1
|
Kamfar S, Haghi S, Zeinali V, Tavana PM, Arjmand R, Malek F. The first national pediatric immune thrombocytopenia registry in Iran: research protocol and preliminary study results. BMC Health Serv Res 2024; 24:675. [PMID: 38807135 PMCID: PMC11134961 DOI: 10.1186/s12913-024-11102-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 05/10/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Disease registries are comprehensive databases that record detailed information on patients diagnosed with specific conditions, providing valuable insights into their diagnosis, treatment, and outcomes. This study aims to describe the pilot phase of the national pediatric Immune Thrombocytopenia(ITP) registry (NPITP) in Iran, serving as the inaugural interpretive report. METHODS This patient-centered software system was implemented as a national program across multiple pediatric centers in Iran. Several focus groups were conducted to establish a minimum data set (MDS) comprising six main classes, 14 sub-classes, and 187 data elements. Following expert consensus on the final data set, a web-based software tool was developed by the dedicated IT team, accessible online and offline via https://disreg.sbmu.ac.ir/q/ITP.html . The registry included children aged between two months and 18 years with a platelet count below 100 × 109/L, based on predefined inclusion criteria. RESULTS Within a four-month period, a total of 60 ITP patients were registered, including 41 (68.3%) newly diagnosed cases, 68 (13.6%) persistent cases, and 14 (23.3%) with chronic ITP. The mean age of the registered patients was 55.93 ± 9.72 months. The most frequently observed bleeding symptoms were petechiae (68.3%), purpura (51.6%), and ecchymosis (13.3%). Among the newly diagnosed patients, 20 (33.3%) received intravenous immunoglobulin (IVIG), 17 (28.3%) were treated with prednisolone, and 17 (28.3%) received combined IVIG and steroid therapy. Of all patients, 40 (66.7%) demonstrated a complete response to treatment, while 16 (26.7%) exhibited a partial response. Four patients (6.7%) remained unresponsive to therapy. Treatment-related complications, such as Cushing's syndrome, edema, weight gain, hirsutism, and mood disorders, were reported in 10 patients (16.6%). However, the majority of patients (81.7%) did not experience therapy-related complications. CONCLUSION The pilot phase of the NPITP registry successfully implemented a web-based software tool for data collection, aiming to enhance the quality of care, facilitate clinical research, and support health service planning in the future.
Collapse
Affiliation(s)
- Sharareh Kamfar
- Pediatric Congenital Hematologic Disorders Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sabahat Haghi
- Department of Hematology and Oncology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Vahide Zeinali
- Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Parastoo Molaei Tavana
- Department of pediatrics, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Arjmand
- Department of Pediatrics, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Fatemeh Malek
- Pediatric Congenital Hematologic Disorders Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
2
|
Wang JD, Ku FC, Chiang IJ, Ku MY, Chen YM, Chien LN. Longitudinal evaluation of adverse events due to steroid use in primary immune thrombocytopenia: A population-based study. Br J Haematol 2024; 204:1986-1993. [PMID: 38438140 DOI: 10.1111/bjh.19358] [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: 08/08/2023] [Revised: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 03/06/2024]
Abstract
This study aimed to investigate the association between the steroid use patterns and the risk of AEs in patients with primary immune thrombocytopenia (ITP). A total of 2691 newly diagnosed adults with ITP between 2011 and 2018 were identified from the National Health Insurance Research Database in Taiwan, and the date of first steroid use was defined as the index date. Post-index steroid use was calculated on a 90-day basis as a time-dependent variable and categorized by the average prednisolone-equivalent daily dose (<10 mg vs. ≥10 mg) and intensity (medication possession ratio <80% vs. ≥80%). Patients were followed up for 1 year from the index date for acute AE events, while chronic AEs were assessed until death, or end of 2019. Compared to patients with low-dose+low-intensity steroid use, those with high-dose+high-intensity steroid use were associated with a higher risk of acute AE (adjusted incident rate ratio [aIRR]: 1.57, 95% confidence interval [CI]: 1.38-1.78, p < 0.01) and chronic AE (aIRR: 1.26, 95% CI: 1.08-1.47, p < 0.01). Metabolic/endocrine and ophthalmologic disorders demonstrated the strongest correlation with a high dose and intensity. The joint effect of steroid dose and intensity was observed in patients with ITP, and the findings suggest that steroids should be used carefully.
Collapse
Affiliation(s)
- Jiaan-Der Wang
- Center for Rare Disease and Hemophilia, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | | | - Meng-Yun Ku
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Yi-Ming Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Li-Nien Chien
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Institute of Health and Welfare Policy, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| |
Collapse
|
3
|
Aiello A, Mariano EE, Prada M, Teruzzi C, Martone N, Capri S, Carli G, Siragusa S. Budget impact analysis for avatrombopag in the treatment of chronic primary immune thrombocytopenia in adult patients refractory to other treatments. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2230663. [PMID: 37405228 PMCID: PMC10316730 DOI: 10.1080/20016689.2023.2230663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/31/2023] [Accepted: 06/23/2023] [Indexed: 07/06/2023]
Abstract
Introduction: Primary immune thrombocytopenia is a rare autoimmune disease characterised by a decreased platelet count resulting in an increased risk of bleeding events and even life-threatening haemorrhages. Thrombopoietin receptor agonists (TPO-RAs) are the standard of care second-line therapy for adult patients with chronic immune thrombocytopenia. The first TPO-RAs approved and reimbursed in Italy, eltrombopag and romiplostim, while effective, pose some issues in terms of safety (e.g., hepatotoxicity) or general management (e.g., dietary restrictions). Avatrombopag, an effective and well-tolerated TPO-RA, was recently granted reimbursement. Methods: A 3-year (2023-2025) budget impact analysis (BIA) was conducted to estimate its impact on the Italian National Health Service (NHS). Two scenarios were compared, of which one represents the current situation, without avatrombopag, and the other provides for an increasing market share of avatrombopag (up to 26.6%). Results: BIA shows that the increase in the use of avatrombopag correlates with savings for NHS: in the first year, saving would be €1,300,564, increasing to €2,774,210 in the third year, for a total of €6,083,231 over the 3-year period. The sensitivity analysis confirmed these savings in the scenario with avatrombopag. Conclusions: Based on this BIA, the introduction and reimbursement of avatrombopag is an efficient and advantageous choice for the Italian NHS.
Collapse
Affiliation(s)
| | | | | | | | | | - Stefano Capri
- School of Economics and Management, LIUC University, Castellanza, Italy
| | - Giuseppe Carli
- Department of Haematology, “S. Bortolo” Hospital, Vicenza, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMise), University of Palermo, Palermo, Italy
| |
Collapse
|
4
|
Naguib M, El Sawy S, Rashed L, AlHelf M, Abdelgwad M. Long non-coding RNA maternally expressed gene 3, miR-125a-5p, CXCL13, and NF-kB in patients with immune thrombocytopenia. Genes Immun 2023; 24:108-115. [PMID: 37045944 PMCID: PMC10110462 DOI: 10.1038/s41435-023-00200-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/27/2023] [Accepted: 02/02/2023] [Indexed: 04/14/2023]
Abstract
The main aim of this study was to assess the expression level of circulating long non-coding RNA maternally expressed gene 3 (lncRNA-MEG3), microRNA (miR-125a-5P), the chemokine C-X-C motif ligand13 (CXCL13), and the nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) in immune thrombocytopenia (ITP) cases and to study its relation to the disease severity and treatment response. This case-control study included 45 patients newly diagnosed as ITP and 45 healthy subjects. We assessed complete blood count, antinuclear antibodies, hepatitis B and C virus serology, lncRNA-MEG3, miR-125a-5P, and CXCL13 expression in serum by real-time PCR and NF-kb protein by ELISA. In ITP patients compared to control, lncRNA-MEG3 was significantly increased, and miRNA-125a-5P was decreased, and this was associated with higher CXCL13 and NF-kB levels (P < 0.001, for all).There was a significant negative correlation between platelet count and lncRNA-MEG3, CXCL13, and NF-kb, while a positive correlation with miR-125a-5p in ITP patients. Patients who responded to steroids had significantly higher miR-125a-5p (P = 0.016) and significantly lower lncRNA-MEG3 (P < 0.001), CXCL13 (P = 0.005), and NF-kb (p = 0.002). Based on the ROC curves, lncRNA-MEG3 displayed the highest area under the curve (AUC) in the identification of organ bleeding (AUC = 0.805), the response to steroids (AUC = 0.853), and the need for splenectomy (AUC = 0.75).
