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Anti-CD20 Treatment of Autoimmune Hemolytic Anemia Refractory to Corticosteroids and Azathioprine: A Pediatric Case Report and Mini Review. Case Rep Hematol 2018; 2018:8471073. [PMID: 30225153 PMCID: PMC6129358 DOI: 10.1155/2018/8471073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/30/2018] [Indexed: 12/18/2022] Open
Abstract
Autoimmune hemolytic anemia (AIHA) is a relatively uncommon hematological entity in children and sometimes is characterized by a severe course requiring more than one line course therapy. Treatment decisions depend on the severity and chronicity of the anemia and the characteristics of the autoantibodies. Immunosuppression with corticosteroids is the first-line treatment, especially in warm-reactive AIHA. Refractory cases are treated with immunosuppressive drugs, cytotoxic agents, androgens, or splenectomy, with various side effects and questionable efficacy. Another second-line option is rituximab, an anti-CD20 monoclonal antibody, which has been used as an off-label agent with encouraging results from small limited studies or case reports. Herein, we add our experience on the safety and clinical efficacy of rituximab by presenting the case of a boy with warm-type AIHA resistant to corticosteroids and azathioprine, successfully treated with rituximab. We also offer a review of the relevant literature.
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Kyriakidis I, Tragiannidis A, Zündorf I, Groll AH. Invasive fungal infections in paediatric patients treated with macromolecular immunomodulators other than tumour necrosis alpha inhibitors. Mycoses 2017; 60:493-507. [DOI: 10.1111/myc.12621] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/06/2017] [Accepted: 03/07/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Ioannis Kyriakidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Athanasios Tragiannidis
- 2nd Department of Pediatrics; Aristotle University of Thessaloniki; AHEPA University General Hospital; Thessaloniki Greece
| | - Ilse Zündorf
- Institute of Pharmaceutical Biology; Goethe-University of Frankfurt; Frankfurt am Main Germany
| | - Andreas H. Groll
- Infectious Disease Research Program; Center for Bone Marrow Transplantation and Department of Pediatric Hematology/Oncology; University Childrens Hospital; Muenster Germany
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Ducassou S, Leverger G, Fernandes H, Chambost H, Bertrand Y, Armari-Alla C, Nelken B, Monpoux F, Guitton C, Leblanc T, Fisher A, Lejars O, Jeziorski E, Fouissac F, Lutz P, Pasquet M, Pellier I, Piguet C, Vic P, Bayart S, Marie-Cardine A, Michel M, Perel Y, Aladjidi N. Benefits of rituximab as a second-line treatment for autoimmune haemolytic anaemia in children: a prospective French cohort study. Br J Haematol 2017; 177:751-758. [PMID: 28444729 DOI: 10.1111/bjh.14627] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/31/2016] [Indexed: 11/28/2022]
Abstract
Childhood autoimmune haemolytic anaemia (AIHA) requires second-line immunosuppressive therapy in 30-50% of cases. It appears that rituximab is indicated in such circumstances. This prospective national study reports the practice, efficacy and tolerance of rituximab in children with isolated AIHA and AIHA in the setting of Evans syndrome (ES). Sixty-one children were given rituximab between 2000 and 2014. The median interval from diagnosis to rituximab was 9·9 [interquartile range (IQR) 1·6-28·5] months. Forty-six patients responded (75%) and the 6-year relapse-free survival (RFS) was 48%. Twenty patients relapsed at a median interval of 10·8 (IQR 3·9-18·7) months, rituximab allowed steroid withdrawal in 44/61 (72%) of children. In isolated AIHA, complete response and 6-year RFS were significantly higher than in ES (P < 0·05). Ten out of 61 patients were infants, seven of who responded with a 6-year RFS of 71%. Among patients without immunoglobulin substitution before rituximab, 4 are still receiving substitutions. Five patients died, including one potentially attributable to rituximab. This large observational series of childhood AIHA established the rituximab benefit-risk ratio, allowing steroid withdrawal, with 37% of long-term responders, mainly in isolated AIHA. All subgroups of patients drew benefit. Our long-term results indicate the baseline to be challenged by new treatment approaches.
