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Maitland H, Lambert C, Ghanima W. Patient-centric care in primary immune thrombocytopenia (ITP): shared decision-making and assessment of health-related quality of life. Hematology 2024; 29:2375177. [PMID: 38975804 DOI: 10.1080/16078454.2024.2375177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 06/26/2024] [Indexed: 07/09/2024] Open
Abstract
ABSTRACTImmune thrombocytopenia (ITP), an autoimmune disease characterized by low platelet counts and increased bleeding risk, can impair health-related quality of life (HRQoL), impacting patients' daily lives and mental health. A number of patient-reported outcome (PRO) measures (both generic and specific to ITP) can be used to understand the impact of ITP on HRQoL and generate evidence to guide disease management. As well-developed PRO tools could help in HRQoL assessment, their optimization could help to solidify a patient-centric approach to ITP management. Shared decision-making is a collaborative process between a patient and their healthcare professional in making decisions about care. Treatment decisions based on this shared process between physician and patient are recommended by clinical guidelines. The goal of this narrative review is to discuss treatment decisions with regards to patient-centric ITP management, with a focus on the impact of PRO measures and the process of shared decision-making in practice.
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Affiliation(s)
- Hillary Maitland
- Division of Hematology and Oncology, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Catherine Lambert
- Haemostasis and Thrombosis Unit, Division of Hematology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Waleed Ghanima
- Department of Hemato-oncology, Østfold Hospital, and Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
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Mannering N, Hansen DL, Pottegård A, Andersen K, Frederiksen H. Mental health and use of psychotropic prescription drugs in adult patients with primary immune thrombocytopenia: a nationwide population-based cohort study. Haematologica 2024; 109:2944-2954. [PMID: 38721747 PMCID: PMC11367223 DOI: 10.3324/haematol.2024.285364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/26/2024] [Indexed: 09/03/2024] Open
Abstract
Patients with primary immune thrombocytopenia (ITP) suffer from reduced survival and quality of life, but the underlying reasons for this are largely undescribed. Mental health and the use of psychotropic drugs in ITP is unknown. We investigated the risk of hospital-registered mental health events including fatigue and the use of psychotropic drugs in adult patients with ITP compared with the general population, using nationwide registry-data. We identified 3,749 patients with ITP and 149,849 age- and sex-matched general population comparators in the Danish Health Registries in the period 1997-2016. The median age was 60 years (interquartile range [IQR], 40-73) and 53% were women. We followed the individuals for incident mental health events and estimated the use of psychotropic drugs over calendar-years and in temporal relation to diagnosis of ITP. The first year cumulative incidence of any mental health event was 2.3% (95% confidence interval [CI]: 1.9-2.9) in patients and 0.7% (95% CI: 0.6-0.7) in comparators, yielding an adjusted cause-specific hazard ratio (csHR) of 3.57 (95% CI: 2.84-4.50). The corresponding estimates for depression were 1.2% (95% CI: 0.9-1.6) and 0.3% (0.3-0.4) respectively, with an adjusted csHR of 3.53 (95% CI: 2.56-4.85). We found similar findings for anxiety and fatigue, but risks generally diminished after 1-5 years. The use of opioids, antidepressants, and benzodiazepines increased in temporal relation to diagnosis of ITP. The risk of mental health events and the use of psychotropic drugs is higher in adult patients with ITP compared with the general population, and has a temporal relation to diagnosis of ITP emphasizing that mental health in ITP is a concern.
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Affiliation(s)
- Nikolaj Mannering
- Department of Hematology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense.
| | - Dennis Lund Hansen
- Department of Hematology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense
| | - Anton Pottegård
- Department of Public Health, University of Southern Denmark, Odense
| | - Kjeld Andersen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Department of Psychiatry - Odense, Region of Southern Denmark, Odense
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense
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Chaudhry M, Stadler JK, Fitzgerald K, Modi J, Jones G, Magana K, Ward S, Magee T, Hughes G, Ford AI, Vassar M. Assessing uptake of the core outcome set in clinical trials for immune thrombocytopenia: A cross-sectional analysis. Thromb Res 2024; 234:113-119. [PMID: 38211379 DOI: 10.1016/j.thromres.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Clinical trials (CTs) guide clinical practice, but inconsistent outcome reporting presents challenges. To increase comparability, a core outcome set (COS) was created for primary Immune thrombocytopenia (ITP) in 2009 to standardize outcome measurements. We aimed to evaluate uptake of the primary ITP COS in CT registries. MATERIALS & METHODS Our cross-sectional analysis employed a search string on ClinicalTrials.gov and ICTRP for phase III/IV CTs in June 2023. Inclusion criteria consisted of subjects with primary ITP, study was registered five years before COS publication to June 26, 2023, and assessed effectiveness of interventions. Two investigators extracted data in a masked, duplicate manner. Interrupted time series analysis, ANOVAs, and correlation analyses were conducted to assess the main outcome of COS uptake pre/post COS publication. RESULTS The search identified 131 eligible trials for data extraction. Altogether, 38.2 % (50/131) followed IWG platelet response guidelines. An alternative platelet count measurement was 50,000 × 109 L, with 46.56 % (61/131) of trials reporting it. The most measured outcome was adverse events (106/131, 80.9 %). Remaining secondary outcomes were measured in <50 % of studies. After COS publication, there was a statistically non-significant 0.03 % (p = 0.50, CI 95 % = [-0.06, 0.13]) 0.03 % (p = 0.50, CI 95 % = [-0.06, 0.13]) increase in the monthly trend of COS-defined outcomes. CONCLUSION We found a non-significant increase in uptake of the ITP COS since its publication and highlighted the lack of standardization among endpoints within ITP clinical trials. Our analysis highlights the need for heightened awareness and a COS update that acknowledges the variability in clinical trials.
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Affiliation(s)
- Mahad Chaudhry
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States.
| | - John K Stadler
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Kyle Fitzgerald
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Jay Modi
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Garrett Jones
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Kimberly Magana
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Shaelyn Ward
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Trevor Magee
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Griffin Hughes
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Alicia Ito Ford
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
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Thakre R, Gharde P, Raghuwanshi M. Idiopathic Thrombocytopenic Purpura: Current Limitations and Management. Cureus 2023; 15:e49313. [PMID: 38143653 PMCID: PMC10748795 DOI: 10.7759/cureus.49313] [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: 08/21/2023] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
Idiopathic thrombocytopenic purpura (ITP), also known as immune thrombocytopenia, is a blood disorder characterized by a reduction in the number of platelets. A reduction in the number of platelets beyond the normal levels leads to several consequences. A severe reduction in blood platelet levels leads to a rash of purple spots on the skin, joints, etc. due to leakage in the small blood vessels, easy bruising, bleeding gums, intestinal bleeding, and hemorrhage. Suppose a case of ITP resolves in fewer than six months. In that case, it is an acute case of ITP. Still, if a case settles in more than six months, it is a case of ITP. The cause of a reduced platelet count can be increased peripheral destruction or impaired production; this is termed an autoimmune condition in which the body's immune system attacks platelets thinking it to be a foreign antigen. ITP in children occurs commonly following a previous viral attack. Even though evaluating patients' reports is useful for understanding and guiding the treatment, these estimates might not be regularly evaluated in clinical settings. First-line drugs in the treatment of ITP are corticosteroids, and long-term use of these drugs has several side effects, such as excessive increase in weight, mental health disturbances, and sleep disturbances; additional therapies to treat hemorrhage are usually momentary. As a result, it is essential to recognize the flaws in current procedures and adopt innovative measures for the management and minimization of difficulties.
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Affiliation(s)
- Rakshanda Thakre
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Pankaj Gharde
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mohit Raghuwanshi
- Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Rüfer A, Terrell DR. Burden of immune thrombocytopenia (ITP): Special considerations for refractory ITP. Br J Haematol 2023; 203:79-85. [PMID: 37735553 DOI: 10.1111/bjh.19068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
It is known that patients with immune thrombocytopenia (ITP) have fatigue and impairment of health-related quality of life (HRQoL). However, it is hypothesized that patients with refractory ITP have additional burdens that should be considered. Specifically, fatigue is more pronounced in patients with refractory disease, there are additional side effects from second- and third-line treatments, additional anxiety about the long-term course of the disease, impairment in HRQoL resulting from heavy menstrual bleeding and concerns related to family planning. The burden of disease, therefore, should be carefully assessed and considered in these patients. However, researchers have utilized numerous tools for evaluating HRQoL and fatigue, making comparison of data across studies challenging. There is a need to standardize assessment using either disease-specific or generic instruments that can be easily implemented in routine clinical practice. Additionally, whether treatment of low platelet count and bleeding symptoms will have a positive influence on HRQoL remains to be seen and published evidence is conflicting. Nevertheless, improvement of HRQoL is a major treatment goal for both patients and physicians and should be especially considered when treating patients with refractory ITP.