Collapse
Affiliation(s)
- Mervat Naguib
- Internal Medicine Department, Faculty of Medicine Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt.
| | - Shereen El Sawy
- Internal Medicine Department, Faculty of Medicine Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Laila Rashed
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maha AlHelf
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
- Biotechnology School, Nile University, Giza, Egypt
| | - Marwa Abdelgwad
- Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
5
|
Ali MA, Anwar MY, Aiman W, Dhanesar G, Omar Z, Hamza M, Zafar M, Rengarajan HK, Maroules M. Safety and Efficacy of Tyrosine Kinase Inhibitors in Immune Thrombocytopenic Purpura: A Systematic Review of Clinical Trials. J Xenobiot 2023; 13:29-41. [PMID: 36810430 PMCID: PMC9944448 DOI: 10.3390/jox13010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023] Open
Abstract
Immune thrombocytopenic purpura (ITP) is an acquired antibody or cell-mediated platelet damage or decreased platelet production. Steroids, IV immunoglobulins (IVIG), and Rho-anti-D antibodies are the commonly used initial treatments for ITP. However, many ITP patients either do not respond or do not maintain a response to initial therapy. Splenectomy, rituximab, and thrombomimetics are the commonly used second-line treatment. More treatment options include tyrosine kinases inhibitors (TKI), including spleen tyrosine kinase (Syk) and Bruton's tyrosine kinase (BTK) inhibitors. This review aims to assess the safety and efficacy of TKIs. Methods: Literature was searched on PubMed, Embase, WOS, and clinicaltrials.gov using keywords, "tyrosine kinase" and "idiopathic thrombocytopenic purpura". PRISMA guidelines were followed. Results: In total, 4 clinical trials were included with 255 adult patients with relapsed/refractory ITP. In all, 101 (39.6%) patients were treated with fostamatinib, 60 (23%) patients with rilzabrutinib, and 34 (13%) with HMPL-523. Patients treated with fostamatinib achieved a stable response (SR) and overall response (OR) in 18/101 (17.8%) and 43/101 (42.5%) of the patients, respectively, while SR and OR were achieved in 1/49 (2%) and 7/49 (14%) of the patients, respectively, in the placebo group. Patients treated with HMPL-523 (300 mg dose expansion) achieved an SR and OR in 5/20 (25%) and 11/20 (55%) of the patients, respectively, while SR and OR were achieved in 1/11 (9%) of the patients treated with the placebo. Patients treated with rilzabrutinib achieved an SR in 17/60 (28%) patients. Dizziness (1%), hypertension (2%), diarrhea (1%), and neutropenia (1%) were serious adverse events in fostamatinib patients. Rilzabrutinib or HMPL-523 patients did not require a dose reduction due to drug-related adverse effects. Conclusions: Rilzabrutinib, fostamatinib, and HMPL-523 were safe and effective in the treatment of relapsed/refractory ITP.
Collapse
Affiliation(s)
- Muhammad Ashar Ali
- Department of Internal Medicine, St. Mary’s and St. Clare’s Hospitals, New York Medical College, Denville, NJ 07834, USA
| | - Muhammad Yasir Anwar
- Department of Internal Medicine, BronxCare Hospital, Icahn School of Medicine, Bronx, NY 10457, USA
| | - Wajeeha Aiman
- Department of Internal Medicine, Saint Michael’s Medical Center, New York Medical College, Newark, NJ 07102, USA
| | - Gurneel Dhanesar
- Department of Internal Medicine, St. Mary’s and St. Clare’s Hospitals, New York Medical College, Denville, NJ 07834, USA
| | - Zainab Omar
- Department of Pediatrics, Dubai Medical College for Girls, Dubai 20170, United Arab Emirates
| | - Mohammad Hamza
- Department of Internal Medicine, Albany Medical Center Hospital, Albany, NY 12208, USA
| | - Maha Zafar
- Department of Internal Medicine, Mercy Hospital Fort Smith, Arkansas College of Osteopathic Medicine, Fort Smith, AR 72903, USA
| | - Harish Kumar Rengarajan
- Department of Internal Medicine, St. Mary’s and St. Clare’s Hospitals, New York Medical College, Denville, NJ 07834, USA
| | - Michael Maroules
- Department of Hematology/Oncology, St. Mary’s General Hospital, New York Medical College, Passaic, NJ 07102, USA
| |
Collapse
|
6
|
Hashemzaei M, Nezafat N, Ghoshoon MB, Negahdaripour M. In-silico selection of appropriate signal peptides for romiplostim secretory production in Escherichia coli. INFORMATICS IN MEDICINE UNLOCKED 2022. [DOI: 10.1016/j.imu.2022.101146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
7
|
Nguyen T, Gao H, Liu D, Philips TJ, Ye Z, Lee JH, Shi GX, Copenhaver K, Zhang L, Wei L, Yu J, Zhang H, Barath A, Luong M, Zhang C, Gaspar-Maia A, Li H, Wang L, Ordog T, Weinshilboum R. Glucocorticoids unmask silent non-coding genetic risk variants for common diseases. Nucleic Acids Res 2022; 50:11635-11653. [PMID: 36399508 PMCID: PMC9723631 DOI: 10.1093/nar/gkac1045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022] Open
Abstract
Understanding the function of non-coding genomic sequence variants represents a challenge for biomedicine. Many diseases are products of gene-by-environment interactions with complex mechanisms. This study addresses these themes by mechanistic characterization of non-coding variants that influence gene expression only after drug or hormone exposure. Using glucocorticoid signaling as a model system, we integrated genomic, transcriptomic, and epigenomic approaches to unravel mechanisms by which variant function could be revealed by hormones or drugs. Specifically, we identified cis-regulatory elements and 3D interactions underlying ligand-dependent associations between variants and gene expression. One-quarter of the glucocorticoid-modulated variants that we identified had already been associated with clinical phenotypes. However, their affected genes were 'unmasked' only after glucocorticoid exposure and often with function relevant to the disease phenotypes. These diseases involved glucocorticoids as risk factors or therapeutic agents and included autoimmunity, metabolic and mood disorders, osteoporosis and cancer. For example, we identified a novel breast cancer risk gene, MAST4, with expression that was repressed by glucocorticoids in cells carrying the risk genotype, repression that correlated with MAST4 expression in breast cancer and treatment outcomes. These observations provide a mechanistic framework for understanding non-coding genetic variant-chemical environment interactions and their role in disease risk and drug response.
Collapse
Affiliation(s)
- Thanh Thanh L Nguyen
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic; Rochester, MN, USA
| | - Huanyao Gao
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Duan Liu
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Trudy Janice Philips
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Zhenqing Ye
- Department of Health Sciences Research, Mayo Clinic; Rochester, MN, USA
- Current affiliation: Greehey Children's Cancer Research Institute, University of Texas Health San Antonio; San Antonio, TX 78229, USA
| | - Jeong-Heon Lee
- Epigenomics Program, Center for Individualized Medicine, Mayo Clinic; Rochester, MN, USA
| | - Geng-xian Shi
- Epigenomics Program, Center for Individualized Medicine, Mayo Clinic; Rochester, MN, USA
| | - Kaleigh Copenhaver
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Lingxin Zhang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Lixuan Wei
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Jia Yu
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Huan Zhang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | | | - Maggie Luong
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Cheng Zhang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Alexandre Gaspar-Maia
- Epigenomics Program, Center for Individualized Medicine, Mayo Clinic; Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Division of Experimental Pathology and Lab Medicine, Mayo Clinic; Rochester, MN, USA
| | - Hu Li
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| | - Tamas Ordog
- Epigenomics Program, Center for Individualized Medicine, Mayo Clinic; Rochester, MN, USA
- Department of Physiology and Biomedical Engineering, Mayo Clinic; Rochester, MN, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic; Rochester, MN, USA
| | - Richard M Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic; Rochester, MN, USA
| |
Collapse
|
8
|
ASLANER AK M, SAHİP B. İmmun Trombositopenili Hastalarda Dörtlü Tedavi. KONURALP TIP DERGISI 2022. [DOI: 10.18521/ktd.1130819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Amaç:İmmün trombositopeni tedavisinde son yıllarda deksametazon, rituksimab ve siklosporin kombinasyon tedavileri umut verici sonuçlar vermiştir. Bu çalışmada, immün trombositopenide verilen kombinasyon tedavilerinin eltrombopag ile birleştirilmesiyle oluşturulan dörtlü tedavinin hastalardaki yanıtlarının araştırılması amaçlanmıştır.
