M, Wang X, Wang Z, Ran X, Zhao H, Wang L, Zhang H, Bi K, Li D, Yuan C, Xu R, Wang Y, Zhou Y, Peng J, Liu X, Hou M. High-dose dexamethasone plus recombinant human thrombopoietin vs high-dose dexamethasone alone as frontline treatment for newly diagnosed adult primary immune thrombocytopenia: A prospective, multicenter, randomized trial. Am J Hematol 2020; 95:1542-1552. [PMID: 32871029 DOI: 10.1002/ajh.25989] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 08/19/2020] [Accepted: 08/29/2020] [Indexed: 12/24/2022]
Abstract
We conducted a prospective, multicenter, randomized, controlled clinical trial to compare the efficacy and safety of high-dose dexamethasone (HD-DXM) plus recombinant human thrombopoietin (rhTPO), vs HD-DXM alone in newly diagnosed adult immune thrombocytopenia (ITP) patients. Enrolled patients were randomly assigned to receive DXM plus rhTPO or DXM monotherapy. Another 4-day course of DXM was repeated if response was not achieved by day 10 in both arms. One hundred patients in the HD-DXM plus rhTPO arm and 96 patients in the HD-DXM monotherapy arm were included in the full analysis set. So, HD-DXM plus rhTPO resulted in a higher incidence of initial response (89.0% vs 66.7%, P < .001) and complete response (CR, 75.0% vs 42.7%, P < .001) compared with HD-DXM monotherapy. Response rate at 6 months was also higher in the HD-DXM plus rhTPO arm than that in the HD-DXM monotherapy arm (51.0% vs 36.5%, P = .02; sustained CR: 46.0% vs 32.3%, P = .043). Throughout the follow-up period, the overall duration of response was greater in the HD-DXM plus rhTPO arm compared to the HD-DXM monotherapy arm (P = .04), as estimated by the Kaplan-Meier analysis. The study drugs were generally well tolerated. In conclusion, the combination of HD-DXM with rhTPO significantly improved the initial response and yielded favorable SR in newly diagnosed ITP patients, thus could be further validated as a frontline treatment for ITP. This study is registered as clinicaltrials.gov identifier: NCT01734044.
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Affiliation(s)
- Yafei Yu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Miaomiao Wang
- Department of Pediatrics The Second Hospital, Cheeloo College of Medicine, Shandong University Jinan China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Ping Qin
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Qingshu Zeng
- Department of Hematology The First Affiliated Hospital of Anhui Medical University Hefei China
| | - Wenzheng Yu
- Department of Hematology Binzhou Medical University Hospital Binzhou China
| | - Xinhong Guo
- Department of Hematology The First Affiliated Hospital of Xinjiang Medical University Urumqi China
| | - Jingxia Wang
- Department of Hematology Liaocheng People’s Hospital Liaocheng China
| | - Xiaomin Wang
- Department of Hematology Xinjiang Uiger Municipal People’s Hospital Urumqi China
| | - Guoqiang Liu
- Department of Hematology Shengli Oilfield Central Hospital Dongying China
| | - Xiaoxia Chu
- Department of Hematology Yantai Yuhuangding Hospital Yantai China
| | - Lan Yang
- Department of Hematology Xijing Hospital, Fourth Military Medical University Xi’an China
| | - Ying Feng
- Department of Hematology The Second Affiliated Hospital of Guangzhou Medical University Guangdong China
| | - Fang Zhou
- Department of Hematology Military General Hospital Jinan China
| | - Zhaogang Sun
- Department of Hematology Taian City Central Hospital Taian China
| | - Mei Zhang
- Department of Hematology The First Affiliated Hospital of Xi’an Jiaotong University Xi’an China
| | - Xin Wang
- Department of Hematology Shandong Provincial Hospital Affiliated to Shandong University Jinan China
| | - Zhencheng Wang
- Department of Hematology Zibo Central Hospital Zibo China
| | - Xuehong Ran
- Department of Hematology Weifang People’s Hospital Weifang China
| | - Hongguo Zhao
- Department of Hematology The Affiliated Hospital of Qingdao University Qingdao China
| | - Lei Wang
- Department of Hematology Qingdao Municipal Hospital Qingdao China
| | - Haiyan Zhang
- Department of Hematology Linyi People’s Hospital Linyi China
| | - Kehong Bi
- Department of Hematology Shandong Provincial Qianfoshan Hospital Jinan China
| | - Daqi Li
- Department of Hematology Jinan Central Hospital Jinan China
| | - Chenglu Yuan
- Department of Hematology Qilu Hospital (Qingdao), Shandong University Qingdao China
| | - Ruirong Xu
- Department of Hematology Shandong Provincial Hospital of Traditional Chinese Medicine Jinan China
| | - Yili Wang
- Department of Hematology Weihai Municipal Hospital Weihai China
| | - Yuhong Zhou
- Department of Hematology Zhejiang Provincial Hospital of TCM Hangzhou China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Xin‐guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan Shandong China
- Shandong Province Key Laboratory of Hematology/Immunology, Creative Studio of Scientific and Technologic Leading Talents Qilu Hospital, Shandong University Jinan China
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45
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Zhou Z, Feng T, Xie Y, Zhang X, Du J, Tian R, Qian B, Wang R. Prognosis and rescue therapy for sepsis-related severe thrombocytopenia in critically ill patients. Cytokine 2020; 136:155227. [PMID: 32810784 DOI: 10.1016/j.cyto.2020.155227] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/19/2020] [Accepted: 07/30/2020] [Indexed: 12/20/2022]
Abstract