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Affiliation(s)
- Axel Rüfer
- Division of Hematology, Luzerner Kantonsspital-in association with University Luzern, Luzern, Switzerland
| | - Deirdra R Terrell
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Zhang W, Xie S, Fu R, Chen Y, Liu W, Sun T, Ju M, Li H, Xue F, Zhang L, Liu X, Yang R. Fatigue and health-related quality of life in patients with immune thrombocytopenia: a longitudinal assessment in China. Expert Rev Hematol 2023; 16:1125-1133. [PMID: 38009277 DOI: 10.1080/17474086.2023.2286730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/22/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND There is lacking studies of longitudinally assessment of fatigue and health-related quality of life (HRQoL) among Chinese immune thrombocytopenia (ITP) adults. We aimed to evaluate changes in fatigue and HRQoL and identify the associated factors. METHODS Patients' characteristics, Functional Assessment of Chronic Illness Therapy (FACIT-F) and the ITP-specific Patient Assessment Questionnaire (ITP-PAQ) scores at admission (T0), at discharge (T1), and three months after discharge (T2) were collected. Linear mixed effects models were used to examine changes over time. RESULTS We included 175 patients. The mean score of FACIT-F at T0 was 37.2 and increased at T1 (39.0), while then decreased at T2 (34.7). Patients who were single, retired, had persistent ITP, splenomegaly had more severe fatigue, whereas those who had not received any prior treatment and had a bleeding score of 0 at admission had milder fatigue. The mean score of ITP-PAQ was 57.7 at T0, then gradually increased to 60.3 at T1 and 62.8 at T2. Patients with persistent ITP and those who have never received treatment for ITP have better HRQoL. CONCLUSION ITP adults' fatigue and HRQoL were impaired. Patients' fatigue improved at discharge but worsened at three months after discharge, while HRQoL gradually improved over time.
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Affiliation(s)
- Wenhui 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, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Department of Hematology, The Affiliated Hospital of Qingdao University, Qingdao, People's Republic of China
| | - Shitong Xie
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
- Center for Social Science Survey and Data, Tianjin University, Tianjin, China
| | - Rongfeng Fu
- 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, China
| | - Yunfei 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, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Wei 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, China
| | - Ting Sun
- 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, China
| | - Mankai Ju
- 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, China
| | - Huiyuan Li
- 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, China
| | - Feng Xue
- 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, China
| | - Lei 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, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - 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, 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, China
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Dijk WEM, Punt MC, Galen KPM, Leeuwen J, Lely AT, Schutgens REG. Menstrual problems in chronic immune thrombocytopenia: A monthly challenge ‐ a cohort study and review. Br J Haematol 2022; 198:753-764. [PMID: 35662003 PMCID: PMC9540539 DOI: 10.1111/bjh.18291] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/15/2022] [Accepted: 05/18/2022] [Indexed: 11/08/2022]
Abstract
Immune thrombocytopenia (ITP) may cause menstrual problems. This cross‐sectional study assessed menstrual problems in premenopausal chronic ITP women by several questionnaires, including the pictorial bleeding assessment calendar (PBAC; score ≥100 indicates heavy menstrual bleeding [HMB]), and the menorrhagia multiattribute scale (MMAS). Spearman was used for assessing correlations. A literature review was performed in Pubmed. The cohort comprised 37 women (mean age 31 ± 9). A total of 29/37 (78%) had experienced clinical menstrual problems in the present or past. Of the 33 patients who returned the PBAC, 13 (39%) had a score of ≥100. The median MMAS score was 79 (IQR 60–95). The PBAC scores correlated with the MMAS. Both questionnaires were unrelated to the platelet count. Patients with a levonorgestrel intrauterine device (LNG‐IUD) had lower PBAC scores than patients with other or no hormonal therapy. MMAS scores were correlated with fatigue. The review identified 14 papers. HMB occurred in 6%–55% at ITP diagnosis and 17%–79% during disease. Menstrual symptoms influenced the quality of life, particularly in patients with a low platelet count. This explorative study suggested that HMB is frequent in women with chronic ITP despite management and platelet counts >50 *109/l. An LNG‐IUD seemed to reduce blood loss significantly.
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Affiliation(s)
- Wobke E. M. Dijk
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Marieke C. Punt
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Karin P. M. Galen
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Jeanette Leeuwen
- Division of Woman and Baby University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - A. Titia Lely
- Division of Woman and Baby University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
| | - Roger E. G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University Utrecht The Netherlands
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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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Cooper N, Cuker A, Bonner N, Ghanima W, Provan D, Morgan M, Taylor B, D'Alessio D, Arnold D, Viana R. Qualitative study to support the content validity of the immune thrombocytopenia (ITP) Life Quality Index (ILQI). Br J Haematol 2021; 194:759-766. [PMID: 34263940 DOI: 10.1111/bjh.17694] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/17/2021] [Accepted: 06/19/2021] [Indexed: 11/29/2022]
Abstract
Immune thrombocytopenia (ITP) is an acquired immune-mediated disorder. Bleeding is the primary symptom that presents in varying severities. ITP has a negative impact on health-related quality of life (HRQoL). The ITP Life Quality Index (ILQI) was developed as a 10-item patient-reported outcome measure to assess impact on HRQoL in ITP. The objective of the present study was to confirm the content validity of the ILQI with a qualitative interview study in the UK involving 15 adult participants with ITP. Combined concept elicitation (CE) and cognitive debriefing (CD) interviews were conducted to explore the symptoms and impacts associated with ITP and confirm content validity of the draft ILQI. The CE phase elicited 14 ITP symptom concepts, including: bruising (all 15 patients, 100%), fatigue (14, 93·3%) and bleeding gums/blood blisters (13, 86·7%). Impacts included decreased ability to participate in sport (all 15 patients, 100%) and anxiety (12, 80%). The CD phase resulted in an adjustment to the ILQI recall period from 1 week to 'the past month'. Updates were made to improve relevance and response options. The qualitative interviews support the content validity of the ILQI and confirm that the concepts assessed are relevant and consistently understood and interpreted by adult patients with ITP.
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Affiliation(s)
- Nichola Cooper
- Centre for Haematology, Imperial College London, London, UK
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Waleed Ghanima
- Ostfold Hospital Trust, Gralum, Norway.,Department of Hematology, Oslo university Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Drew Provan
- Barts and The Royal London Hospital, London, UK
| | - Mervyn Morgan
- ITP Support Association, Bolnhurst, Bedfordshire, UK
| | | | | | - Donald Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ricardo Viana
- Novartis Pharma AG, Global Value and Access, Oncology, Basel, Switzerland
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Mathias SD. I-WISh: A wish list for immune thrombocytopenia quality of life indicators becomes reality. Am J Hematol 2021; 96:172-173. [PMID: 33219702 DOI: 10.1002/ajh.26053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/18/2020] [Indexed: 11/07/2022]
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Terrell DR, Neunert CE, Cooper N, Heitink-Pollé KM, Kruse C, Imbach P, Kühne T, Ghanima W. Immune Thrombocytopenia (ITP): Current Limitations in Patient Management. ACTA ACUST UNITED AC 2020; 56:medicina56120667. [PMID: 33266286 PMCID: PMC7761470 DOI: 10.3390/medicina56120667] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 11/28/2020] [Indexed: 01/19/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an acquired autoimmune disorder characterized by isolated thrombocytopenia caused by increased platelet destruction and impaired platelet production. First-line therapies include corticosteroids, intravenous immunoglobulin, and anti-D immunoglobulin. For patients who are refractory to these therapies, those who become corticosteroid dependent, or relapse following treatment with corticosteroid, options include splenectomy, rituximab, and thrombopoietin-receptor agonists, alongside a variety of additional immunosuppressive and experimental therapies. Despite recent advances in the management of ITP, many areas need further research. Although it is recognized that an assessment of patient-reported outcomes in ITP is valuable to understand and guide treatment, these measures are not routinely measured in the clinical setting. Consequently, although corticosteroids are first-line therapies for both children and adults, there are no data to suggest that corticosteroids improve health-related quality of life or other patient-related outcomes in either children or adults. In fact, long courses of corticosteroids, in either children or adults, may have a negative impact on a patient's health-related quality of life, secondary to the impact on sleep disturbance, weight gain, and mental health. In adults, additional therapies may be needed to treat overt hemorrhage, but unfortunately the results are transient for the majority of patients. Therefore, there is a need to recognize the limitations of current existing therapies and evaluate new approaches, such as individualized treatment based on the probability of response and the size of effect on the patient's most bothersome symptoms and risk of adverse effects or complications. Finally, a validated screening tool that identifies clinically significant patient-reported outcomes in routine clinical practice would help both patients and physicians to effectively follow a patient's health beyond simply treating the laboratory findings and physical symptoms of ITP. The goal of this narrative review is to discuss management of newly diagnosed and refractory patients with ITP, with a focus on the limitations of current therapies from the patient's perspective.