Yöntem:İmmun trombositopeni tanısı almış birinci basamak tedavide steroid, 2.basamak tedavide eltrombopag alan, tam ya da kısmı remisyon sağlanamayan 4 hasta retrospektif olarak aldıkları tedavi ve yanıt oranları açısından değerlendirdi.
Sonuç:Relaps /refrakter immün trombositopenisi olan hastalar, eltrombopag tedavisine ek olarak oral deksametazon, oral siklosporin ve intravenöz düşük doz rituksimab ile tedavi edildi. Eltrombopag tedavisine 50 mg/gün dozunda devam edildi. Siklosporin için yükleme dozu verilmedi, haftalık kan siklosporin düzeyi toksisite açısından izlendi ve tedavi 200 ile 400 µg/L'lik bir hedef doza titre edildi. Toksisite kaynaklı ölüm, tedaviye bağlı ciddi advers olaylar veya tedaviye uyumsuzluk gözlenmedi. 6 aylık yanıt oranı %75 idi ve tedavi iyi tolere edildi. Hastalarımızdan iki tanesi halen tam yanıtlı olarak tarafımızca takipli iken bir hastamızda 6.aydan sonra relaps olması nedeniyle splenektomi yapılmış olup halen eltrombopag tedavi ile takiplidir. Yanıtsız olan daha önce splenektomili olan hastamıza ise romiplastim tedavisi uygulandı ancak bu tedaviye de yanıt alınamadı. Hasta klinik çalışmaya dahil edildi.
Sonuç:Tedaviye dirençli immün trombositopenili hastalarda dörtlü tedavi kombinasyonunun bir tedavi seçeneği olabileceğini gösteren çalışmamız umut vaad etmektedir.
Collapse
Affiliation(s)
| | - Birsen SAHİP
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ ERZURUM BÖLGE EĞİTİM VE ARAŞTIRMA MERKEZİ
| |
Collapse
|
9
|
Bestwick JP, Skelly BJ, Swann JW, Glanemann B, Bexfield N, Gkoka Z, Walker DJ, Silvestrini P, Adamantos S, Seth M, Warland J. Splenectomy in the management of primary immune-mediated hemolytic anemia and primary immune-mediated thrombocytopenia in dogs. J Vet Intern Med 2022; 36:1267-1280. [PMID: 35801263 PMCID: PMC9308443 DOI: 10.1111/jvim.16469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 05/27/2022] [Indexed: 11/27/2022] Open
Abstract
Background Current reports about the use of splenectomy for the management of immune‐mediated hemolytic anemia (IMHA) or immune‐mediated thrombocytopenia (ITP) or both in dogs are limited. Objectives To retrospectively describe the use of splenectomy as part of the management for IMHA, ITP, and concurrent IMHA and severe thrombocytopenia (CIST) in dogs. It was hypothesized that splenectomy would be beneficial in allowing for reduction of dose of immunosuppressive drugs or discontinuation in 1 or more of these groups. Animals Seventeen client‐owned dogs (7 with IMHA, 7 with ITP, and 3 with CIST) were identified across 7 UK‐based referral hospitals from a study period of 2005 to 2016. Methods Data were collected retrospectively via questionnaires and included information about diagnosis, management and treatment response before and after splenectomy. Based on clinical outcome, treatment with splenectomy as part of the management protocol was classified as either successful or unsuccessful. Results Six of 7 dogs with ITP were managed successfully with splenectomy as part of their management protocol (3 complete and 3 partial responses), although 1 subsequently developed suspected IMHA. Of the 7 dogs with IMHA, splenectomy was part of a successful management protocol in 4 dogs (2 complete and 2 partial responses). In the CIST group, 1 case (1/3) responded completely to management with splenectomy as part of the management protocol. Conclusions and Clinical Importance Splenectomy was considered successful and well tolerated in most cases of isolated ITP. Whether there is a benefit of splenectomy in cases of IMHA and CIST could not be determined in the current study.
Collapse
Affiliation(s)
- Jason P Bestwick
- Animal Health Trust, Newmarket, Suffolk, United Kingdom.,Department of Veterinary Medicine, Univeristy of Cambridge, Cambridge, United Kingdom
| | - Barbara J Skelly
- Queen's Veterinary School Hospital, University of Cambridge, Cambridge, United Kingdom
| | - James W Swann
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, Hertfordshire, United Kingdom.,Columbia Stem Cell Initiative, Columbia University, New York, New York, USA
| | - Barbara Glanemann
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, Hertfordshire, United Kingdom
| | - Nick Bexfield
- Queen's Veterinary School Hospital, University of Cambridge, Cambridge, United Kingdom.,Pride Veterinary Centre, Derbyshire, United Kingdom
| | - Zeta Gkoka
- Anderson Moores Veterinary Specialists, Winchester, United Kingdom
| | - David J Walker
- Anderson Moores Veterinary Specialists, Winchester, United Kingdom
| | - Paolo Silvestrini
- Small Animal Teaching Hospital, Institute of Veterinary Science, University of Liverpool, Neston, United Kingdom
| | - Sophie Adamantos
- Langford Vets/University of Bristol, Bristol, North Somerset, United Kingdom.,Paragon Veterinary Referrals, Wakefield, West Yorkshire, United Kingdom
| | - Mayank Seth
- Animal Health Trust, Newmarket, Suffolk, United Kingdom.,Dick White Referrals, Cambridge, United Kingdom
| | - James Warland
- Animal Health Trust, Newmarket, Suffolk, United Kingdom.,Southfields Veterinary Specialists, Part of Linnaeus Veterinary Limited, Laindon, Essex, United Kingdom.,Wellcome-MRC Cambridge Stem Cell Institute, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
10
|
Hamzah R, Yusof N, Tumian NR, Abdul Aziz S, Mohammad Basri NS, Leong TS, Ho KW, Selvaratnam V, Tan SM, Muhamad Jamil SA. Clinical Epidemiology, Treatment Outcome and Mortality Rate of Newly Diagnosed Immune Thrombocytopenia in Adult Multicentre Study in Malaysia. J Blood Med 2022; 13:337-349. [PMID: 35761846 PMCID: PMC9233512 DOI: 10.2147/jbm.s358993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Immune thrombocytopenia (ITP) is well characterized in Western, European and other Asia-Pacific countries. Nevertheless, the clinical epidemiology, treatment pattern and disease outcome of ITP in Malaysia are still limited and not well known. Objective This study aimed to describe the clinical epidemiology, treatment outcome and mortality of ITP patients in haematology tertiary multicentre in Malaysia. Methods Clinical and laboratory data of newly diagnosed adults with ITP by a platelet count <100 × 109/L from January 2010 to December 2020 were identified and analyzed. Results Out of 500 incident ITP, 71.8% were females with a striking age preponderance of both genders among those aged 18–29 years. The median age was 36 years. The median platelet count was 17.5 × 109/L, 23.0% had a secondary ITP, 34.6% had a Charlson’s score ≥1, 53.0% had bleeding symptoms including 2.2% intracranial bleedings (ICB). Helicobacter pylori screening was performed in <5% of cases. Persistency and chronicity rates were 13.6% and 41.8%, respectively. Most (80.6%) were treated at diagnosis onset and 31.2% needed second-line treatment. Throughout the course of ITP, 11.0% of patients died; 3.0% and 8.0% with bleeding and non-bleeding related ITP. Conclusion This study confirms the epidemiology of ITP is comparable with worldwide studies. Our incidence is high in the female, Malay ethnicity, primary ITP and events of cutaneous bleeding at ITP onset with 18–29 years predominance age group for both genders. The frequency of persistent and chronic ITP is inconsistent with published literature. Corticosteroids and immunotherapies are the most prescribed first-line and second-line pharmacological treatments. Thrombopoietin receptor agonist medications (TPO-RAs) usage is restricted and splenectomy is uncommon. Our mortality rate is similar but ITP related bleeding death is fourth-fold lower than previous studies. Mortality risks of our ITP patients include age ≥60 years, male, severe bleeding at presentation, CCI≥1 and secondary ITP.