Sepsis is the most common critical disease with high mortality in intensive care unit. Platelet count (PC) frequently altered in sepsis patients and implicated in the pathogenesis of multi-organ failure. It is also worth mentioning that thrombocytopenia was closely associated with poor outcomes in sepsis patients. However, whether drug intervention aimed at correcting thrombocytopenia would improve the prognosis of sepsis patients and which kind of sepsis patients could benefit from this therapy is still unclear. This study aims to explore the effect of severe thrombocytopenia on the prognosis of sepsis and the impact of a platelet-elevating drug (recombinant human thrombopoietin, rhTPO) for these sepsis patients. In this study, we included 249 sepsis patients diagnosed by sepsis 3.0, and these patients were classified into the three groups based on PC: normal (PC ≥ 100 × 109/L), mild-moderate thrombocytopenia (50 × 109/L ≤ PC < 100 × 109/L), and severe thrombocytopenia (PC < 50 × 109/L). We found that patients with severe thrombocytopenia had more blood transfusion, shorter days free from organ support, and worse outcomes as compared with the normal group. However, there was no significant difference between normal and mild-moderate thrombocytopenia groups. Furthermore, a subgroup analysis showed that rescue therapy with rhTPO could rapidly lead to a recovery of the PC, prolong days free from organ support, increase survival days, and reduce the 28-day mortality in sepsis patients with severe thrombocytopenia. These results suggested that sepsis patients with severe thrombocytopenia, not mild-moderate thrombocytopenia, had a poorer prognosis. RhTPO, probably as effective rescue therapy, could quickly recover PC and improve the prognosis in these sepsis patients.
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Affiliation(s)
- Zhigang Zhou
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Tienan Feng
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yun Xie
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Xiaoyan Zhang
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Jiang Du
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Rui Tian
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Biyun Qian
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Ruilan Wang
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China.
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Zhang ML, Chen WS, Han B. [Evaluation of the efficacy of cyclosporin A combined with recombined human thrombopoietin for treating patients with non-severe aplastic anemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:637-642. [PMID: 32942816 PMCID: PMC7525171 DOI: 10.3760/cma.j.issn.0253-2727.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Indexed: 11/05/2022]
Abstract
Objectives: To compare the efficacy of cyclosporin A (CsA) alone and CsA combined with recombined human thrombopoietin (rhTPO) in patients with non-severe aplastic anemia (NSAA) . Methods: Data from 83 patients with NSAA between August 2014 and February 2019 were collected retrospectively. The study population included 35 men and 48 women, with a median age of 45 years (14-85 years) . Among them, 57 had been treated with CsA + rhTPO, TPO was administered at 15 000 U QD for 7 days, once a month for 3 months, and the other 26 patients with compatible baseline characters were treated with CsA alone. All the enrolled patients had been treated with CsA for at least 6 months and were followed up for at least 1 year. The efficacy and outcome were compared between the two groups. Results: Total 23 men and 34 women, with a median age of 46 years (14-85 years) were treated with CsA + rhTPO. The median duration of CsA treatment was 17 (8-28) months, and the patients were followed up for a median of 27 (12-45) months. Total 12 men and 14 women, with a median age of 40 years (20-64) were treated with CsA alone. The median duration of CsA treatment was 19 months (9-30 months) , and the median follow-up duration was 29 months (16-66 months) . There was no significant difference in the baseline characteristics of the two groups (P>0.05) . There was no significant difference in the CR and OR rates of the two groups at 1, 3, 6, 12, and 24 months of treatment (P>0.05) . The change in the platelet level for the CsA + rhTPO treated group after 1 month[8 (-12-86) ×10(9)/L vs. 3 (16-57) ×10(9)/L, P=0.029) , 3 months[24 (-6-102) ×10(9)/L vs. 7 (-9-76) ×10(9)/L, P=0.006], and 6 months[33.5 (-4-123) ×10(9)/L vs. 12.5 (-14-109) ×10(9)/L, P=0.048] of treatment was higher than that in the CsA alone group, while no significant difference was found between the two groups at other time points. There was no significant difference in the change in the megakaryocyte level between the two groups[3 (0-4) vs. 2 (0-5) , z=-0.868, P=0.385] after 6 months of treatment. Apart from 10.5% (6/57) of the patients in the CsA + rhTPO treated group who reported soreness at the injection site, there was no other significant difference between the two groups in terms of adverse effects. During the follow-up period, there were two cases of increasing paroxysmal nocturnal hemoglobinuria clone to over 10%, one in the CsA + rhTPO treated group, the other in the CsA alone group; and there was one case of progression to SAA in the CsA + rhTPO treated group; while no case of death or thromboembolic event (TEE) , fibrosis or reticulin proliferation, progression to myelodysplastic syndrome (MDS) , or acute myeloid leukemia was observed in either group. There was one case of progression to SAA in the CsA + rhTPO treated group but none in the CsA alone group. Conclusion: Compared to CsA alone, CsA + rhTPO treatment can accelerate the recovery of the platelet level with acceptable adverse effects.