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Affiliation(s)
- Deirdra R. Terrell
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Correspondence:
| | - Cindy E. Neunert
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA;
| | - Nichola Cooper
- Centre for Haematology, Department of Medicine, Hammersmith Hospital, Imperial College London, London SW7 2BU, UK;
| | - Katja M. Heitink-Pollé
- Department of Pediatric Hemato-oncology, Princess Maxima Center, 3584 Utrecht, The Netherlands;
| | - Caroline Kruse
- Platelet Disorder Support Association, Cleveland, OH 44141, USA;
| | - Paul Imbach
- Medical Faculty, University of Basel, 4051 Basel, Switzerland;
| | - Thomas Kühne
- University Children’s Hospital, Oncology/Hematology, 4056 Basel, Switzerland;
| | - Waleed Ghanima
- Departments of Hemato-oncology and Research, Østfold Hospital, 1714 Grålum, Norway;
- Department of Hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
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12
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Idiopathic thrombocytopenic purpura (ITP) - new era for an old disease. ACTA ACUST UNITED AC 2020; 57:273-283. [PMID: 31199777 DOI: 10.2478/rjim-2019-0014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia is an autoimmune hematological disorder characterized by severely decreased platelet count of peripheral cause: platelet destruction via antiplatelet antibodies which may also affect marrow megakaryocytes. Patients may present in critical situations, with cutaneous and/or mucous bleeding and possibly life-threatening organ hemorrhages (cerebral, digestive, etc.) Therefore, rapid diagnosis and therapeutic intervention are mandatory. Corticotherapy represents the first treatment option, but as in any autoimmune disorder, there is a high risk of relapse. Second line therapy options include: intravenous immunoglobulins, thrombopoietin receptor agonists, rituximab or immunosuppression, but their benefit is usually temporary. Moreover, the disease generally affects young people who need repeated and prolonged treatment and hospitalization and therefore, it is preferred to choose a long term effect therapy. Splenectomy - removal of the site of platelet destruction - represents an effective and stable treatment, with 70-80% response rate and low complications incidence. A challenging situation is the association of ITP with pregnancy, which further increases the risk due to the immunodeficiency of pregnancy, major dangers of bleeding, vital risks for mother and fetus, potential risks of medication, necessity of prompt intervention in the setting of specific obstetrical situations - delivery, pregnancy loss, obstetrical complications, etc. We present an updated review of the current clinical and laboratory data, as well as a detailed analysis of the available therapeutic options with their benefits and risks, and also particular associations (pregnancy, relapsed and refractory disease, emergency treatment).
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13
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Newland A, Bentley R, Jakubowska A, Liebman H, Lorens J, Peck-Radosavljevic M, Taieb V, Takami A, Tateishi R, Younossi ZM. A systematic literature review on the use of platelet transfusions in patients with thrombocytopenia. ACTA ACUST UNITED AC 2020; 24:679-719. [PMID: 31581933 DOI: 10.1080/16078454.2019.1662200] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: Investigate globally, current treatment patterns, benefit-risk assessments, humanistic, societal and economic burden of platelet transfusion (PT). Methods: Publications from 1998 to June 27, 2018 were identified, based on databases searches including MEDLINE®; Embase and Cochrane Database of Systematic Reviews. Data from studies meeting pre-specified criteria were extracted and validated by independent reviewers. Data were obtained for efficacy and safety from randomized controlled trials (RCTs); data for epidemiology, treatment patterns, effectiveness, safety, humanistic and societal burden from real-world evidence (RWE) studies; and economic data from both. Results: A total of 3425 abstracts, 194 publications (190 studies) were included. PT use varied widely, from 0%-100% of TCP patients; 1.7%-24.5% in large studies (>1000 patients). Most were used prophylactically rather than therapeutically. 5 of 43 RCTs compared prophylactic PT with no intervention, with mixed results. In RWE studies PT generally increased platelet count (PC). This increase varied by patient characteristics and hence did not always translate into a clinically significant reduction in bleeding risk. Safety concerns included infection risk, alloimmunization and refractoriness with associated cost burden. Discussion: In RCTs and RWE studies there was significant heterogeneity in study design and outcome measures. In RWE studies, patients receiving PT may have been at higher risk than those not receiving PT creating potential bias. There were limited data on humanistic and societal burden. Conclusion: Although PTs are used widely for increasing PC in TCP, it is important to understand the limitations of PTs, and to explore the use of alternative treatment options where available.
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Affiliation(s)
- Adrian Newland
- Barts Health National Health Service (NHS) Trust , London , UK
| | | | | | - Howard Liebman
- Jane Anne Nohl Division of Hematology, USC Norris Cancer Hospital , Los Angeles , CA , USA
| | | | - Markus Peck-Radosavljevic
- Department of Gastroenterology & Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt , Klagenfurt , Austria.,Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna , Vienna , Austria
| | | | - Akiyoshi Takami
- Department of Internal Medicine, Division of Hematology, Aichi Medical University School of Medicine , Nagakute , Japan
| | - Ryosuke Tateishi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - Zobair M Younossi
- Department of Medicine, Inova Fairfax Hospital , Falls Church , VA , USA
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14
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Rodeghiero F, Marranconi E. Management of immune thrombocytopenia in women: current standards and special considerations. Expert Rev Hematol 2020; 13:175-185. [PMID: 31903814 DOI: 10.1080/17474086.2020.1711729] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Immune thrombocytopenia (ITP) is an acquired autoimmune disorder, with an incidence rate of 20-40/million adults/year and an estimated prevalence in women of childbearing age of 24.5/million.Areas covered: Authors discuss management of ITP in pregnancy, treatment-related toxicity, delivery, neonatal thrombocytopenia and breastfeeding, and other women's specific issues. The search of papers published between January 1990 and December 2019 was done on PubMed using combinations of the keywords below. The distinction between ITP and other thrombocytopenias in pregnancy is of paramount importance. The current belief (at variance with the past) that ITP is a relatively benign disease pregnancy is emphasized.Expert opinion: The lack of randomized, prospective, controlled studies hampers evidence-based statements. Remarkably, ITP diagnosis is still one of exclusion, there are no clinical or laboratory criteria for prognosis and we still need more solid data on the risks related to neonatal thrombocytopenia. Corticosteroids and IVIG remain the mainstay of treatment, since rituximab, thrombopoietin-receptor agonists, fostamatinib may be toxic in pregnancy. Safety and efficacy of recombinant-human-thrombopoietin, available in China, require confirmation studies. Quality of life and women-related toxicity of treatments in young girls, adults, and elders are still an orphan area of investigation.
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Affiliation(s)
- Francesco Rodeghiero
- Hematology Project Foundation and Department of Hematology, S. Bortolo Hospital, Vicenza, Italy
| | - Ettore Marranconi
- Hematology Project Foundation and Department of Hematology, S. Bortolo Hospital, Vicenza, Italy.,Graduate School in Hospital Pharmacy, Pisa University, Pisa, Italy
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15
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Gilbert MM, Grimes AB, Kim TO, Despotovic JM. Romiplostim for the Treatment of Immune Thrombocytopenia: Spotlight on Patient Acceptability and Ease of Use. Patient Prefer Adherence 2020; 14:1237-1250. [PMID: 32801654 PMCID: PMC7383044 DOI: 10.2147/ppa.s192481] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/28/2020] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an immune-mediated disorder resulting in platelet destruction and subsequent thrombocytopenia. Bleeding symptoms range from mild cutaneous bleeding to life-threatening hemorrhage. Romiplostim, a peptide-antibody fusion product, is a thrombopoietin receptor agonist (TPO-RA) indicated for use in patients with ITP. Romiplostim is US Food and Drug Administration (FDA) approved in children ≥1 year of age with ITP of >6 months' duration who have had an inadequate response to first-line therapies or splenectomy. FDA approval in adults with chronic ITP was expanded in October 2019 to include adults with newly diagnosed (<3 months' duration) and persistent (3-12 months' duration) ITP who demonstrated an inadequate response to first-line therapies, including corticosteroids and immunoglobulins, or splenectomy. The newly published 2019 American Society of Hematology ITP Guidelines place TPO-RAs, including romiplostim, as second-line therapies in both children and adults. Here, we review the use of romiplostim as second-line therapy with a spotlight on health-related quality of life, ease of use, and patient preference.
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Affiliation(s)
- Megan M Gilbert
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
- Correspondence: Megan M Gilbert Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Texas Children’s Hospital, 6701 Fannin Suite 1510, Houston, TX77030, USATel +1 (832) 824-4736Fax +1 (832) 825-4846 Email
| | - Amanda B Grimes
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Taylor Olmsted Kim
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Jenny M Despotovic
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
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16
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Khelif A, Saleh MN, Salama A, Portella MDSO, Duh MS, Ivanova J, Grotzinger K, Roy AN, Bussel JB. Changes in health-related quality of life with long-term eltrombopag treatment in adults with persistent/chronic immune thrombocytopenia: Findings from the EXTEND study. Am J Hematol 2019; 94:200-208. [PMID: 30417939 PMCID: PMC6587804 DOI: 10.1002/ajh.25348] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 12/30/2022]
Abstract
Patients with persistent/chronic immune thrombocytopenia (cITP) have low platelet counts, increased risk of bleeding and bruising, and often suffer from reduced health‐related quality of life (HRQoL). cITP treatments may either improve HRQoL by increasing platelet counts or decrease it because of side effects. The open‐label EXTEND study (June 2006 to July 2015) evaluated long‐term safety, tolerability, and efficacy of eltrombopag (an oral thrombopoietin‐receptor‐agonist) in adults with cITP who completed a previous eltrombopag ITP trial. The final results of EXTEND were published and used to assess changes in patient‐reported HRQoL over time and association between HRQoL and platelet response. Four validated HRQoL instruments were administered: SF‐36v2 including physical component summary (PCS) and Mental Component Summary; Motivation and Energy Inventory Short Form (MEI‐SF); Fatigue Subscale of FACIT (FACIT‐Fatigue); and FACT‐Thrombocytopenia Subscale Six‐Item Extract (FACT‐Th6). For the 302 patients enrolled, median duration of eltrombopag treatment was 2.37 years. All 4 HRQoL instruments demonstrated positive mean changes from baseline over time adjusted for patient baseline characteristics and rescue therapy use, and had positive association with platelet response (platelet count ≥30 × 109/L; ≥50 × 109/L; and ≥50 × 109/L and >2 times baseline). Improvements from baseline started within 3 months and persisted through 5 years of treatment for FACIT‐Fatigue and FACT‐Th6 (P <.05 for nearly all time points); through 2.5 years for SF‐36v2 PCS and less consistently for the MEI‐SF. In conclusion, in addition to eltrombopag increasing platelet counts and reducing bleeding/bruising, it also alleviated fatigue, concerns about bleeding and bruising, and improved physical function in many patients, especially responders.