Collapse
Affiliation(s)
- Roszymah Hamzah
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia.,Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Nurasyikin Yusof
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Nor Rafeah Tumian
- Haematology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Suria Abdul Aziz
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Nur Syahida Mohammad Basri
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Tze Shin Leong
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Kim Wah Ho
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Veena Selvaratnam
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Sen Mui Tan
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Siti Afiqah Muhamad Jamil
- Faculty of Computer and Mathematical Sciences, Universiti Teknologi Mara, Shah Alam, Selangor, Malaysia
| |
Collapse
|
11
|
Sharon CE, Straker RJ, Perry N, Miura JT, Karakousis GC. Postsplenectomy morbidity and mortality in patients with immune thrombocytopenic purpura: A national cohort study. J Surg Oncol 2022; 126:718-727. [PMID: 35712894 DOI: 10.1002/jso.26986] [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: 05/31/2022] [Accepted: 06/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND We sought to identify factors associated with 30-day morbidity, and their impact on 30-day mortality, among patients undergoing splenectomy for immune thrombocytopenic purpura (ITP). METHODS Using the ACS-NSQIP database, patients undergoing splenectomy for ITP were identified (2005-2019), and those with and without postoperative complications within 30 days of surgery were compared. RESULTS Of 2483 patients evaluated, 280 (11.3%) developed 30-day morbidity: infection (n= 145 [5.8%]), venous thromboembolism (n = 71 [2.9%]), acute renal failure (n = 7 [0.3%]), respiratory failure (n = 40 [1.6%]), cardiac arrest/myocardial infarction (n = 16 [0.6%]), cerebrovascular accident (n = 4 [0.2%]), or postoperative blood transfusion (n = 62 [2.5%]). Risk-factors for 30-day morbidity included age ≥50 years (odds ratio [OR] 1.50, p = 0.020), body mass index ≥30 kg/m2 (OR 1.45, p = 0.023), functional dependence (OR 2.90, p = 0.009), preoperative albumin <3.5 g/dL (OR 2.10, p < 0.001), preoperative platelets <30 000/μL (OR 1.54, p = 0.020), open surgical approach (OR 2.32, p < 0.001), and inpatient status before surgery (OR 1.85, p = 0.040). Among patients at low-risk for 30-day morbidity (no risk-factors present), the 30-day morbidity rate was 5.0% versus 41.5% for ≥5 risk-factors (p < 0.001). Thirty-day mortality was 1.2%. CONCLUSIONS Thirty-day morbidity and mortality are low with splenectomy for ITP. Select patients have particularly low perioperative risk and may benefit from early splenectomy if initial medical therapy fails.
Collapse
Affiliation(s)
- Cimarron E Sharon
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richard J Straker
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nikhita Perry
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John T Miura
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Giorgos C Karakousis
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
12
|
Wang Y, Yu T, Dong Q, Liu S, Yu Y, Zhao HY, Ma J, Dong L, Wang L, Ma D, Zhao Y, Hou Y, Liu X, Peng J, Hou M. Clonal hematopoiesis in primary immune thrombocytopenia. Blood Cancer J 2022; 12:40. [PMID: 35293382 PMCID: PMC8924250 DOI: 10.1038/s41408-022-00641-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Yanming Wang
- Department of Hematology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, China.,Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tianshu Yu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiaofeng Dong
- Department of Hematology, Heze Municipal Hospital, Heze, China
| | - Shuang Liu
- Department of Hematology, Taian Central Hospital, Taian, China
| | - Yafei Yu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hong Yu Zhao
- Department of Hematology, Jinan Central Hospital Affiliated to Shandong University, Jinan, China
| | - Ji Ma
- Department of Medical Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province, China
| | - Lin Dong
- Department of Hematology, The First Affiliated Hospital of Shandong First Medical University, Taian, China
| | - Liang Wang
- Department of Hematology, Shengli Oilfield Central Hospital, Dongying, China
| | - Daoxin Ma
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yajing Zhao
- 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.
| | - Xinguang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Shandong Provincial Key Laboratory of Immunohaematology, 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.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| |
Collapse
|
13
|
Meyer O, Richter H, Lebioda A, Schill M. Treatment patterns in adults with immune thrombocytopenia before, during and after use of thrombopoietin receptor agonists: a longitudinal prescription database study from Germany. Hematology 2021; 26:697-708. [PMID: 34547980 DOI: 10.1080/16078454.2021.1974203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To assess real-world treatment patterns in patients with immune thrombocytopenia (ITP) who received thrombopoietin receptor agonists (TPO-RAs) in Germany. METHODS This was a longitudinal, retrospective study using anonymized patient-level data (IQVIA healthcare prescription database, covering 82% of German statutory prescriptions). Eligible patients (aged ≥18 years) had received ≥1 TPO-RA prescription (romiplostim/eltrombopag) from July 2016 to June 2019 (treatment duration ≥30 days). ITP medication use was assessed for 18 months prior to, during and for ≥6 months after TPO-RA treatment. RESULTS A total of 3553 patients (median age 64 years) were included. Median persistence on TPO-RAs was 12 months (range 1-34). In the periods before, during and after TPO-RA treatment, oral corticosteroids were the most commonly used therapy (64.4%, 43.4% and 36.1% of patients, respectively); median cumulative doses across each period were 2521.9, 2000.0 and 2277.8 mg. The median total duration of corticosteroid use before, during and after TPO-RA therapy was 15, 18 and 32 weeks, respectively. The total median cumulative corticosteroid dose was 6799.7 mg. CONCLUSION We identified a potential overuse of corticosteroids in patients with ITP in Germany. Earlier use of TPO-RA therapy after a short course of corticosteroids could avoid side effects associated with long-term use.
Collapse
|
14
|
Grainger JD, Kühne T, Hippenmeyer J, Cooper N. Romiplostim in children with newly diagnosed or persistent primary immune thrombocytopenia. Ann Hematol 2021; 100:2143-2154. [PMID: 34308495 PMCID: PMC8310729 DOI: 10.1007/s00277-021-04590-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/28/2021] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a disease of heterogenous origin characterized by low platelet counts and an increased bleeding tendency. Three disease phases have been described: newly diagnosed (≤ 3 months after diagnosis), persistent (> 3-12 months after diagnosis), and chronic (> 12 months after diagnosis). The majority of children with ITP have short-lived disease and will not need treatment. For children with newly diagnosed ITP, who have increased bleeding symptoms, short courses of steroids are recommended. In children who do not respond to first-line treatment or who become steroid dependent, thrombopoietin receptor agonists (TPO-RAs) are recommended because of their efficacy and safety profiles. In this narrative review, we evaluate the available evidence on the use of the TPO-RA romiplostim to treat children with newly diagnosed or persistent ITP and identify data from five clinical trials, five real-world studies, and a case report. While the data are more limited for children with newly diagnosed ITP than for persistent ITP, the collective body of evidence suggests that romiplostim is efficacious in increasing platelet counts in children with newly diagnosed or persistent ITP and may result in long-lasting treatment-free responses in some patients. Furthermore, romiplostim was found to be well tolerated in the identified studies. Collectively, the data suggest that earlier treatment with romiplostim may help children to avoid the side effects associated with corticosteroid use and reduce the need for subsequent treatment.
Collapse
Affiliation(s)
- John D Grainger
- Department of Haematology, University of Manchester, Royal Manchester Children's Hospital, Manchester, UK.
| | - Thomas Kühne
- Oncology/Hematology, University Children's Hospital Basel, Basel, Switzerland
| | | | - Nichola Cooper
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| |
Collapse
|
15
|
Abstract
Fostamatinib (Tavalisse®; Tavlesse®) is the first spleen tyrosine kinase (Syk) inhibitor approved for the treatment of chronic immune thrombocytopenia (ITP) in adult patients who have had an insufficient response to previous treatment. By inhibiting Syk activation in macrophages, fostamatinib blocks autoantibody-mediated platelet phagocytosis. In the placebo-controlled phase III FIT1 and FIT2 trials, 24 weeks of oral fostamatinib therapy increased platelet count in previously treated adults with ITP. A significantly higher proportion of patients achieved stable response with fostamatinib than with placebo in FIT1, but not in FIT2; however, pooled analyses of the two studies showed that fostamatinib produced significantly higher stable and overall response rates than placebo. Interim findings from the ongoing FIT3 open-label extension study suggested that the efficacy of fostamatinib was maintained with long-term treatment (up to 62 months; median duration 6 months), including in patients receiving fostamatinib as second- or later-line treatment. Fostamatinib had a generally manageable tolerability profile in all three FIT studies, with no serious safety risks. Fostamatinib therefore provides an alternative treatment option for chronic ITP in adult patients with an insufficient response to previous treatment.
