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Capecchi M, Serpenti F, Giannotta J, Pettine L, Reda G, Martinelli I, Artoni A, Barcellini W, Fattizzo B. Off-Label Use of Thrombopoietin Receptor Agonists: Case Series and Review of the Literature. Front Oncol 2021; 11:680411. [PMID: 34650908 PMCID: PMC8505995 DOI: 10.3389/fonc.2021.680411] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/06/2021] [Indexed: 12/15/2022] Open
Abstract
Since their license in 2008, studies on thrombopoietin receptor agonists (TPO-RAs) are proceeding at a fast pace. Their favorable efficacy and safety profile makes them good candidates for the management of thrombocytopenia in different settings, even beyond their current indications. In the last 10 years, we faced patients with refractory thrombocytopenia that required treatment with off-label TPO-RA, despite the paucity of data in the literature and the possible risks, particularly that of thrombosis. We hereby report our 10-year real-life single-center experience of TPO-RA used off-label. Fourteen patients were divided into three groups according to the etiology of thrombocytopenia: myelodysplastic syndromes, post-transplantation, and lymphoproliferative diseases. Clinical features and results are reported within each group. Overall, TPO-RA proved effective in all these conditions achieving responses also in heavily pretreated patients. The overall response rate (ORR) was 100% in patients with thrombocytopenia after transplantation and in those with lymphoproliferative diseases and 75% in patients with myelodysplastic syndromes. The median duration of therapy was 285 days (range 93–1,513 days). Four patients (29%) discontinued treatment because of lack of response (n=2) or a sustained response (n=2). No grade 3–4 adverse events occurred, particularly no thrombosis. In our real-life experience, TPO-RAs were effective and safe and proved of value in the challenging management of patients with refractory thrombocytopenia associated with different conditions.
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Affiliation(s)
- Marco Capecchi
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Fabio Serpenti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Oncology and Onco-hematology, Università degli Studi di Milano, Milan, Italy
| | - Juri Giannotta
- Department of Oncology and Onco-hematology, Università degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Loredana Pettine
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Gianluigi Reda
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Ida Martinelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Bruno Fattizzo
- Department of Oncology and Onco-hematology, Università degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
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2
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McGrath LJ, Nielson C, Saul B, Breskin A, Yu Y, Nicolaisen SK, Kilpatrick K, Ghanima W, Christiansen CF, Bahmanyar S, Linder M, Eisen M, Wasser J, Altomare I, Kuter D, Sørensen HT, Kelsh M, Brookhart MA. Lessons Learned Using Real-World Data to Emulate Randomized Trials: A Case Study of Treatment Effectiveness for Newly Diagnosed Immune Thrombocytopenia. Clin Pharmacol Ther 2021; 110:1570-1578. [PMID: 34416023 DOI: 10.1002/cpt.2399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/17/2021] [Indexed: 11/09/2022]
Abstract
Regulatory agencies are increasingly considering real-world evidence (RWE) to support label expansions of approved medicines. We conducted a comparative effectiveness study to emulate a proposed randomized trial of romiplostim vs. standard-of-care (SOC) therapy among patients with recently diagnosed (≤12 months) immune thrombocytopenia (ITP), that could support expansion of the romiplostim label. We discuss challenges that we encountered and solutions that were developed to address those challenges. Study size was a primary concern, particularly for romiplostim initiators, given the rarity of ITP and the stringent trial eligibility criteria. For this reason, we leveraged multiple data sources (Nordic Country Patient Registry for Romiplostim; chart review study of romiplostim initiators in Europe; Flatiron Health EMR linked with MarketScan claims). Additionally, unlike the strictly controlled clinical trial setting, platelet counts were not measured at regular intervals in the observational data sources, and therefore the end point of durable platelet response often used in trials could not be reliably measured. Instead, the median platelet count was chosen as the primary end point. Ultimately, while we observed a slightly higher median platelet count in the romiplostim group vs. SOC, precision was limited because of small study size (median difference was 11 × 109 /L (95% CI: -59, 81)). We underscore the importance of conducting comprehensive feasibility assessments to identify fit-for-purpose data sources with sufficient sample size, data elements, and follow-up. Beyond technical challenges, we also discuss approaches to increase the credibility of RWE, including systematic incorporation of clinical expertise into study design decisions, and separation between decision makers and the data.