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Affiliation(s)
| | - Mansoor N. Saleh
- Comprehensive Cancer Center; University of Alabama at Birmingham; Birmingham Alabama
| | | | | | | | | | | | - Anuja N. Roy
- Novartis Pharmaceuticals Corporation; East Hanover New Jersey
| | - James B. Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine; New York City New York
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17
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18
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Trotter P, Hill QA. Immune thrombocytopenia: improving quality of life and patient outcomes. PATIENT-RELATED OUTCOME MEASURES 2018; 9:369-384. [PMID: 30568522 PMCID: PMC6267629 DOI: 10.2147/prom.s140932] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an immune-mediated disorder characterized by a reduced platelet count and patients may develop bruising or mucosal bleeding. Since 2003, generic health-related quality of life (HRQoL) measures have been applied and ITP-specific measures developed, alongside trials of novel therapeutic agents. These have identified significant morbidity in patients with ITP, including fatigue, fear of bleeding and a negative impact on role, social and work activities. This review critically evaluates HRQoL data in adults and children with ITP. It also considers the impact of treatment and how patient-reported outcomes might be applied to care to optimize patients' quality of life.
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Affiliation(s)
- Patrick Trotter
- Department of Surgery, University of Cambridge, Cambridge, UK.,National Health Service Blood and Transplant, Organ Donation and Transplant Directorate, Bristol, UK
| | - Quentin A Hill
- Department of Haematology, St James's University Hospital, Leeds, UK,
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19
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Sestøl HG, Trangbæk SM, Bussel JB, Frederiksen H. Health-related quality of life in adult primary immune thrombocytopenia. Expert Rev Hematol 2018; 11:975-985. [DOI: 10.1080/17474086.2018.1548930] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Hanna Gran Sestøl
- Depatment of Haematology, Odense University Hospital, Odense, Denmark
| | | | - James B Bussel
- Department of Pediatrics, Division of Hematology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Henrik Frederiksen
- Depatment of Haematology, Odense University Hospital, Odense, Denmark
- Quality of Life Research Center, Odense University Hospital, Odense, Denmark
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20
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Bohn JP, Steurer M. Current and evolving treatment strategies in adult immune thrombocytopenia. MEMO 2018; 11:241-246. [PMID: 30220932 PMCID: PMC6132792 DOI: 10.1007/s12254-018-0428-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/01/2018] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an acquired autoimmune phenomenon resulting in low platelet count and increased bleeding risk. Goals of upfront management include prompt control of severe bleeding-which is rare-as well as induction and maintenance of a hemostatic platelet count. Thus, optimal management of ITP patients is often challenging and requires a highly individualized approach. Many patients may not suffer significant bleeding despite severe thrombocytopenia and the risk of toxicity associated with treatment may outweigh its benefit. Most patients treated with standard first-line regimen of glucocorticoids achieve an initial response. However, the rate of long-term remission remains low and multiple lines of therapy are often required. Current investigations aim at defining the subgroup of patients at risk of relapse and providing intensified risk-balanced induction regimens to improve long-term disease control. This short review summarizes current and emerging treatment strategies in adult ITP.
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Affiliation(s)
- Jan-Paul Bohn
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Michael Steurer
- Department of Internal Medicine V, Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
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21
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Grace RF, Neunert C. Second-line therapies in immune thrombocytopenia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:698-706. [PMID: 27913549 PMCID: PMC6142486 DOI: 10.1182/asheducation-2016.1.698] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare, acquired autoimmune condition characterized by a low platelet count and an increased risk of bleeding. Although many children and adults with ITP will not need therapy beyond historic first-line treatments of observation, steroids, intravenous immunoglobulin (IVIG), and anti-D globulin, others will have an indication for second-line treatment. Selecting a second-line therapy depends on the reason for treatment, which can vary from bleeding to implications for health-related quality of life (HRQoL) to likelihood of remission and patient preference with regard to adverse effects, route of administration, and cost. Published studies of these treatments are limited by lack of comparative trials, in addition to inconsistent outcome measures, definitions, and efficacy endpoints. This article provides an up-to-date comparison of the second-line treatments, highlighting important outcome measures including bleeding, HRQoL, fatigue, and platelet counts, which influence treatment selection in a shared decision-making model.
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Affiliation(s)
- Rachael F Grace
- Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorder Center, Boston, MA; and
| | - Cindy Neunert
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Medical Center, New York, NY
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22
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Moukhadder HM, Chaya BF, Bazarbachi AHA, Taher AT. Immune thrombocytopenia: a comprehensive review from pathophysiology to promising treatment modalities. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1247691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
Fatigue is an important aspect of health-related quality of life from the patient perspective and can have significant socio-economic consequences. It is a common feature of chronic illnesses and a significant number of both adults and children with immune thrombocytopenia (ITP) suffer from fatigue. Reliable, validated fatigue scales have been developed for use in ITP. These will facilitate future investigation of its pathogenesis and the effectiveness of intervention. Acute inflammation acts on neural and endocrine systems resulting in 'sickness behaviour', an adaptive response to infection and injury. Inflammation is also thought to cause fatigue in chronic disease and immune dysregulation in ITP appears to have a number of pro-inflammatory components. Clinicians should consider fatigue when assessing the burden of disease. Although effective ITP-directed therapy can improve fatigue, a number of fatigue-directed strategies may also need to be considered.
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Affiliation(s)
- Quentin A Hill
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - Adrian C Newland
- Department of Haematology, The Royal London Hospital, London, UK
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24
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Tran H, Brighton T, Grigg A, McRae S, Dixon J, Thurley D, Gandhi MK, Truman M, Marlton P, Catalano J. A multi-centre, single-arm, open-label study evaluating the safety and efficacy of fixed dose rituximab in patients with refractory, relapsed or chronic idiopathic thrombocytopenic purpura (R-ITP1000 study). Br J Haematol 2014; 167:243-51. [PMID: 25041261 DOI: 10.1111/bjh.13029] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/16/2014] [Indexed: 11/27/2022]
Abstract
The efficacy of a fixed-dose rituximab schedule was prospectively explored in primary/acute refractory, relapsed or chronic (platelet count >10 × 10(9) /l and ≤50 × 10(9) /l) idiopathic thrombocytopenic purpura (ITP). Patients received two doses of rituximab (1000 mg) on days 1 and 15 and were followed-up on weeks 1-8, 12, 26, 39 and 52. A total of 122 patients were included in the safety population; efficacy was analysed in 108 patients. Overall response rate (ORR) at week 8, defined as the proportion of patients achieving complete response (CR; platelet count >150 × 10(9) /l) or partial response (PR; platelet count >50 × 10(9) /l) was 44%. Therapeutic response, defined as achieving a response at week 8, with at least a minor response (MR; platelet count >30 × 10(9) /l), sustained up to weeks 26 and 52 and accompanied by a reduction in ITP medications, was achieved in 44% (week 26) and 35% (week 52) of patients, respectively. Treatment was well tolerated with no safety concerns. While this study failed to meet its primary endpoint of an ORR of 50%, the efficacy of two fixed doses of rituximab appear to provide similar efficacy to the standard 375 mg/m(2) four-dose schedule in relapsed/chronic ITP.
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Affiliation(s)
- Huyen Tran
- Monash Medical Centre, Clayton, Vic., Australia; Australian Centre for Bloods Diseases, Monash University, Melbourne, Vic., Australia
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25
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Zhan Y, Zou S, Hua F, Li F, Ji L, Wang W, Ye Y, Sun L, Chen H, Cheng Y. High-dose dexamethasone modulates serum cytokine profile in patients with primary immune thrombocytopenia. Immunol Lett 2014; 160:33-38. [DOI: 10.1016/j.imlet.2014.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 01/19/2014] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
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Grace RF. Standardized clinical assessment and management plans (SCAMPs): perspectives on a new method to understand treatment decisions and outcomes in immune thrombocytopenia. Semin Hematol 2014; 50 Suppl 1:S31-8. [PMID: 23664514 DOI: 10.1053/j.seminhematol.2013.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Modern evidence based guidelines in immune thrombocytopenia (ITP) are mostly based on expert opinion. Standardized clinical assessment and management plans (SCAMPs) are flexible, feedback-based practice guidelines that could be valuable for both managing patients with ITP and understanding treatment decisions and outcomes. At Boston Children's Hospital, we have implemented a SCAMP for patients with newly diagnosed and persistent ITP. To develop the algorithm, a group of local ITP experts devised an initial guideline, which was then modified by the attending hematologists who care for ITP patients until consensus was reached. Since deviations from the algorithm are encouraged, all clinicians did not need to agree with all aspects of the algorithm. At each clinic visit, clinicians fill out data collection forms explaining practice deviations. The goals of this process are to decrease practice variation and resource utilization and learn from the outcomes and deviations that occur to continually improve our practice. SCAMPs are an innovative approach to improve quality of care in ITP.
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Affiliation(s)
- Rachael F Grace
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02115, USA.