Collapse
Affiliation(s)
- Julia Paik
- Springer Nature, Mairangi Bay, Private Bag 65901, Auckland, 0754, New Zealand.
| |
Collapse
|
16
|
Thrombopoietin receptor agonists as an emergency treatment for severe newly diagnosed immune thrombocytopenia in children. Blood 2021; 137:138-141. [PMID: 33410895 DOI: 10.1182/blood.2020006807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/08/2020] [Indexed: 01/19/2023] Open
|
17
|
Swan D, Newland A, Rodegheiro F, Thachil J. Thrombosis in immune thrombocytopenia - current status and future perspectives. Br J Haematol 2021; 194:822-834. [PMID: 33822358 DOI: 10.1111/bjh.17390] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder in which a combination of defective platelet production and enhanced clearance leads to thrombocytopenia. The primary aim for therapy in patients with this condition is the prevention of bleeding. However, more recently, increased rates of venous and arterial thrombotic events have been reported in ITP, even in the context of marked thrombocytopenia. In this review we discuss the epidemiology, aetiology and management of thrombotic events in these patients. We consider the impact of ITP therapies on the increased thrombotic risk, in particular the use of thrombopoietin-receptor agonists (TPO-RAs), as well as factors inherent to ITP itself. We also discuss the limited evidence available to guide clinicians in the treatment of these complex cases.
Collapse
Affiliation(s)
- Dawn Swan
- Department of Haematology, University Hospital Galway, Galway, Republic of Ireland
| | - Adrian Newland
- Department of Haematology, The Royal London Hospital, London, UK
| | | | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| |
Collapse
|
18
|
Looking long-term: an unmet need in immune thrombocytopenia. LANCET HAEMATOLOGY 2021; 8:e245-e246. [PMID: 33770476 DOI: 10.1016/s2352-3026(21)00071-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 01/19/2023]
|
19
|
The molecular basis of immune-based platelet disorders. Clin Sci (Lond) 2021; 134:2807-2822. [PMID: 33140828 DOI: 10.1042/cs20191101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/12/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022]
Abstract
Platelets have a predominant role in haemostasis, the maintenance of blood volume and emerging roles as innate immune cells, in wound healing and in inflammatory responses. Platelets express receptors that are important for platelet adhesion, aggregation, participation in inflammatory responses, and for triggering degranulation and enhancing thrombin generation. They carry a cargo of granules bearing enzymes, adhesion molecules, growth factors and cytokines, and have the ability to generate reactive oxygen species. The platelet is at the frontline of a host of cellular responses to invading pathogens, injury, and infection. Perhaps because of this intrinsic responsibility of a platelet to rapidly respond to thrombotic, pathological and immunological factors as part of their infantry role; platelets are susceptible to targeted attack by the adaptive immune system. Such attacks are often transitory but result in aberrant platelet activation as well as significant loss of platelet numbers and platelet function, paradoxically leading to elevated risks of both thrombosis and bleeding. Here, we discuss the main molecular events underlying immune-based platelet disorders with specific focus on events occurring at the platelet surface leading to activation and clearance.
Collapse
|
20
|
Arnold DM, Heddle NM, Cook RJ, Hsia C, Blostein M, Jamula E, Sholzberg M, Lin Y, Kassis J, Larratt L, Tinmouth A, Amini S, Schipperus M, Lim W, Vishnu P, Warner M, Carruthers J, Li N, Lane S, Kelton JG. Perioperative oral eltrombopag versus intravenous immunoglobulin in patients with immune thrombocytopenia: a non-inferiority, multicentre, randomised trial. LANCET HAEMATOLOGY 2020; 7:e640-e648. [PMID: 32853584 DOI: 10.1016/s2352-3026(20)30227-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Patients with immune thrombocytopenia are at risk of bleeding during surgery, and intravenous immunoglobulin is commonly used to increase the platelet count. We aimed to establish whether perioperative eltrombopag was non-inferior to intravenous immunoglobulin. METHODS We did a randomised, open-label trial in eight academic hospitals in Canada. Patients were aged at least 18 years, with primary or secondary immune thrombocytopenia and platelet counts less than 100 × 109 cells per L before major surgery or less than 50 × 109 cells per L before minor surgery. Previous intravenous immunoglobulin within 2 weeks or thrombopoietin receptor agonists within 4 weeks before randomisation were not permitted. Patients were randomly assigned to receive oral daily eltrombopag 50 mg from 21 days preoperatively to postoperative day 7 or intravenous immunoglobulin 1 g/kg or 2 g/kg 7 days before surgery. Eltrombopag dose adjustments were allowed weekly based on platelet counts. The randomisation sequence was generated by a computerised random number generator, concealed and stratified by centre and surgery type (major or minor). The central study statistician was masked to treatment allocation. The primary outcome was achievement of perioperative platelet count targets (90 × 109 cells per L before major surgery or 45 × 109 cells per L before minor surgery) without rescue treatment. We did intention-to-treat and per-protocol analyses using an absolute non-inferiority margin of -10%. This trial is registered with ClinicalTrials.gov, NCT01621204. FINDINGS Between June 5, 2013, and March 7, 2019, 92 patients with immune thrombocytopenia were screened, of whom 74 (80%) were randomly assigned: 38 to eltrombopag and 36 to intravenous immunoglobulin. Median follow-up was 50 days (IQR 49-55). By intention-to-treat analysis, perioperative platelet targets were achieved for 30 (79%) of 38 patients assigned to eltrombopag and 22 (61%) of 36 patients assigned to intravenous immunoglobulin (absolute risk difference 17·8%, one-sided lower limit of the 95% CI 0·4%; pnon-inferiority=0·005). In the per-protocol analysis, perioperative platelet targets were achieved for 29 (78%) of 37 patients in the eltrombopag group and 20 (63%) of 32 in the intravenous immunoglobulin group (absolute risk difference 15·9%, one-sided lower limit of the 95% CI -2·1%; pnon-inferiority=0·009). Two serious adverse events occurred in the eltrombopag group: one treatment-related pulmonary embolism and one vertigo. Five serious adverse events occurred in the intravenous immunoglobulin group (atrial fibrillation, pancreatitis, vulvar pain, chest tube malfunction and conversion to open splenectomy); all were related to complications of surgery. No treatment-related deaths occurred. INTERPRETATION Eltrombopag is an effective alternative to intravenous immunoglobulin for perioperative treatment of immune thrombocytopenia. However, treatment with eltrombopag might increase risk of thrombosis. The decision to choose one treatment over the other will depend on patient preference, resource limitations, cost, and individual risk profiles. FUNDING GlaxoSmithKline and Novartis.