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Affiliation(s)
- Stéphane Ducassou
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
| | - Guy Leverger
- Paediatric Onco-Haematology Unit, Hôpital Trousseau, APHP, Paris, France
| | - Helder Fernandes
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
| | - Hervé Chambost
- Paediatric Haematology Unit, Hôpital La Timone Enfants - APHM, Marseille, France
| | - Yves Bertrand
- Paediatric Immuno-Haematology Unit, Institut d'Hématologie et d'Oncologie Pédiatrique (IHOP), Lyon, France
| | | | - Brigitte Nelken
- Paediatrics Unit, University Hospital of Lille, Lille, France
| | - Fabrice Monpoux
- Paediatric Onco-Haematology Unit, University Hospital of Nice, Nice, France
| | - Corinne Guitton
- Paediatrics Unit, University Hospital Bicêtre - APHP, Le Kremlin-Bicêtre, France
| | - Thierry Leblanc
- Haematology Unit, Hôpital Robert Debré - APHP, Paris, France
| | - Alain Fisher
- Immuno-Haematology Unit, Hôpital Necker - APHP, Paris, France
| | - Odile Lejars
- Paediatric Onco-Haematology Unit, University Hospital of Tours, Tours, France
| | - Eric Jeziorski
- Paediatric Onco-Haematology Unit, University Hospital of Montpellier, Montpellier, France
| | - Fanny Fouissac
- Paediatric Onco-Haematology Unit, University Hospital of Nancy, Nancy, France
| | - Patrick Lutz
- Paediatric Onco-Haematology Unit, University Hospital of Strasbourg, Strasbourg, France
| | - Marlène Pasquet
- Paediatric Onco-Haematology Unit, University Hospital of Toulouse, Toulouse, France
| | - Isabelle Pellier
- Paediatric Onco-Haematology Unit, University Hospital of Angers, Angers, France
| | - Christophe Piguet
- Paediatric Onco-Haematology Unit, University Hospital of Limoges, Limoges, France
| | - Philippe Vic
- Paediatric Unit, General Hospital of Quimper, Quimper, France
| | - Sophie Bayart
- Paediatric Onco-Haematology Unit, University Hospital of Rennes, Rennes, France
| | - Aude Marie-Cardine
- Paediatric Onco-Haematology Unit, University Hospital of Rouen, Rouen, France
| | - Marc Michel
- Department of Internal Medicine, Henri Mondor University Hospital, APHP, Université Paris-Est Créteil, Créteil, France
| | - Yves Perel
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
| | - Nathalie Aladjidi
- Paediatric Oncology Haematology Unit/CEREVANCE/CIC 1401, Inserm CICP, University Hospital of Bordeaux, Paediatric Hospital, Bordeaux, France
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Salama A. Treatment Options for Primary Autoimmune Hemolytic Anemia: A Short Comprehensive Review. Transfus Med Hemother 2015; 42:294-301. [PMID: 26696797 PMCID: PMC4678315 DOI: 10.1159/000438731] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 07/15/2015] [Indexed: 12/26/2022] Open
Abstract
Until now, treatment of primary autoimmune hemolytic anemia of the warm type (wAIHA) is primarily based on immunosuppression. However, many patients do not respond adequately to treatment, and treated patients may develop severe side effects due to uncontrolled, mixed and/or long-lasting immunosuppression. Unfortunately, the newly used therapeutic monoclonal antibodies are unspecific and remain frequently ineffective. Thus, development of a specific therapy for AIHA is necessary. The ideal therapy would be the identification and elimination of the causative origin of autoimmunization and/or the correction or reprogramming of the dysregulated immune components. Blood transfusion is the most rapidly effective measure for patients who develop or may develop hypoxic anemia. Although some effort has been made to guide physicians on how to adequately treat patients with AIHA, a number of individual aspects should be considered prior to treatment. Based on my serological and clinical experience and the analysis of evidence-based studies, we remain far from any optimized therapeutic measures for all AIHA patients. Today, the old standard therapy using controlled steroid administration, with or without azathioprine or cyclophosphamide, is, when complemented with erythropoiesis-stimulating agents, still the most effective therapy in wAIHA. Rituximab or other monoclonal antibodies may be used instead of splenectomy in therapy-refractory patients.
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Affiliation(s)
- Abdulgabar Salama
- Institute for Transfusion Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Guillaume-Czitrom S, Bachelez H, Berthelot JM, Bouhnik Y, Bruckert E, Claudepierre P, Constantin A, de Bandt M, Fautrel B, Gaudin P, Goëb V, Gossec L, Gottenberg JE, Goupille P, Hachulla E, Huet I, Jullien D, Launay O, Lemannf M, Lequerré T, Maillefert JF, Mariette X, Marolleau JP, Martinez V, Masson C, Morel J, Mouthon L, Pham T, Pol S, Puéchal X, Richette P, Saraux A, Schaeverbeke T, Sellam J, Blacher J, Soubrier M, Sudre A, Viguier M, Vittecoq O, Wendling D, Sibilia J. Biologic targeted therapies in pediatric rheumatology. Joint Bone Spine 2014; 81 Suppl 1:2-48. [DOI: 10.1016/s1297-319x(14)70020-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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