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27
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Thrombopoietic agents: There is still much to learn. Presse Med 2014; 43:e69-78. [DOI: 10.1016/j.lpm.2014.02.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 02/18/2014] [Indexed: 11/15/2022] Open
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28
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Abstract
Immune thrombocytopenia (ITP) is a common hematologic disorder characterized by isolated thrombocytopenia. ITP presents as a primary or a secondary form. ITP may affect individuals of all ages, with peaks during childhood and in the elderly, in whom the age-specific incidence of ITP is greatest. Bleeding is the most common clinical manifestation of ITP. The pathogenesis of ITP is complex, involving alterations in humoral and cellular immunity. Corticosteroids remain the most common first line therapy for ITP. This article summarizes the classification and diagnosis of primary and secondary ITP, as well as the pathogenesis and options for treatment.
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Affiliation(s)
- Gaurav Kistangari
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
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29
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Psaila B, Bussel JB. Immune Thrombocytopenia (ITP). Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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30
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Brown TM, Horblyuk RV, Grotzinger KM, Matzdorff AC, Pashos CL. Patient-reported treatment burden of chronic immune thrombocytopenia therapies. BMC BLOOD DISORDERS 2012; 12:2. [PMID: 22436142 PMCID: PMC3350461 DOI: 10.1186/1471-2326-12-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2011] [Accepted: 03/22/2012] [Indexed: 01/06/2023]
Abstract
Background Chronic immune thrombocytopenia (ITP) is a debilitating autoimmune disorder that causes a reduction in blood platelets and increased risk of bleeding. ITP is currently managed with various pharmacologic therapies and splenectomy. This study was conducted to assess patient perceived and reported treatment side effects, as well as the perceived burden or bother, and need to reduce or stop treatment, associated with these side effects among adult patients with chronic ITP. Methods A Web-enabled survey was administered to members of a US-based ITP patient support group. Patients reported demographic and clinical characteristics, ITP treatments' side effects for treatments received since diagnosed, level of bother (or distress), and need to reduce or stop treatment, associated with side effects. Current and past exposure was assessed for five specific treatment types: corticosteroids (CS), intravenous immunoglobulin (IVIg), anti-D immunoglobulin (anti-D), rituximab (RT), and splenectomy (SPL), as well as for other patient-referenced therapies (captured as "other"). Results The survey was completed by 589 patients; 78% female, 89% white, mean age 48 years (SD = 14.71), and 68% reported a typical low platelet count of < 50,000/μL. Current or past treatment with CS was reported by 92% (n = 542) of patients, 56% (n = 322) for IVIg, 36% (n = 209) for anti-D, 36% (n = 213) for RT, and 39% (n = 227) for SPL. A substantial proportion of CS-treated patients reported side effects (98%, P < 0.05), were highly bothered by their side effects (53.1%, P < 0.05), and reported the need to stop or reduce treatment due to side effects (37.8%, P < 0.05). Among patients reporting side effects of treatment, significant associations were noted for the number of side effects, aggregate bother of reported side effects, and the need to stop or reduce treatment (all P < 0.05). Conclusions Current ITP treatments, particularly corticosteroids, are associated with multiple bothersome side effects that may lead to patients stopping or reducing therapy. Open, informed and complete communication between clinician and patient regarding both the benefits and the side effects of ITP treatment may better prepare patients for their prescribed regimens.
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Affiliation(s)
| | | | | | - Axel C Matzdorff
- Department of Hematology and Oncology, Caritasklinikum Saarbruecken, St. Theresia, Saarbruecken, Germany
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Deuson R, Danese M, Mathias SD, Schoonen M, Fryzek J. The burden of immune thrombocytopenia in adults: evaluation of the thrombopoietin receptor agonist romiplostim. J Med Econ 2012; 15:956-76. [PMID: 22533524 DOI: 10.3111/13696998.2012.688902] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is a chronic, immune-mediated disease characterized by a transient or long-lasting decrease in platelet counts. ITP is associated with numerous serious clinical consequences. Discussed here are clinical aspects of ITP, the humanistic and economic burden of ITP, and current treatment options with a focus on romiplostim, a thrombopoietin (TPO) receptor agonist. The aim of this review is to provide decision-makers with the background information necessary to evaluate the value of romiplostim. SCOPE PubMed was searched for relevant, English-language papers published from January 2006 through November 2011 relating to the epidemiology and treatment options of chronic ITP, and, focusing on the TPO mimetic romiplostim, patient-reported outcomes (PRO) and economic burden. Recent select conference abstracts were also reviewed. FINDINGS The initial clinical management of ITP (e.g., corticosteroids, immunoglobulins) is often associated with adverse events and recommended for short-term use only. Splenectomy, a potentially curative second-line treatment, is associated with increased risks of bleeding and infection, and patients often require additional long-term drug intervention. ITP and its sequelae are associated with a substantial burden on patients' health-related quality-of-life (HRQoL) and increased medical costs. Use of TPO receptor agonists in ITP patients may represent a more efficient use of healthcare resources than existing therapies. CONCLUSION While this literature review is not a systematic review, e.g., it considers only approved therapies and published literature written in English, it provides a comprehensive overview of the clinical, humanistic, and economic factors that should be considered in treating ITP, particularly with new agents such as romiplostim. Among the limited number of safe and effective therapies currently available for chronic ITP, highly effective and well-tolerated medications such as romiplostim may reduce the healthcare resource utilization associated with ITP while improving patients' HRQoL.
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Affiliation(s)
- Robert Deuson
- Global Health Economics, Amgen Inc., Thousand Oaks, CA 91320, USA.
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Chiche L, Brescianini A, Mancini J, Servy H, Durand JM. Evaluation of a prototype electronic personal health record for patients with idiopathic thrombocytopenic purpura. Patient Prefer Adherence 2012; 6:725-34. [PMID: 23077409 PMCID: PMC3474173 DOI: 10.2147/ppa.s36320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients with rare diseases often lack information about the disease itself and appropriate health care, leading to poor quality of life. Personal health records provide health information which can then be shared between multiple health care providers. Personal health records may also offer a tool for capturing patients' reported outcomes, thus enhancing their empowerment and improving communication with health care professionals. We conducted a pilot study to evaluate the usability of Sanoia, a freely accessible personal health record, which was customized for patients with the rare disease, idiopathic thrombocytopenic purpura (ITP). METHODS The Sanoia interface was expanded with ITP-specific tools. A prospective study was conducted at the referent center to evaluate the usability of this new interface (referred to here as the "tool") by patients. Forty-three patients were randomized into groups to use or to not use the tool. Its use was evaluated by a specific questionnaire and by surveying individual patient adherence profiles. Evaluation of health-related quality of life using the ITP patient assessment questionnaire, was performed at baseline and after 1, 3, and 6 months via postal mail. RESULTS The groups were similar at inclusion in terms of characteristics, including global quality of life. During the study period, the tool was used to update the personal records of 19/28 patients (68%), with a median of two connections to the tool (range 1-12) plus access by various health care professionals (n = 22). In addition, 15/19 (78%) patients used the "personal notes" section at least once. We observed no significant changes in quality of life between patients with or without the tool during the study period. CONCLUSION This pilot study demonstrates the good usability of the new customized Sanoia interface for patients with ITP. Additional studies will increase its usability further, and its interface could be adapted for use with other rare chronic diseases.
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Affiliation(s)
- Laurent Chiche
- Service de Médecine Interne, Centre de Compétence pour la prise en charge des Cytopénies Auto-immunes, Hôpital de la Conception, Marseille
- Correspondence: Laurent Chiche, Service de Médecine Interne, CHU Conception, 147 Boulevard Baille, 13005 Marseille, France, Tel +33 49138 3762, Fax +33 49 138 3768, Email
| | - Alessandra Brescianini
- Service de Médecine Interne, Centre de Compétence pour la prise en charge des Cytopénies Auto-immunes, Hôpital de la Conception, Marseille
| | - Julien Mancini
- Service de Santé Publique, Hôpital de la Timone, Marseille
| | - Hervé Servy
- Association AIMSU, Maison des Associations, La Ciotat, France
| | - Jean-Marc Durand
- Service de Médecine Interne, Centre de Compétence pour la prise en charge des Cytopénies Auto-immunes, Hôpital de la Conception, Marseille
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Iskedjian M, Tinmouth AT, Arnold DM, Deuson R, Isitt JJ, Mikhael J. Elicitation of utility scores in Canada for immune thrombocytopenia treated with romiplostim or watch and rescue. J Med Econ 2012; 15:313-31. [PMID: 22136485 DOI: 10.3111/13696998.2011.646045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The objective of this study was to obtain utilities, or preference-based quality-of-life values, from the Canadian general public, for potential health states experienced by immune thrombocytopenia (ITP) patients receiving either romiplostim (a new thrombopoietin mimetic agent) or 'watch and rescue' therapy. Utilities are needed to conduct a cost-utility analysis of romiplostim for formulary and reimbursement decisions. METHODS An electronic Time Trade-off (TTO) survey was developed and administered to a sample of the general public in Canada, with 12 distinct health states derived from two randomized clinical trials of romiplostim vs watch and rescue treatment. Two pilot tests assessed interpretability and respondent burden. In the final survey, each subject was administered the TTO for four randomly-selected health states. Descriptive statistics were computed for utility scores, and differences between health states were evaluated with an analysis of variance model. RESULTS Eight hundred and twenty-one adults completed the TTO survey. Mean age was 36.4 (SD = 15) years; 63% were female. Mean (SD) utility scores ranged from 0.476 (0.271) for the most severe health state (significant bleeding) to 0.633 (0.282) for the least severe health state depicting successful treatment with romiplostim. Statistical significance was found on the mean difference between the most severe health state and five other health states (p < 0.05). After adjusting utilities for matching Canadian demographic parameters, no substantial difference was found between original utility scores and adjusted scores. CONCLUSIONS This study provides evidence of the Canadian general public's preference for 12 ITP health states pertaining to romiplostim treatment or watch and rescue. This study had a number of limitations, the main ones being the lack of perfect match in demographics between this sample and the Canadian population, as well as the fact that the scenario descriptions were based on both published literature and expert opinion. Despite those limitations, the obtained utility scores may be used in cost-utility models of romiplostim as a treatment for ITP patients in Canada.