Collapse
Affiliation(s)
- Donald M Arnold
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada; Canadian Blood Services, Ancaster, ON, Canada.
| | - Nancy M Heddle
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard J Cook
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON, Canada
| | - Cyrus Hsia
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
| | - Mark Blostein
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Erin Jamula
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jeannine Kassis
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Loree Larratt
- Division of Hematology, University of Alberta, Edmonton, AB, Canada
| | - Alan Tinmouth
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sufia Amini
- Department of Hematology, HagaZiekenhuis, The Hague, Netherlands
| | - Martin Schipperus
- Department of Hematology, HagaZiekenhuis, The Hague, Netherlands; Department of Hematology, University Medical Centre Groningen, Groningen, Netherlands
| | - Wendy Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Prakash Vishnu
- Division of Hematology, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | | | - Julie Carruthers
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Na Li
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon Lane
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John G Kelton
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
21
|
Mancuso S, Carlisi M, Serra N, Napolitano M, Raso S, Consoli U, Palazzolo R, Lanza Cariccio MR, Siragusa S. Clinical Phenotype and Response to Different Lines of Therapy in Elderly with Immune Thrombocytopenia: A Retrospective Study. J Blood Med 2020; 11:251-258. [PMID: 32801981 PMCID: PMC7415458 DOI: 10.2147/jbm.s256620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/17/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose Insufficient knowledge of primary immune thrombocytopenia purpura (ITP) in the elderly, together with a lack of clinical trial data, has resulted in wide variation in treatments. Here, we present a study focused on clinical characteristics of ITP in older subjects at diagnosis integrated with the subsequent course of the disease and treatment history. Methods In a retrospective monoinstitutional study, we evaluated >65-year-old patients with primary ITP. Clinical characteristics at the time of diagnosis were described and analyzed. We aimed to delineate whether subsequent lines of therapy influenced the number of relapses. In addition to initial regimens, we reported subsequent treatments and the impact on relapse trends. Results A total of 50 patients (56% males, mean age 78 years) were included. With regard to clinical variables at diagnosis, statistical significance was found for Eastern Cooperative Oncology Group performance status 1 (46% of patients, p<0.0001), presence of three comorbidities (36% of patients, p<0.0001), World Health Organization grade 0 bleeding (46%, p=0.0001), and World Health Organization grade 1 bleeding (42%, p=0.0009). For bleeding sites, the most frequent were skin or mucosa (40%, p=0.0477). A decrease in platelet count was correlated with moderate or severe bleeding (ρ=-0.52, p=0.0001) and viscera or skin/mucosa + viscera site (ρ=-0.50, p=0.0002). Finally, a decreasing number of patients required treatment from first-line therapy to sixth (p<0.0001). Relapse was most frequent before second-line therapy (54%, p<0.0001) and less frequent before fivth and sixth (4%, p=0.0072; 2%, p=0.0027). Conclusion ITP in older age poses considerable challenges, so specific management strategies should be considered to optimize outcomes. Our findings provide evidence of an inverse relationship between lines of therapy and timing of relapses. This study does not exclude the possibility that agents used after first-line therapy may have an impact on the response and modify the unfavorable course of ITP.
Collapse
Affiliation(s)
- Salvatrice Mancuso
- Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) Department, University of Palermo, Palermo, Italy
| | - Melania Carlisi
- Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) Department, University of Palermo, Palermo, Italy
| | - Nicola Serra
- Department of Molecular Medicine and Medical Biotechnology, University Federico II of Naples, Naples, Italy.,Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Mariasanta Napolitano
- Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) Department, University of Palermo, Palermo, Italy
| | - Simona Raso
- Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy
| | - Ugo Consoli
- UOC Ematologia ARNAS Garibaldi, Catania, Italy
| | | | | | - Sergio Siragusa
- Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) Department, University of Palermo, Palermo, Italy
| |
Collapse
|
22
|
Yassa G, Shakir AR, Jagarlamudi K, Yassa AE. Successful treatment of refractory secondary immune thrombocytopenia (antiphospholipid antibody syndrome-associated) with the combination of rituximab and romiplostim at the cost of severe bone pain: A case report and review of literature. J Oncol Pharm Pract 2020; 27:253-257. [PMID: 32611269 DOI: 10.1177/1078155220935490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Immune thrombocytopenia is an autoimmune disorder associated with increased thrombocyte destruction and impaired production in the bone marrow. Proposed mechanisms include an antibody or autoreactive T-cell-associated autoimmunity and thrombopoietin deficiency among others. Clinical manifestations are predominantly mucocutaneous hemorrhages including petechiae, purpura, mucosal bleeding in the urinary or the gastrointestinal tracts, menorrhagia, and epistaxis. The purpose of the treatment is to prevent bleeding rather than normalizing the platelet counts. First-line treatments include corticosteroids ± intravenous immunoglobulin and Anti-D which mainly decrease antibody-mediated platelet destruction and increase the number of peripheral Tregs. Second-line and subsequent therapies include splenectomy, chimeric anti-CD20 antibody (rituximab), which eliminates B cells and act as an immunomodulatory agent, and Thrombopoietin receptor agonists (romiplostim), which promote platelet production. CASE REPORT We describe a 40-year-old male patient diagnosed with immune thrombocytopenia that was refractory to first-line corticosteroid and intravenous immunoglobulin and second-line romiplostim monotherapy treatments.Management and outcome: The patient was given the romiplostim and rituximab combination which not only successfully treated thrombocytopenia but also resulted in grade 3 bone pains and the patient's subsequent refusal to continue therapy. DISCUSSION Common adverse effects of rituximab are infusion reactions and prolonged immunosuppression; those of romiplostim include thrombosis, headaches, arthralgia-myalgia, and gastrointestinal symptoms. This case shows that romiplostim has not caused any discernible side effects when given alone, while combination with rituximab resulted in severe bone and joint pains. We hypothesize that this combination regimen shows a synergistic effect both in terms of efficacy and adverse-effect probability and/or severity.
Collapse
Affiliation(s)
- Gizem Yassa
- Department of Internal Medicine, Marmara University, Istanbul, Turkey
| | - Abdur R Shakir
- Department of Hematology/Oncology, Sarah Bush Lincoln Hospital-Regional Cancer Center, Mattoon, IL, USA.,University of Illinois at Chicago, IL, USA
| | - Kuppuswamy Jagarlamudi
- Department of Hematology/Oncology, Sarah Bush Lincoln Hospital-Regional Cancer Center, Mattoon, IL, USA
| | - Ahmet E Yassa
- Department of Internal Medicine, Istanbul University-Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| |
Collapse
|
23
|
Woolley P, Newton R, Mc Guckin S, Thomas M, Westwood JP, Scully MA. Immune thrombocytopenia in adults: A single-centre review of demographics, clinical features and treatment outcomes. Eur J Haematol 2020; 105:344-351. [PMID: 32474953 DOI: 10.1111/ejh.13456] [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: 03/25/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Primary immune thrombocytopenia (ITP) is a bleeding disorder characterised by an isolated thrombocytopenia in the absence of an alternative diagnosis. The condition is highly heterogeneous with some patients requiring multiple of therapy before achieving response. In this study, we collected data on a large cohort of primary ITP patients with the objective of identifying variables which may predict treatment requirements. METHODS We collected data on 379 patients, 275 with a confirmed diagnosis of primary ITP included demographics, baseline laboratory results and treatments. These were compared against treatment responses and lines of therapy. RESULTS Patients who presented with a platelet count of <30 × 109 /L or bleeding symptoms were observed to require more subsequent lines of therapy (P-value <0.001). 32% of patients (n = 87) received no treatment, and these patients had a significantly higher median count compared to those with required >2 lines of therapy (P-value <0.001). Superior response rates were demonstrated with thrombopoietin receptor agonists when compared with other agents irrespective of baseline characteristics. CONCLUSIONS Platelet counts at diagnosis are a potentially strong predictive indicator of subsequent lines of therapy. Patients with bleeding symptoms at diagnosis were more likely to have lower median platelets counts.
Collapse
Affiliation(s)
- Philippa Woolley
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rosalind Newton
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Siobhan Mc Guckin
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mari Thomas
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK.,Cardiometabolic Programme-NIHR UCLH/UC BRC, London, UK
| | - John-Paul Westwood
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Marie A Scully
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK.,Cardiometabolic Programme-NIHR UCLH/UC BRC, London, UK
| |
Collapse
|
24
|
Choi PYI. Lifting the fog over ITP. Platelets 2020; 31:283-284. [PMID: 32124683 DOI: 10.1080/09537104.2020.1732747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Philip Young-Ill Choi
- The Haematology Department, The Canberra Hospital, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia.,The John Curtin School of Medical Research, The Australian National University, Canberra, Australia
| |
Collapse
|
25
|
Hicks SM, Coupland LA, Jahangiri A, Choi PY, Gardiner EE. Novel scientific approaches and future research directions in understanding ITP. Platelets 2020; 31:315-321. [PMID: 32054377 DOI: 10.1080/09537104.2020.1727871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Diagnosis of immune thrombocytopenia (ITP) and prediction of response to therapy remain significant and constant challenges in hematology. In patients who present with ITP, the platelet count is frequently used as a surrogate marker for disease severity, and so often determines the need for therapy. Although there is a clear link between thrombocytopenia and hemostasis, a direct correlation between the extent of thrombocytopenia and bleeding symptoms, especially at lower platelet counts is lacking. Thus, bleeding in ITP is heterogeneous, unpredictable, and nearly always based on a multitude of risk factors, beyond the platelet count. The development of an evidence-based, validated risk stratification model for ITP treatment is a major goal in the ITP community and this review discusses new laboratory approaches to evaluate the various pathobiologies of ITP that may inform such a model.