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Affiliation(s)
- M L Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - W S Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - B Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
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47
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[Chinese guideline on the diagnosis and management of adult primary immune thrombocytopenia (version 2020)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:617-623. [PMID: 32942813 PMCID: PMC7525165 DOI: 10.3760/cma.j.issn.0253-2727.2020.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Indexed: 12/15/2022]
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48
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Audia S, Mahevas M, Bonnotte B. [Immune thrombocytopenia: From pathogenesis to treatment]. Rev Med Interne 2020; 42:16-24. [PMID: 32741715 DOI: 10.1016/j.revmed.2020.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/29/2020] [Accepted: 06/20/2020] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disease due to an immune peripheral destruction of platelets and an inappropriate platelet production. The pathogenesis of ITP is now better understood: it involves a humoral immune response which dependents on the stimulation of B cells by specific T cells called T follicular helper cells, leading to their differentiation into plasma cells that produce antiplatelet antibodies thus promoting the phagocytosis of platelets mainly by splenic macrophages. The deciphering of ITP pathogenesis has led to a better understanding of the inefficiency of treatments such as rituximab, although it has not provided yet the determination of biological predictive factor of response to treatments. Moreover, new therapeutic perspectives have been opened in the last few years with the development of molecules targeting Fcγ receptor signalling such as Syk inhibitor, or molecules increasing the clearance of pathogenic autoantibodies such as inhibitors of the neonatal Fc receptor (FcRn).
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Affiliation(s)
- S Audia
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France.
| | - M Mahevas
- 1 Service de Médecine Interne, Centre National de Référence des Cytopénies Auto-Immunes de l'Adulte, Centre Hospitalier Universitaire Henri-Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Créteil, Créteil, France; IMRB - U955 - Equipe n°2 "Transfusion et maladies du globule rouge" EFS Île-de-France, Hôpital Henri-Mondor, AP-HP, 51, avenue du Maréchal-de-Lattre-de-Tassigny, France
| | - B Bonnotte
- Service de Médecine Interne et Immunologie Clinique, Médecine 1-SOC 1, Hôpital François Mitterrand, Centre de référence des cytopénies auto-immunes de l'adulte, CHU Dijon-Bourgogne, 14 rue Paul Gaffarel, 21079 Dijon, France; Unité RIGHT, INSERM UMR 1098, Équipe "Immunorégulation et immunopathologie", Bâtiment B3, 15 rue Maréchal de Lattre de Tassigny, 21000 Dijon, France
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49
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Xu H, Jiang XM, Wu Y, Li YM, Zheng YW, Ohkohchi N. Prominent effect of platelet on improvement of liver cirrhosis. AME Case Rep 2020; 4:14. [PMID: 32420537 DOI: 10.21037/acr.2020.04.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/12/2020] [Indexed: 01/03/2023]
Abstract
Thrombopoietin (TPO) can improve liver regeneration and fibrosis. We report on a patient with liver cirrhosis who received treatment with TPO to improve liver function. An 82-year-old male had liver cirrhosis with ascites due to hepatitis C virus infection. The Child-Pugh classification was Child B. The patient received human recombinant TPO for 12 months. The platelet counts increased and were maintained at 60-80×109/L. The liver function improved, the ascites resolved, and the liver volume increased. These results indicate that the novel treatment with recombinant human TPO (rhTPO) may be effective for improving liver function in patients with liver cirrhosis.
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Affiliation(s)
- Hui Xu
- Institute of Regenerative Medicine, Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang 212001, China.,Department of Dermatology, Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang 212001, China
| | - Xiao-Meng Jiang
- Department of gastroenterology, Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang 212001, China.,Digestive Department, SIR RUN RUN Hospital, Nanjing Medical University, Nanjing 211166, China
| | - Ying Wu
- Department of gastroenterology, Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang 212001, China
| | - Yu-Mei Li
- Institute of Regenerative Medicine, Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang 212001, China.,Department of Dermatology, Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang 212001, China
| | - Yun-Wen Zheng
- Institute of Regenerative Medicine, Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang 212001, China.,Department of Regenerative Medicine, School of Medicine, Yokohama City University, Yokohama, Japan.,Department of Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.,Division of Regenerative Medicine, Center for Stem Cell Biology and Regenerative Medicine, The Institute of Medical Science, the University of Tokyo, Tokyo, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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50
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Wang L, Hou M. [How I treat primary immune thrombocytopenia in pregnancy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 40:977-979. [PMID: 32023725 PMCID: PMC7342684 DOI: 10.3760/cma.j.issn.0253-2727.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- L Wang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan 250012, China
| | - M Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan 250012, China
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