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Affiliation(s)
- M Iskedjian
- PharmIdeas Research and Consulting Inc, Oakville, Ontario, Canada.
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Gershovitz M, Sergienko R, Friedler JM, Wiznitzer A, Zlotnik A, Sheiner E. Pregnancy outcome in women following splenectomy. J Womens Health (Larchmt) 2011; 20:1233-7. [PMID: 21732739 DOI: 10.1089/jwh.2011.2760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To investigate pregnancy outcome of patients following splenectomy. METHODS A retrospective study comparing pregnancies of women who have and have not undergone splenectomy was performed. The study investigated a select population representing the south of Israel. Women lacking antenatal care as well as those having multiple gestations were excluded from the analysis. Stratified analysis, using a multiple logistic regression model, was performed to control for confounders. RESULTS During the study period, there were 219,656 deliveries, of which 150 occurred in women who underwent splenectomy. Postsplenectomy women tended to be older, were more likely to be Jewish, and had a lower number of deliveries and an earlier gestational age at delivery. Higher rates of fertility treatment, previous cesarean delivery, and severe preeclampsia were found among postsplenectomy women. In addition, splenectomy was significantly associated with pregnancy and labor complications, such as cesarean delivery, pneumonia during pregnancy, and complications of anesthesia and sedation during labor. Using a multivariate analysis with backward elimination, the following conditions were independently associated with splenectomy: previous cesarean delivery (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.3, p=0.039), fertility treatment (OR 2.6, 95% CI 1.3-5.4, p=0.008), preterm delivery (OR 1.9, 95% CI 1.3-3.1, p=0.003), and maternal age (OR 1.04, 95% CI 1.015-1.07, p=0.002). After controlling for possible confounders by using another multivariate analysis with preterm delivery as the outcome variable, splenectomy was found to be an independent risk factor for preterm delivery (OR 2.1, 95% CI 1.4-3.3, p=0.001). CONCLUSION Splenectomy is an independent risk factor for preterm delivery.
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Affiliation(s)
- Miriam Gershovitz
- Joyce and Irving Goldman Medical School, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er-Sheva, Israel
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Validation of the FACIT-fatigue subscale, selected items from FACT-thrombocytopenia, and the SF-36v2 in patients with chronic immune thrombocytopenia. Qual Life Res 2011; 20:1737-44. [PMID: 21533818 DOI: 10.1007/s11136-011-9912-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess the validity and reliability of the fatigue subscale of the Functional Assessment of Chronic Illness Therapy (FACIT-F), a 6-item subset from the thrombocytopenia subscale of the Functional Assessment of Cancer Therapy (FACT-Th6) and the Short Form-36 Version 2 (SF-36v2) in 2 clinical trials of the thrombopoietin receptor agonist eltrombopag in chronic immune thrombocytopenia (ITP) patients. METHODS In the 6-month, RAndomized placebo-controlled ITP Study with Eltrombopag (RAISE; n = 197), the FACIT-F, FACT-Th6, and SF-36v2 were administered at baseline, day 43, weeks 14 and 26, or early withdrawal. In the ongoing open-label extension study, Eltrombopag EXTENDed Dosing Study (EXTEND; n = 154), measures were administered at baseline, at the beginning of each stage, and at permanent discontinuation of study medication. RESULTS FACIT-F, FACT-Th6, and SF-36v2 demonstrated acceptable internal consistency reliability (i.e., all Cronbach's alphas >0.70) and test-retest reliability (all intraclass correlation coefficients >0.70). Construct validity was supported by moderate (0.35 < r < 0.50) to strong (r > 0.50) inter-measure correlations for baseline and change scores. A small to medium magnitude of effect was captured by the FACIT-F and FACT-Th6 among patients who experienced sustained platelet responses. CONCLUSIONS Results provide support for the validity, reliability, and responsiveness of the FACIT-F, FACT-Th6, and SF-36v2 in chronic ITP patients.
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Toltl LJ, Arnold DM. Pathophysiology and management of chronic immune thrombocytopenia: focusing on what matters. Br J Haematol 2010; 152:52-60. [PMID: 21083652 DOI: 10.1111/j.1365-2141.2010.08412.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a common autoimmune disease characterized by low platelet counts and an increased risk of bleeding. Antibody-mediated platelet destruction has been the prevailing hypothesis to explain ITP pathogenesis, supported by the efficacy of B-cell depletion therapy; however, the recent success of thrombopoietin receptor agonists lends support to the notion that platelet production is also insufficient. Best practice for the management of chronic ITP has not yet been established because data from comparative trials are lacking. Despite renewed interest in novel drugs capable of increasing platelet counts, ultimate treatment goals for ITP patients must be kept in mind: to improve patients' health and well-being. In this article, the pathophysiology of ITP is reviewed and key remaining questions about mechanism are explored. A rational approach to the management of ITP in adults is outlined, acknowledging evidence and evidence gaps, and highlighting the need for clinically important endpoints in future clinical trials.
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Affiliation(s)
- Lisa J Toltl
- Department of Medicine, Michael DeGroote School of Medicine, McMaster University Canadian Blood Services, 1200 Main Street West, Hamilton, Ontario, Canada
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Szende A, Brazier J, Schaefer C, Deuson R, Isitt JJ, Vyas P. Measurement of utility values in the UK for health states related to immune thrombocytopenic purpura. Curr Med Res Opin 2010; 26:1893-903. [PMID: 20553121 DOI: 10.1185/03007995.2010.494126] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To measure utility values associated with immune (idiopathic) thrombocytopenic purpura (ITP), as perceived by the United Kingdom (UK) general public. RESEARCH DESIGN AND METHODS A multi-step process, including clinical trial data, literature review, and patient focus group, was used to develop ITP health states valued in a web survey. Six ITP health states were defined based on platelet levels, risk of bleeding and key adverse events/disease complications. Clinical trial data on bleeding and ITP-specific quality of life data were key sources for developing health-state descriptions. 359 respondents, randomly selected from a managed web panel in the UK, completed the web-based Time Trade-Off survey. Wilcoxon signed-rank test was used to compare differences between each pair of health states. RESULTS Sample characteristics (mean age: 47.9 +/- 16.9 years; 54% female) were comparable to the UK general population. ITP health states were valued as significantly worse than perfect health. Experiencing bleeding episodes was a more important driver than low platelet levels in valuing a health state to be worse. Substantial disutilities were associated with surviving an intracranial haemorrhage. Mean (SD) utility values for each ITP health state are: HS1: platelets >or=50 x 10(9)/L, no outpatient bleed: 0.863 +/- 0.15; HS2: platelets >or=50 x 10(9)/L, outpatient bleed: 0.734 +/- 0.19; HS3: platelets <50 x 10(9)/L, no outpatient bleed: 0.841 +/- 0.19; HS4: platelets <50 x 10(9)/L, outpatient bleed: 0.732 +/- 0.19; HS5: intracranial haemorrhage (2-6 months): 0.038 +/- 0.46; HS6: steroid treatment adverse events: 0.758 +/- 0.20. Potential limitations relate to web user population characteristics and lack of comparative testing of web-based TTO methods. CONCLUSIONS Results provide evidence that the UK general population associate substantial loss of value living with ITP, suggesting an important role for new ITP treatments. Utility values based on these health states may be useful in future cost-effectiveness studies of existing and/or new ITP treatments.
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Health-related quality of life outcomes for patients with immune thrombocytopenic purpura. Ann Hematol 2010; 89 Suppl 1:51-4. [PMID: 20461516 DOI: 10.1007/s00277-010-0981-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 04/27/2010] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenic purpura (ITP) is a rare disease with infrequent serious bleeding making clinical trials difficult. One solution to this problem is to use alternative outcome measures such as health-related quality of life (HRQL). This review describes the various HRQL tools available to researchers including measures that are generic (applicable to many different disease types) and disease-specific measures developed explicitly for ITP specifically detailing the Kids' ITP Tools and the ITP-patient administered questionnaire. This review describes how incorporating HRQL tools such as these will allow researchers to move forward and do methodologically sound research.
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Neunert CE. Evaluating bleeding severity in immune thrombocytopenia (ITP). Ann Hematol 2010; 89 Suppl 1:47-50. [PMID: 20309688 DOI: 10.1007/s00277-010-0930-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 02/17/2010] [Indexed: 01/19/2023]
Abstract
Despite immune thrombocytopenia (ITP) being one of the most common conditions encountered by the pediatric hematologist, relatively few prospective investigations of ITP exist, and treatment approaches remain highly variable. The ideal prospective clinical trial would use a reduction in severe bleeding as an outcome; however, recent data shows that due to the rarity of severe bleeding events such a trial is not feasible due to the large number of children needed to be enrolled on such studies. Therefore, platelet count is often used a surrogate risk for bleeding severity and an increase in platelet count as the primary outcome in clinical trials. Reliance solely on the platelet count fails to account for relevant patient-related outcomes, among them bleeding severity. Bleeding assessment instruments published to date lack validity and reliability. Therefore, rigorous methods to design and analysis of patient-related outcome measurement tools need to be applied. Once designed appropriately, these measures can be applied to enhance research and help to guide treatment for those patients who truly need it.