Collapse
Affiliation(s)
- Sarah M Hicks
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia
| | - Lucy A Coupland
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia
| | - Anila Jahangiri
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia
| | - Philip Y Choi
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia.,Haematology Department, The Canberra Hospital, Canberra, Australia
| | - Elizabeth E Gardiner
- ACRF Department of Cancer Biology and Therapeutics, The John Curtin School of Medical Research, The Australian National University, Canberra, Australia.,The National Platelet Research and Referral Centre (NPRC), Canberra, Australia
| |
Collapse
|
26
|
Association of Immune Thrombocytopenia and T-Lymphoblastic Lymphoma in a Pediatric Patient. Case Rep Hematol 2019; 2019:1425151. [PMID: 31929920 PMCID: PMC6935784 DOI: 10.1155/2019/1425151] [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: 05/18/2019] [Accepted: 11/11/2019] [Indexed: 12/02/2022] Open
Abstract
Immune thrombocytopenia (ITP) is characterized by isolated thrombocytopenia of unclear etiology. We present a unique case of an 8-year-old girl with chronic ITP who was subsequently diagnosed with T-lymphoblastic lymphoma at age 11. The clinical course was complicated by the occurrence of nonepileptiform events with bizarre behavior changes following the administration of nelarabine and intrathecal and high-dose systemic methotrexate. This case highlights an unusual co-occurrence of hematologic malignancy and chronic ITP in an otherwise healthy child. We speculate that underlying genetic or immunologic lesions may predispose a subset of pediatric ITP patients to the development of hematologic malignancies.
Collapse
|
27
|
Hawkins J, Aster RH, Curtis BR. Post-Transfusion Purpura: Current Perspectives. J Blood Med 2019; 10:405-415. [PMID: 31849555 PMCID: PMC6910090 DOI: 10.2147/jbm.s189176] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 11/22/2019] [Indexed: 12/15/2022] Open
Abstract
Post transfusion purpura (PTP) is an uncommonly reported post transfusion adverse event that can present with severe thrombocytopenia; sometimes resulting in significant bleeding and hemorrhage. Its diagnosis can be elusive given its substantial symptomatic overlap with other thrombocytopenic syndromes. Underdiagnosis and underreporting make the true incidence of disease difficult to define. While clinical suspicion is key, laboratory evidence of platelet-targeted antibodies and identification of the antigen(s) they recognize are necessary to confirm the diagnosis. A curious aspect of PTP is paradoxical destruction of both transfused and autologous platelets. Although the first case was reported over 50 years ago, this aspect of PTP pathogenesis is still not fully understood and is widely debated. Several theories exist, but conclusive evidence to support most is lacking. Despite limited understanding of disease incidence and etiology, treatment with IVIG (Intravenous Immunoglobulin) has become standard practice and can be highly effective. Although recurrence is rare, precautions should be taken if patients with a history of PTP require transfusions in the future.
Collapse
Affiliation(s)
- Jaleah Hawkins
- Versiti, Blood Center of Michigan, Grand Rapids, MI, USA
| | - Richard H Aster
- Versiti, Blood Center of Wisconsin, Milwaukee, WI, USA.,Blood Research Institute, Milwaukee, WI, USA
| | - Brian R Curtis
- Versiti, Blood Center of Wisconsin, Milwaukee, WI, USA.,Blood Research Institute, Milwaukee, WI, USA
| |
Collapse
|
28
|
Malpica L, van Duin D, Moll S. Preventing infectious complications when treating non-malignant immune-mediated hematologic disorders. Am J Hematol 2019; 94:1396-1412. [PMID: 31571266 DOI: 10.1002/ajh.25642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/11/2019] [Accepted: 09/16/2019] [Indexed: 01/19/2023]
Abstract
Immunosuppressants, targeted antibody therapies, and surgical splenectomy are amongst the treatment choices for immune-mediated non-malignant hematologic disorders, with infection being the most common non-hematological adverse event from these therapies. Corticosteroids are associated with a length-of-treatment and dose-dependent risk for infection, including opportunistic infections. Screening and antimicrobial prophylaxis against tuberculosis, Strongyloides stercoralis, and Pneumocystis jirovecii pneumonia, are indicated in selected patients on steroids and with certain risk factors for infection. Rituximab is associated with hepatitis B virus reactivation. All patients planned to be started on rituximab should be screened for hepatitis B surface antigen and total core antibody, with antiviral prophylaxis given depending on test results. In eculizumab treated patients, immunization against meningococcal serogroups ACWY and B is recommended. In addition, some guidelines suggest antibiotic prophylaxis for the duration of eculizumab treatment. In splenectomized patients, counseling and immunization are cornerstones of infection prevention. Several federal and society guidelines about immunizations and prophylactic antimicrobial therapies for patients treated with various immunosuppressive agents exist and are summarized in this manuscript in a clinical-focused table. In addition, management suggestions are made where no formal guidelines exist.
Collapse
Affiliation(s)
- Luis Malpica
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David van Duin
- Department of Medicine, Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Stephan Moll
- Department of Medicine, Division of Hematology and Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| |
Collapse
|
29
|
Ma TJ, Sun GL, Yao F, Yang ZL. Wilson disease associated with immune thrombocytopenia: A case report and review of the literature. World J Clin Cases 2019; 7:2630-2636. [PMID: 31559303 PMCID: PMC6745329 DOI: 10.12998/wjcc.v7.i17.2630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/30/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Wilson disease (WD) is a genetic disorder of hepatic copper excretion, leading to copper accumulation in various tissues. The manifestations are quite variable, and hemolytic anemia is the most common hematological presentation. WD associated with thrombocytopenia is very rare.
CASE SUMMARY We report the case of an 11-year-old Chinese girl with WD that was associated with immune thrombocytopenia (ITP). Thrombocytopenia was the initial chief complaint for her to visit a hematologist, and ITP was diagnosed based on the results of a bone marrow biopsy and positive antiplatelet autoantibodies. About two weeks before the thrombocytopenia was found, the patient developed drooling. Tremors developed in her right hand about one week after being diagnosed with ITP, after which she was admitted to our hospital. Further evaluations were performed. Ceruloplasmin was decreased, with an increased level of copper in her 24-h urine excretion. Kayser Fleischer's ring (K-F ring) was positive. The ultrasound showed liver cirrhosis, and brain magnetic resonance imaging showed that the lenticular nucleus, caudate nucleus, and brainstem presented a low signal intensity in T1-weighted images and high signal intensity in T2-weighted images. WD was diagnosed and a genetic analysis was performed. A compound heterozygous mutation in ATP7B was detected; c.2333G>T (p.Arg778Leu) in exon 8 and c.3809A>G (p.Asn1270Ser) in exon 18. The former was inherited from her father and the latter from her mother. However, her parents showed normal liver function and negative K-F rings. Such a compound mutation in a case of WD associated with ITP in children has not been published previously.
CONCLUSION WD can associate with thrombocytopenia but the mechanism is still unclear. We recommend that antiplatelet autoantibodies should be tested in WD patients with thrombocytopenia in future to verify the association.
