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Fattizzo B, Gurnari C, Cassanello G, Bortolotti M, Awada H, Giammarco S, Consonni D, Sica S, Gandhi S, Trikha R, Large J, Salter S, Maciejewski JP, Barcellini W, Kulasekararaj AG. Deciphering treatment patterns in non-severe/moderate aplastic anemia: an international observational study. Leukemia 2023; 37:2479-2485. [PMID: 37794100 PMCID: PMC10681892 DOI: 10.1038/s41375-023-02047-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/06/2023]
Abstract
Non-severe aplastic anemia is a rare bone marrow failure disorder characterized by variable degrees and combination of cytopenias, with limited data on management and outcome. We describe a large multicentric series of 259 patients, focusing on clinical and molecular features, treatment, evolution, and survival. The majority required treatment with cyclosporine (CyA) alone (N = 84) or in combination with anti-thymocyte globulin (ATG,44) or eltrombopag (20), eltrombopag alone (10), or others (25) including androgens. Similar outcomes were observed across different strategies, with a 6-month overall response rate of 73% for CyA, 74% for ATG plus CyA, 68% for CyA plus eltrombopag, 87% for eltrombopag, and 79% for others. Notably, 56 patients (39%), mainly receiving CyA plus eltrombopag, achieved a trilineage response (p = 0.02). Progression to myeloid neoplasms was limited (8%) and not related to mutational status. Hemolytic PNH developed in 10% of cases, being predicted by detection of small clones at diagnosis. Survival was negatively impacted by age, male gender, LDH, platelets/erythrocyte transfusion need, and somatic mutations by NGS, and positively by higher neutrophils at diagnosis, PNH clones, and trilineage response at 6 and 12 months. Multivariable analysis confirmed the detrimental role of age and the favorable association with PNH clone and trilineage response at 6 months.
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Affiliation(s)
- Bruno Fattizzo
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Giulio Cassanello
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Bortolotti
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Hussein Awada
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sabrina Giammarco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Dario Consonni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Shreyans Gandhi
- Department of Hematological Medicine, King's College Hospital, London, UK
| | - Roochi Trikha
- Department of Hematological Medicine, King's College Hospital, London, UK
| | - Joanna Large
- Department of Hematological Medicine, King's College Hospital, London, UK
| | - Sarah Salter
- Department of Hematological Medicine, King's College Hospital, London, UK
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Austin G Kulasekararaj
- Department of Hematological Medicine, King's College Hospital, London, UK
- Faculty of Life Sciences and Medicine, King's College London, London, UK
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Frol S, Pretnar Oblak J, Šabovič M, Kermer P, Sever M. Treatment of Acute Ischaemic Stroke and Concomitant Multiple Arterial Splanchnic Thromboses in a Patient with Immune Thrombocytopenia on Thrombopoietin Agonist: A Case Report. Neurol Int 2023; 15:1191-1199. [PMID: 37755365 PMCID: PMC10537946 DOI: 10.3390/neurolint15030074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune blood disorder characterised by isolated severe thrombocytopenia. Arterial thrombotic events, such as acute ischaemic stroke (AIS), are rare complications. A 56-year-old woman with chronic ITP on eltrombopag and dexamethasone therapy presented to the emergency department due to AIS in the vertebrobasilar territory, and lower abdominal pain. The computed tomography (CT) scan of the head was unremarkable, whereas CT angiography revealed left vertebral artery occlusion. As the platelet count was sufficient, intravenous thrombolysis (IVT) was initiated. However, after 15 min, an anaphylactic reaction occurred, which was appropriately solved. Although the IVT was prematurely stopped, the NIHSS score improved from 7 to 2, and the follow-up head CT scan remained unremarkable. CT angiography of the thoracoabdominal aorta revealed multiple thrombi in the infrarenal aorta, inferior mesenteric artery (IMA), and left renal artery. The abdominal pain subsided after IVT, but recurred within 24 h. Repeated CT angiography showed ischaemia of the descending colon, with persistent IMA occlusion. After the hemicolectomy condition stabilised. Discrete left-sided ataxia and impaired sensation were the only neurological sequelae. We found two articles reporting only three patients with ITP who suffered AIS and were treated with IVT. A favourable outcome was observed in two cases, while one patient suffered an intracranial haemorrhage (ICH) and died. A review of AIS cases with undefined thrombocytopenia treated with IVT reported ICH in up to 6.8% of patients. Our case suggests that IVT for AIS may be effective in patients with ITP. Further data are needed to better clarify this issue.