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Affiliation(s)
- Cindy E Neunert
- Division of Hematology/Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA,
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Bussel JB. Traditional and new approaches to the management of immune thrombocytopenia: issues of when and who to treat. Hematol Oncol Clin North Am 2010; 23:1329-41. [PMID: 19932437 DOI: 10.1016/j.hoc.2009.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Diagnosis and management of chronic ITP requires experience and the appropriate use of the laboratory despite the absence of a diagnostic test for ITP. Consideration of secondary ITP is important because identification of immunodeficiency infections or of lymphoproliferative disorders would change the management approach to a given patient. The development of newer therapies such as rituximab and the thrombopoietic agents has had a major impact on the management of ITP. In the future, combinations of agents may be a critical approach although the schedule and dosing remains difficult to establish. Finally, current studies to augment therapy in newly diagnosed ITP patients to prevent chronic disease may lessen the number of patients in chronic disease category.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Weill Medical College of Cornell University, 525 E 68th Street, P695, New York, NY 10065, USA.
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Tarantino MD, Mathias SD, Snyder CF, Isitt JJ, Gernsheimer T, Young J. Impact of ITP on physician visits and workplace productivity. Curr Med Res Opin 2010; 26:319-28. [PMID: 19968458 DOI: 10.1185/03007990903451298] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the impact of immune thrombocytopenic purpura (ITP) on primary care and specialist visits and workplace productivity. RESEARCH DESIGN AND METHODS This was a cross-sectional, descriptive study comparing ITP patients to age- and gender-matched controls. Subjects completed a one-time web-based survey, which included questions on work loss, work productivity, and physician visits. ITP patients and controls were compared on these outcomes. For ITP patients, the relationship between work-related issues and physician visits with clinical characteristics (time since diagnosis, platelet count, number of treatments received, and an ITP-specific health-related quality of life measure, the ITP-PAQ) was explored. RESULTS A total of 1002 ITP patients and 1031 controls completed the survey. On average, ITP patients were 46 years old, diagnosed 9 years ago, and had platelet counts of 148 x 10(9)/L; 37% had undergone splenectomy. More ITP patients had primary care (20% vs. 11%) and specialist (28% vs. 11%) visits in the past month versus controls (p < or = 0.001). Higher proportions of ITP patients have ever taken sick leave (56% vs. 30%), and missed chore hours in the past week (18% vs. 13%) (p < or = 0.003). ITP patients scored significantly worse than controls on all six work productivity items. Patients diagnosed within the past year were more likely to have specialist visits and to miss chore hours versus those diagnosed less recently. Worse ITP-PAQ scores and more ITP-related treatments were related to more physician visits and worse work-related and productivity outcomes. Platelet count is not associated with these outcomes. The study is limited by the potential for biased samples due to recruitment approaches, the inherent issues of a cross-sectional study design and recall bias in questionnaire responses. CONCLUSIONS ITP was consistently associated with more physician visits and worse work and productivity outcomes. Future research should build on these findings by calculating a comprehensive cost-of-illness of ITP including both direct and indirect costs.
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Affiliation(s)
- Michael D Tarantino
- University of Illinois College of Medicine-Peoria, Medical Director, Comprehensive Bleeding Disorders Center, 4727 N. Sheridan Road, Peoria, IL 61614, USA.
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Abstract
The age-adjusted prevalence of immune thrombocytopenic purpura (ITP) is estimated to be 9.5 per 100,000 persons in the USA while its annual incidence is estimated to be 2.68 per 100,000 in Northern Europe (at a cut-off platelet count of <100 x 10(9)/L). The mean age of adults at diagnosis in Europe is 50 yrs and the incidence of ITP increases with age. Both the treatments used to treat patients with ITP and the disease itself can impact on patient health-related quality of life (HRQoL). As the incidence of ITP in Europe rises, especially in the elderly, the number of patients with a decreased HRQoL is increasing. Literature searches and focus groups have aided the development of a conceptual model to assess HRQoL. In this model, low platelet counts and the associated symptoms of ITP in addition to the side effects of treatment are proposed as the main determinants of a negatively impacted HRQoL. Primary conceptual domains of HRQoL, affected in patients with ITP, include emotional health, functional health, work, social and leisure activities and reproductive health. As treatment benefits are likely to improve these domains, the conceptual model could be used for better management of patients, taking into account HRQoL. The short-form 36-item questionnaire (SF-36) and the ITP Patient Assessment Questionnaire (ITP-PAQ) are validated measures of HRQoL which can provide a comprehensive assessment of numerous factors to help evaluate decisions about patient management. Future clinical trials investigating treatment options for ITP should assess HRQoL using these validated questionnaires.
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Affiliation(s)
- Marc Michel
- Service de Médecine Interne, CHU Henri Mondor, Créteil, France.
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International consensus report on the investigation and management of primary immune thrombocytopenia. Blood 2009; 115:168-86. [PMID: 19846889 DOI: 10.1182/blood-2009-06-225565] [Citation(s) in RCA: 1219] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Previously published guidelines for the diagnosis and management of primary immune thrombocytopenia (ITP) require updating largely due to the introduction of new classes of therapeutic agents, and a greater understanding of the disease pathophysiology. However, treatment-related decisions still remain principally dependent on clinical expertise or patient preference rather than high-quality clinical trial evidence. This consensus document aims to report on new data and provide consensus-based recommendations relating to diagnosis and treatment of ITP in adults, in children, and during pregnancy. The inclusion of summary tables within this document, supported by information tables in the online appendices, is intended to aid in clinical decision making.
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Xie F, Blackhouse G, Assasi N, Campbell K, Levin M, Bowen J, Tarride JE, Pi D, Goeree R. Results of a model analysis to estimate cost utility and value of information for intravenous immunoglobulin in canadian adults with chronic immune thrombocytopenic purpura. Clin Ther 2009; 31:1082-91; discussion 1066-8. [DOI: 10.1016/j.clinthera.2009.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2009] [Indexed: 11/30/2022]
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Mathias SD, Gao SK, Rutstein M, Snyder CF, Wu AW, Cella D. Evaluating clinically meaningful change on the ITP-PAQ: preliminary estimates of minimal important differences. Curr Med Res Opin 2009; 25:375-83. [PMID: 19192982 DOI: 10.1185/03007990802634119] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Interpretation of data from health-related quality of life (HRQoL) questionnaires can be enhanced with the availability of minimally important difference (MID) estimates. This information will aid clinicians in interpreting HRQoL differences within patients over time and between treatment groups. The Immune Thrombocytopenic Purpura (ITP)-Patient Assessment Questionnaire (PAQ) is the only comprehensive HRQoL questionnaire available for adults with ITP. RESEARCH DESIGN AND METHODS Forty centers from within the US and Europe enrolled ITP patients into one of two multicenter, randomized, placebo-controlled, double-blind, 6-month, phase III clinical trials of romiplostim. Patients enrolled in these studies self-administered the ITP-PAQ and two items assessing global change (anchors) at baseline and weeks 4, 12, and 24. Using data from the ITP-PAQ and these two anchors, an anchor-based estimate was computed and combined with the standard error of measurement and standard deviation to compute a distribution-based estimate in order to provide an MID range for each of the 11 scales of the ITP-PAQ. RESULTS A total of 125 patients participated in these clinical trials and provided data for use in these analyses. Combining results from anchor- and distribution-based approaches, MID values were computed for 9 of the 11 scales. MIDs ranged from 8 to 12 points for Symptoms, Bother, Psychological, Overall QOL, Social Activity, Menstrual Symptoms, and Fertility, while the range was 10 to 15 points for the Fatigue and Activity scales of the ITP-PAQ. These estimates, while slightly higher than other published MID estimates, were consistent with moderate effect sizes. CONCLUSIONS These MID estimates will serve as a useful tool to researchers and clinicians using the ITP-PAQ, providing guidance for interpretation of baseline scores as well as changes in ITP-PAQ scores over time. Additional work should be done to finalize these initial estimates using more appropriate anchors that correlate more highly with the ITP-PAQ scales.
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George JN, Mathias SD, Go RS, Guo M, Henry DH, Lyons R, Redner RL, Rice L, Schipperus MR. Improved quality of life for romiplostim-treated patients with chronic immune thrombocytopenic purpura: results from two randomized, placebo-controlled trials. Br J Haematol 2009; 144:409-15. [DOI: 10.1111/j.1365-2141.2008.07464.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood 2008; 113:2386-93. [PMID: 19005182 DOI: 10.1182/blood-2008-07-162503] [Citation(s) in RCA: 1756] [Impact Index Per Article: 109.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Diagnosis and management of immune thrombocytopenic purpura (ITP) remain largely dependent on clinical expertise and observations more than on evidence derived from clinical trials of high scientific quality. One major obstacle to the implementation of such studies and in producing reliable meta-analyses of existing data is a lack of consensus on standardized critical definitions, outcome criteria, and terminology. Moreover, the demand for comparative clinical trials has dramatically increased since the introduction of new classes of therapeutic agents, such as thrombopoietin receptor agonists, and innovative treatment modalities, such as anti-CD 20 antibodies. To overcome the present heterogeneity, an International Working Group of recognized expert clinicians convened a 2-day structured meeting (the Vicenza Consensus Conference) to define standard terminology and definitions for primary ITP and its different phases and criteria for the grading of severity, and clinically meaningful outcomes and response. These consensus criteria and definitions could be used by investigational clinical trials or cohort studies. Adoption of these recommendations would serve to improve communication among investigators, to enhance comparability among clinical trials, to facilitate meta-analyses and development of therapeutic guidelines, and to provide a standardized framework for regulatory agencies.