Collapse
Affiliation(s)
- Tian-Jiao Ma
- Department of Pediatrics, The First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Gui-Lian Sun
- Department of Pediatrics, The First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Fang Yao
- Department of Pediatrics, The First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Zhi-Liang Yang
- Department of Pediatrics, The First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| |
Collapse
|
30
|
Ribeiro RDA, Galiza Neto GCD, Furtado ADS, Ribeiro LLPA, Kubrusly MS, Kubrusly ES. Proposal of treatment algorithm for immune thromocytopenia in adult patients of a hematology service at a referral center in Northeastern Brazil. Hematol Transfus Cell Ther 2019; 41:253-261. [PMID: 31085155 PMCID: PMC6732411 DOI: 10.1016/j.htct.2018.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/05/2018] [Accepted: 10/15/2018] [Indexed: 01/19/2023] Open
Abstract
Introduction The management of adult (≥18 years) immune thrombocytopenia patients relies on platelet count, the risk of bleeding and presence of bleeding. Objective Confirming the diagnosis of immune thrombocytopenia and the start of therapy, our hematology service, a referral center, favors the establishment of this algorithm to treat those patients. Results Presentation, recently diagnosed or recurrence – group 1: life-threatening bleeding: high-dose intravenous immunoglobulins with methylprednisolone or dexamethasone. Hospitalization and platelet transfusion are considered. Group 2: Platelets <30 × 109/L with bleeding or risk factor for bleeding, or platelets <20 × 109/L: prednisone or dexamethasone. No response, platelets <20 × 109/L: replace corticoid or increase doses. If platelets continue <20 × 109/L: immunization and splenectomy. Investigation of Helicobacter pylori, if positive: treatment for H. pylori. Chronic immune thrombocytopenia with platelets <20 × 109/L we propose two new groups (A and B): Group A: <65 years, no or low surgical risk, patient declines maintenance therapy or patient intends to get pregnant: immunization and splenectomy. Group B: failure of splenectomy (refractory) or no splenectomy indication or history of exposure to malaria or babesiosis and no response to corticoids or corticoid dependence: choose thrombopoietin receptor agonists: eltrombopag or romiplostim. Patient at high risk for arterial or venous thrombosis: recommend rituximab. After rituximab or thrombopoietin receptor agonists, if platelets continue <20 × 109/L: indicate immunosuppressants (azathioprine or cyclophosphamide), dapsone or mycophenolate mofetil or vinca alkaloids. The goals of treatment for chronic or refractory immune thrombocytopenia are to keep platelets >20 × 109/L and stop bleeding.
Collapse
Affiliation(s)
| | | | - Amanda da Silva Furtado
- Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (HUWC UFC), Fortaleza, CE, Brazil
| | | | | | - Elsie Sobreira Kubrusly
- Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (HUWC UFC), Fortaleza, CE, Brazil; Centro Universitário Christus (UNICHRISTUS), Fortaleza, CE, Brazil
| |
Collapse
|
31
|
Długosz-Danecka M, Zdziarska J, Jurczak W. Avatrombopag for the treatment of immune thrombocytopenia. Expert Rev Clin Immunol 2019; 15:327-339. [PMID: 30799645 DOI: 10.1080/1744666x.2019.1587294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Thrombopoietin-receptor agonists (TPO-RAs) are the only American Society of Hematology (ASH) guideline-advocated, second-line treatment for immune thrombocytopenia (ITP) that have been validated by randomized, controlled trials with a placebo comparator. Avatrombopag is a new candidate in this class that has been investigated as a treatment option for the treatment of ITP. Areas covered: In this Drug Profile, we provide a review of the clinical data of avatrombopag, which was approved in May 2018 by the United States Food and Drug Administration (FDA) for the treatment of thrombocytopenia in patients with chronic liver disease undergoing an invasive procedure, and an opinion of its potential place in the current evidence-based ITP treatment landscape. Expert commentary: Avatrombopag induces doubling of platelet counts, increasing them to above 50 X 109/L, and prevents the need for platelet transfusions while minimizing the need for rescue medications. Treatment-emergent adverse events (TEAEs) are comparable to placebo. Oral delivery, a 5-day dosing schedule and good tolerability (<1% discontinuation rate) with no clinically significant hepatoxicity make it a promising entrant as a potential second-line treatment for ITP. Further, data from a phase 3 study in patients with ITP supports its utility in the treatment of patients with ITP.
Collapse
Affiliation(s)
| | - Joanna Zdziarska
- a Department of Hematology , Jagiellonian University , Krakow , Poland
| | - Wojciech Jurczak
- a Department of Hematology , Jagiellonian University , Krakow , Poland
| |
Collapse
|
32
|
Abstract
BACKGROUND Autoimmune thrombocytopenia in immune thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP), and heparin-induced thrombocytopenia (HIT) is associated with immunologic degradation of platelets and reduced platelet counts in patients, leading to bleeding risk in patients. Considering the role of human leukocyte antigens (HLA) in the development of immune response, in this review, we examine the relationship between HLA and pathogenesis of the above-mentioned diseases. METHODS Relevant English-language literature was searched and retrieved from Google Scholar search engine and PubMed database (1979 to 2018). The following keywords were used: "Immune Thrombocytopenic purpura," "Thrombotic Thrombocytopenic Purpura," Human Leukocyte Antigen," and "Heparin-induced thrombocytopenia." RESULTS In autoimmune thrombocytopenia, HLA molecule presents self-antigens or foreign antigens similar to self-antigens, provoking an immune response against platelets that results in the degradation of platelets in peripheral blood and possible bleeding in the patient. For example, HLA-DRB1 *11 presents the self-antigen and induces an immune response against ADAMTS13, which is associated with thrombocytopenia in TTP patients. CONCLUSIONS HLA alleles can be used as prognostic biomarkers for immunologic disorders of platelet such as ITP, TTP, and HIT. Different DRB1 alleles enable the assessment of resistance to common ITP treatments as well as disease prognosis. Due to the genetic association between HLA-DR1 and HLA-DQ1 alleles and the role of HLA-DRB1 *11 in TTP, the HLA-DQB1 *02: 02 allele may also play a role in TTP pathogenesis.
Collapse
|
33
|
Xiang Y, Li J, Sun Y. A case report of pulmonary arterial hypertension in pregnancy and complications of anticoagulation therapy. Medicine (Baltimore) 2018; 97:e11810. [PMID: 30095650 PMCID: PMC6133479 DOI: 10.1097/md.0000000000011810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Treprostinil, a potent vasodilator, is the treatment of choice for severe pulmonary arterial hypertension (PAH) during pregnancy. Its inhibition of platelet aggregation increases the risk of hemorrhage. In addition, anticoagulation therapy is widely used in pregnancy with PAH due to the hypercoagulable state. However, very little is known about the complications of anticoagulants' use in pregnancy with PAH. PATIENT CONCERNS A 27-year-old pregnant woman was admitted to the hospital at 32weeks with progressive dyspnea. DIAGNOSES The pregnant was diagnosed with ventricular septal defect 12 years prior to presentation. Combining clinical manifestation with results of right heart catheterization (RHC) and echocardiography, it was consistent with severe World Health Organization (WHO) group I PAH. INTERVENTIONS Supportive treatment included supplemental oxygen, intravenous treprostinil, sildenafil and prophylactic anticoagulation. OUTCOMES Gastrointestinal bleeding is occurred in our patient when dalteparin were used in conjunction with treprostinil. Her care was further complicated refractory to usual conservative measures before delivery. LESSONS This case report illustrates the complexities that arise when prostacyclin therapies are combined with necessary anticoagulation in patients with PAH during pregnancy. More intention should play to the complications of anticoagulant in pregnancy with PAH during treprostinil therapy.
Collapse
Affiliation(s)
| | - Jun Li
- Cardiovascular Medicine Department, People's Hospital of Zhuhai City, Zhuhai City, China
| | | |
Collapse
|
34
|
Chen C, Song J, Wang Q, Wang LH, Guo PX. Mean platelet volume at baseline and immune thrombocytopenia relapse in Chinese newly-diagnosed patients: a retrospective cohort study. Hematology 2018; 23:646-652. [PMID: 29633664 DOI: 10.1080/10245332.2018.1461317] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Chi Chen
- Department of Immunology and Microbiology, Guiyang College of Traditional Chinese Medicine, Guiyang, Guizhou, People’s Republic of China
| | - Jun Song
- Department of Hematology, The People’s Hospital of Guizhou Province, Guiyang, Guizhou, People’s Republic of China
| | - Qing Wang
- Department of Hematology, The People’s Hospital of Guizhou Province, Guiyang, Guizhou, People’s Republic of China
| | - Lin-Hui Wang
- Department of Hematology, The People’s Hospital of Guizhou Province, Guiyang, Guizhou, People’s Republic of China
| | - Peng-Xiang Guo
- Department of Hematology, The People’s Hospital of Guizhou Province, Guiyang, Guizhou, People’s Republic of China
| |
Collapse
|