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Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
| | - Mišo Šabovič
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Vascular Disorders, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
| | - Pawel Kermer
- Department of Neurology, Nordwest-Krankenhaus Sanderbusch, Friesland Kliniken GmbH, 26452 Sande, Germany
- Department of Neurology, University of Göttingen, Robert-Koch Str. 40, 37075 Göttingen, Germany
| | - Matjaž Sever
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Department of Haematology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
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Chen YY, Liu H, Li LY, Li LJ, Wang HQ, Song J, Wu YH, Guan J, Xing LM, Wang GJ, Qu W, Liu H, Wang XM, Shao ZH, Fu R. [Role and clinical significance of MUC4 gene mutations in thrombotic events in patients with classic paroxysmal nocturnal hemoglobinuria]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:561-566. [PMID: 37749036 PMCID: PMC10509626 DOI: 10.3760/cma.j.issn.0253-2727.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Indexed: 09/27/2023]
Abstract
Objective: This study aimed to investigate the role and clinical significance of MUC4 gene mutations in thrombotic events in patients with classic paroxysmal nocturnal hemoglobinuria (PNH) patients. Methods: A retrospective analysis was conducted on the clinical data and gene sequencing results of 45 patients with classic PNH admitted to the Department of Hematology, Tianjin Medical University General Hospital, from June 2018 to February 2022. MUC4 gene mutations in patients with classic PNH were summarized, and the risk factors for thrombotic events in these patients were analyzed. Additionally, the effects of MUC4 gene mutations on the cumulative incidence and survival of thrombotic events in patients with classic PNH were determined. Results: The detection rate of MUC4 gene mutations in patients with classic PNH who experienced thrombotic events (thrombotic group) was 68.8% (11/16), which was significantly higher than that in the non-thrombotic group [10.3% (3/29) ] (P<0.001). All mutations occurred in exon 2. MUC4 mutation (OR=20.815, P=0.010) was identified as an independent risk factor for thrombotic events in patients with classic PNH. The cumulative incidence of thrombotic events was 78.6% (11/14) in the MUC4 gene mutation group (mutation group) and 16.1% (5/31) in the non-mutation group, showing a statistically significant difference between the two groups (P<0.001). Survival analysis showed a lower overall survival (OS) rate in the thrombotic group compared with that in the non-thrombotic group [ (34.4±25.2) % vs. (62.7±19.3) % ] (P=0.045). The OS rate of patients was (41.7±29.9) % in the mutation group and (59.1±18.3) % in the non-mutation group (P=0.487) . Conclusion: MUC4 gene mutations are associated with an increased incidence of thrombotic events in classic PNH patients, highlighting their role as independent risk factors for thrombosis in this population. These mutations can be considered a novel predictive factor that aids in evaluating the risk of thrombosis in patients with classic PNH.
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Affiliation(s)
- Y Y Chen
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Liu
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L Y Li
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L J Li
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Q Wang
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Song
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Y H Wu
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Guan
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L M Xing
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - G J Wang
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - W Qu
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Liu
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - X M Wang
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Z H Shao
- Tianjin Medical University General Hospital, Tianjin 300052, China
| | - R Fu
- Tianjin Medical University General Hospital, Tianjin 300052, China
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Hamed EM, Ibrahim ARN, Meabed MH, Khalaf AM, El Demerdash DM, Elgendy MO, Saeed H, Salem HF, Rabea H. The Outcomes and Adverse Drug Patterns of Immunomodulators and Thrombopoietin Receptor Agonists in Primary Immune Thrombocytopenia Egyptian Patients with Hemorrhage Comorbidity. Pharmaceuticals (Basel) 2023; 16:868. [PMID: 37375815 DOI: 10.3390/ph16060868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Immune thrombocytopenia (ITP) treatment has evolved recently. However, none of the treatments have only benefits without drawbacks. This study aimed to compare the clinical outcomes and adverse drug patterns of Eltrombopag, Romiplostim, Prednisolone + Azathioprine, High Dose-dexamethasone (HD-DXM) (control group), and Rituximab in primary ITP Egyptian patients. All patients were initiated with corticosteroids, HD-DXM, as a first-line treatment for the first month immediately following diagnosis. Four hundred sixty-seven ITP patients were randomly assigned to five groups. The outcome measures were judged at baseline, at the end of treatment (6 months), and after an additional 6-month free treatment period. The follow-up period for which relapse is noted was 6 months after the end of treatment. Eltrombopag and Romiplostim resulted in a significantly higher incidence of sustained response than Rituximab, HD-DXM, and Prednisolone + Azathioprine (55.2% and 50.6% vs. 29.2%, 29.1%, and 18%, respectively; p-value < 0.001). More patients on immunomodulators (Prednisolone+ Azathioprine, HD-DXM, and Rituximab) relapsed than those on Romiplostim and Eltrombopag (81.9%, 70.8%, and 70.7% vs. 49.3%, and 44.7%, respectively; p-value < 0.01). We also describe 23 reports of pulmonary hypertension with Prednisolone+ Azathioprine and 13 reports with HD-DXM. The thrombotic events occurred in 16.6% and 13% of patients who received Eltrombopag and Romiplostim treatment, respectively. Most patients had at least one or two risk factors (92.8% of cases). Corticosteroids are effective first-line therapy in primary ITP patients. However, relapse is frequent. Eltrombopag and Romiplostim are safer and more effective than Prednisolone, HD-DXM, and Rituximab. They might be reasonable beneficial options after a one-month HD-DXM regimen.