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Snyder CF, Mathias SD, Cella D, Isitt JJ, Wu AW, Young J. Health-related quality of life of immune thrombocytopenic purpura patients: results from a web-based survey. Curr Med Res Opin 2008; 24:2767-76. [PMID: 18715526 DOI: 10.1185/03007990802377461] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the health-related quality of life (HRQOL) of immune thrombocytopenic purpura (ITP) patients. RESEARCH DESIGN AND METHODS This was a cross-sectional, descriptive study comparing ITP patients' HRQOL to age and gender matched controls. ITP patients from the Platelet Disorder Support Association were recruited until 1000 surveys had been completed. Controls were randomly sampled from the Harris Interactive Online Panel. ITP patients and controls completed a one-time web-based survey, including a comprehensive HRQOL assessment. ITP patients completed the SF-36, the EQ-5D, and the ITP-Patient Assessment Questionnaire (ITP-PAQ). Controls completed the SF-36 and EQ-5D only. ITP patients' SF-36 and EQ-5D scores were compared to controls in unadjusted and adjusted analyses. Associations between splenectomy status, duration of illness, and platelet count with ITP patients' HRQOL scores were also examined. RESULTS This analysis included 1002 ITP patients and 1031 controls. ITP patients scored worse on seven of eight SF-36 domains and the Physical and Mental Summary scores (all p < 0.05) and on the EQ-5D visual analog scale (65.5 vs. 82.3; p = 0.002). ITP patients who had undergone splenectomy had similar SF-36 and EQ-5D scores to non-splenectomy patients but scored significantly worse on 5 of 10 ITP-PAQ scales: Bother, Psychological, Fear, Social Activity, and Work (all p < 0.05). ITP patients diagnosed within the past 5 years had worse Bother and Overall Quality of Life scores than less recently diagnosed patients but were similar on other ITP-PAQ scales. Lower platelet count was consistently associated with worse ITP-PAQ scores and had weaker associations with SF-36 and EQ-5D scores. CONCLUSIONS ITP was associated with consistent and statistically significant deficits on generic HRQOL measures. The ITP-PAQ demonstrated differences based on disease severity and treatments. The self-selection bias in the two samples limits the generalizability of the results to all patients with ITP. Further research is needed in more generalizable samples.
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Affiliation(s)
- Claire F Snyder
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Mathias SD, Gao SK, Miller KL, Cella D, Snyder C, Turner R, Wu A, Bussel JB, George JN, McMillan R, Wysocki DK, Nichol JL. Impact of chronic Immune Thrombocytopenic Purpura (ITP) on health-related quality of life: a conceptual model starting with the patient perspective. Health Qual Life Outcomes 2008; 6:13. [PMID: 18261217 PMCID: PMC2275726 DOI: 10.1186/1477-7525-6-13] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Accepted: 02/08/2008] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immune thrombocytopenic purpura (ITP), a condition characterized by autoimmune-mediated platelet destruction and suboptimal platelet production, is associated with symptoms such as bruising, epistaxis, menorrhagia, mucosal bleeding from the gastrointestinal and urinary tracts and, rarely central nervous system bleeding. The aim of this research is to develop a conceptual model to describe the impact of ITP and its treatment on patients' health-related quality of life (HRQoL). METHODS A literature search and focus groups with adult ITP patients were conducted to identify areas of HRQoL affected by ITP. Published literature was reviewed to identify key HRQoL issues and existing questionnaires used to assess HRQoL. Focus group transcripts were reviewed, and common themes were extracted by grouping conceptual categories that described the impact on HRQoL. RESULTS The literature synthesis and themes from the focus group data suggest that decreased platelet counts, disease symptoms, and treatment side effects influence multiple domains of HRQoL for ITP patients. Key areas affected by ITP and its treatments include emotional and functional health, work life, social and leisure activities, and reproductive health. CONCLUSION ITP affects various areas of HRQoL. This conceptual model will help inform the evaluation of therapeutic strategies for ITP.
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Affiliation(s)
- Susan D Mathias
- Health Outcomes Solutions, P.O. Box 2343; Winter Park, Florida 32790, USA
| | - Sue K Gao
- Amgen, Inc., One Amgen Center Drive; Thousand Oaks, CA 91320-1799, USA
| | - Kimberly L Miller
- ICON Clinical Research, Lifecycle Sciences Group, 188 Embarcadero, Suite 200; San Francisco, CA 94105, USA
| | - David Cella
- Evanston Northwestern Healthcare and Northwestern University Medical School, 1001 University Place, Suite 100; Evanston IL 60201, USA
| | - Claire Snyder
- John Hopkins University, 624 North Broadway; Baltimore, MD 21205, USA
| | - Ralph Turner
- Phase V Technologies, Inc., 20 Walnut Street; Wellesley Hills, MA 02481, USA
| | - Albert Wu
- John Hopkins University, 624 North Broadway; Baltimore, MD 21205, USA
| | - James B Bussel
- New York Presbyterian Hospital/Weill Cornell Medical Center, 525 East 68th Street; New York, NY 10021, USA
| | - James N George
- University of Oklahoma Health Sciences Center, P.O. Box 26901; Oklahoma City, OK 73190, USA
| | - Robert McMillan
- The Scripps Research Institute, 10550 N Torrey Pines Road; La Jolla, CA 92037, USA
| | | | - Janet L Nichol
- Amgen, Inc., One Amgen Center Drive; Thousand Oaks, CA 91320-1799, USA
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Mathias SD, Bussel JB, George JN, McMillan R, Okano GJ, Nichol JL. A disease-specific measure of health-related quality of life in adults with chronic Immune Thrombocytopenic Purpura: Psychometric testing in an open-label clinical trial. Clin Ther 2007; 29:950-962. [PMID: 17697914 DOI: 10.1016/j.clinthera.2007.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2007] [Indexed: 01/21/2023]
Abstract
BACKGROUND The Immune Thrombocytopenic Purpura Patient Assessment Questionnaire (ITP-PAQ) was developed to assess disease-specific quality of life (QoL) in adults with ITP. It is a 44-item questionnaire that includes scales for physical health (symptoms, fatigue/sleep, bother, and activity), emotional health (psychological and fear), overall QoL, social activity, women's reproductive health, and work. A previous study reported preliminary evidence of its reliability and validity. OBJECTIVES The present study was conducted to ascertain the responsiveness (ability to detect a clinically important treatment effect), reliability, and validity of the ITP-PAQ and to corroborate the earlier findings. The women's reproductive health scale was evaluated for psychometric evidence of the existence of separate menstrual symptoms and fertility subscales. METHODS The ITP-PAQ was evaluated in the context of an ongoing open-label extension study assessing the tolerability and durability of increases in the platelet count with AMG 531 (a thrombopoiesis peptibody that increases platelet production by targeting the thrombopoietin receptor) administered by subcutaneous injection once weekly in adult patients with ITP It was self-administered at baseline and at weeks 4, 12, and 24. The responsiveness of the questionnaire was evaluated by calculating and comparing the change scores of patients who showed clinical improvement-categorized as platelet responders (those with a platelet count > or =50 x 10(9) cells/L and a doubling of baseline values at week 24) and durable platelet responders (those with a platelet count > or =50 x 10(9) cells/L and a doubling of baseline values on > or =6 occasions during weeks 17-24)-with the change scores of patients wh did not show clinical improvement. The reliability (internal consistency and test-retest) and validity (convergent, discriminant, and known groups) of the questionnaire were also evaluated. Validity was examined in terms of correlations between the ITP-PAQ and the 36-item Short-Form Health Survey (SF-36), a generic measure of health-related QoL. RESULTS Thirty-four patients completed the ITP-PAQ. Most of the scales were found capable of detecting clinically important treatment effects, with the scales for symptoms, fatigue/sleep, bother, and activity being particularly responsive. All scales were found to have internal consistency reliability (Cronbach's alpha, 0.700-0.950), with the exceptions of the menstrual symptoms subscale (0.988 and 0.959 at weeks 12 and 24, respectively) and the work scale (0.691 at week 24). Test-retest reliability was acceptable (intraclass correlation coefficient, 0.725-0.867), with the exceptions of the scales for symptoms (0.677) and women's reproductive health (0.592) and the fertility subscale (0.171). Construct validity was supported by correlations between specific ITP-PAQ and SF-36 scales, with the exceptions of the menstrual symptoms and fertility subscales. Discriminant validity was reported for the symptoms, fatigue/sleep, bother, and activity scales. Durable platelet responders had significantly better scores than nonresponders on the symptoms (P = 0.022), bother (P = 0.008), psychological (P = 0.033), and overall QoL scales (P = 0.032). Compared with those who had undergone splenectomy, patients without splenectomy had significantly higher scores on the women's reproductive health scale (P = 0.03). CONCLUSIONS The results of this analysis indicate that the ITP-PAQ has acceptable responsiveness, reliability, and validity. Further study of the minimal clinically important difference in ITP-PAQ scale scores is needed.
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Affiliation(s)
| | - James B Bussel
- New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - James N George
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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