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Affiliation(s)
- Eman Mostafa Hamed
- Department of Clinical Pharmacy, Faculty of Pharmacy, Nahda University (NUB), Beni-Suef 62521, Egypt
| | - Ahmed R N Ibrahim
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia
| | - Mohamed Hussein Meabed
- Department of Pediatrics, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt
| | - Ahmed M Khalaf
- Department of Internal Medicine and Clinical Hematology, Beni-Suef University, Beni-Suef 62521, Egypt
| | - Doaa Mohamed El Demerdash
- Department of Internal Medicine and Clinical Hematology, Faculty of Medicine, Cairo University, Giza 54212, Egypt
| | - Marwa O Elgendy
- Department of Clinical Pharmacy, Faculty of Pharmacy, Nahda University (NUB), Beni-Suef 62521, Egypt
- Department of Clinical Pharmacy, Teaching Hospitals of Faculty of Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef 62521, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62521, Egypt
| | - Heba F Salem
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62521, Egypt
- Pharmaceutics and Industrial Pharmacy Department, 6 October Technological University, Giza 62521, Egypt
| | - Hoda Rabea
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62521, Egypt
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Adam LC, Burgstaller M, Taetweiler U, Mueller J. Successful Systemic Lysis Therapy of a Floating Carotid Thrombus in an Acute Stroke Patient with Known Immune Thrombocytopenia (ITP) on Ongoing Eltrombopag Therapy and Acute COVID-19 Infection: a Case Report. SN COMPREHENSIVE CLINICAL MEDICINE 2023; 5:133. [PMID: 37151759 PMCID: PMC10140722 DOI: 10.1007/s42399-023-01465-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 05/09/2023]
Abstract
Patients with immune thrombocytopenia (ITP) under eltrombopag therapy are vulnerable to thrombotic disbalance, both due to the disease itself and therapy-related hypercoagulability. Vascular events such as the development of a free-floating carotid thrombus are known rare complications of acute COVID-19 infections due to endothelial inflammation and presumptive underlying hypercoagulable state. In patients at risk, the onset of new focal neurological symptoms should prompt immediate angiographic diagnostics and, if necessary, appropriate treatment. Here, we report a case of a 38-year-old female with a medical history of ITP and the presence of COVID-19 infection presenting an acute sensorimotor hemiparesis of the right side while on eltrombopag therapy. Initial CT angiography revealed a free-floating thrombus in the left common carotid artery. Upon admission, the patient's platelet count was significantly elevated at 896 × 109/l. After systemic lysis therapy, the thrombus was fully dissolved. Follow-up diffusion-weighted imaging revealed multilocular cortical infarction of the left MCA territory. The patient soon recovered and was discharged with residual mild sensorimotor deficits in the right arm. Eltrombopag was paused at admission, and the patient's platelet count was quickly returning to normal. She was discharged with a daily intake of acetylsalicylic acid, a reduced daily dose of eltrombopag, and weekly monitoring of her platelet count for the next three months. This unique case highlights the need for caution in patients at vascular risk who contract COVID-19 and discusses thrombocytic derailment under thrombopoietin receptor agonist therapy in the context of an acute COVID-19 infection.
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Affiliation(s)
- Lucas C. Adam
- Department of Neurology, Vivantes Klinikum Spandau, Berlin, Germany
- Department of Neurology and Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Urs Taetweiler
- Department of Hematology, Vivantes Klinikum Spandau, Berlin, Germany
| | - Joerg Mueller
- Department of Neurology, Vivantes Klinikum Spandau, Berlin, Germany
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Bosi A, Barcellini W, Fattizo B. Correction: Pulmonary embolism in a patient with eltrombopag-treated aplastic anaemia and paroxysmal nocturnal haemoglobinuria clone during COVID-19 pneumonia. Thromb J 2022; 20:51. [PMID: 36100921 PMCID: PMC9469054 DOI: 10.1186/s12959-022-00412-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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