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Affiliation(s)
| | - Carrie Nielson
- Center for Observational Research, Amgen, Thousand Oaks, California, USA
| | | | | | - Ying Yu
- NoviSci, Inc, Durham, North Carolina, USA
| | - Sia K Nicolaisen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Karynsa Kilpatrick
- Center for Observational Research, Amgen, Thousand Oaks, California, USA
| | - Waleed Ghanima
- Department of Hematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Shahram Bahmanyar
- Clinical Epidemiology Division & Center for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.,Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden
| | - Marie Linder
- Clinical Epidemiology Division & Center for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Melissa Eisen
- Center for Observational Research, Amgen, Thousand Oaks, California, USA
| | | | | | - David Kuter
- Department of Hematology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Michael Kelsh
- Center for Observational Research, Amgen, Thousand Oaks, California, USA
| | - M Alan Brookhart
- NoviSci, Inc, Durham, North Carolina, USA.,Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
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Abstract
Purpose of review Although antiphospholipid syndrome (APS) is best known for conveying increased risk of thrombotic events and pregnancy morbidity, thrombocytopenia is also recognized as a common association. In this review, we will explore the relationship between thrombocytopenia and APS, highlighting our evolving understanding – and persistent knowledge gaps – through clinically oriented questions and answers. Recent findings A history of thrombocytopenia likely portends a more severe APS phenotype (including increased risk of thrombosis). Although the pathophysiology underlying thrombocytopenia in APS has yet to be definitively revealed, mechanisms that play a role (at least in subsets of patients) include: immune thrombocytopenic purpura/ITP-like autoantibodies against platelet glycoproteins; antiphospholipid antibody (aPL)-mediated platelet activation and consumption; and potentially life threatening thrombotic microangiopathy. Although thrombocytopenia is often ‘mild’ in APS (and therefore, may not require specific therapy), there are causes of acute-onset thrombocytopenia that mandate emergent work-up and treatment. When APS-related thrombocytopenia does require therapy, the approach must be individualized (requiring an understanding of pathophysiology in the particular APS patient). For patients with ITP-like disease, rituximab is emerging as a popular approach to treatment; in contrast, there are hints that thrombopoietin mimetics may be associated with elevated thrombotic risk. Summary Thrombocytopenia is common in APS, and is likely associated with more severe disease. Improved understanding of thrombocytopenia in APS has the potential to improve risk stratification, reveal novel aspects of APS pathophysiology, and lead to treatments that are more individualized and holistic.
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4
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Eltrombopag for immune thrombocytopenia secondary to chronic lymphoproliferative disorders: a phase 2 multicenter study. Blood 2020; 134:1708-1711. [PMID: 31570488 DOI: 10.1182/blood.2019001617] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/05/2019] [Indexed: 12/12/2022] Open
Abstract
Immune thrombocytopenia (ITP) secondary to chronic lymphoproliferative disorders (LPDs) is poorly responsive to conventional treatments. We conducted a multicenter phase 2 prospective 24-week study in 18 patients with ITP secondary to LPDs to assess the safety and efficacy of eltrombopag. Responsive patients entered an extension study for up to 5 years. For inclusion, patients should not require cytotoxic treatment and should have a platelet count <30 × 109/L or have symptoms of bleeding. Eltrombopag was initiated at 50 mg/day, with a maximum of 150 mg/day. The primary end point was platelet response after 4 weeks. Median age was 70 years (range, 43-83 years), and 14 patients had chronic lymphocytic leukemia, 2 had classic Hodgkin lymphoma, and 2 had Waldenström macroglobulinemia. All patients had received previous ITP treatments. Response rate at week 4 was 78% (95% confidence interval [CI], 58%-97%), with 50% of patients having a complete response (CR) (95% CI, 43%-57%); respective results at week 24 were 59% (95% CI, 36%-82%) with 30% reaching a CR (95% CI, 8%-52%). Median exposure to eltrombopag was 16 months; median dose at week 4 was 50 mg/day (range, 25-100 mg/day), and at week 24, it was 50 mg/day (range, 25-150 mg/day). No grade >2 adverse events were reported. Eltrombopag is active and well tolerated in ITP secondary to LPDs. This trial was registered at www.clinicaltrials.gov as #NCT01610180.
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González-López TJ, Sánchez-González B, Jarque I, Bernat S, Fernández-Fuertes F, Caparrós I, Soto I, Fernández-Rodríguez A, Bolaños E, Pérez-Rus G, Pascual C, Hernández-Rivas JA, López-Ansoar E, Gómez-Nuñez M, Martínez-Robles V, Olivera P, Yera Cobo M, Peñarrubia MJ, Fernández-Miñano C, de Cabo E, Martínez Badas MP, Perdomo G, García-Frade LJ. Use of eltrombopag for patients 65 years old or older with immune thrombocytopenia. Eur J Haematol 2020; 104:259-270. [PMID: 31840311 DOI: 10.1111/ejh.13370] [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] [Received: 10/08/2019] [Revised: 12/03/2019] [Accepted: 12/11/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Eltrombopag is useful for immune thrombocytopenia (ITP). However, results of clinical trials may not accurately mirror clinical practice reality. Here we evaluated eltrombopag for primary and secondary ITP in our ≥65-year-old population. METHODS A total of 106 primary ITP patients (16 with newly diagnosed ITP, 16 with persistent ITP, and 74 with chronic ITP) and 39 secondary ITP patients (20 with ITP secondary to immune disorders, 7 with ITP secondary to infectious diseases, and 12 with ITP secondary to lymphoproliferative disorders [LPD]) were retrospectively evaluated. RESULTS Median age of our cohort was 76 (interquartile range, IQR, 70-81) years. 75.9% of patients yielded a platelet response including 66.2% complete responders. Median time to platelet response was 14 (IQR, 8-21) days. Median time on response was 320 (IQR, 147-526) days. Sixty-three adverse events (AEs), mainly grade 1-2, occurred. The most common were hepatobiliary laboratory abnormalities (HBLAs) and headaches. One transient ischemic attack in a newly diagnosed ITP and two self-limited pulmonary embolisms in secondary ITP were the only thrombotic events observed. CONCLUSION Eltrombopag showed efficacy and safety in ITP patients aged ≥65 years with primary and secondary ITP. However, efficacy results in LPD-ITP were poor. A relatively high number of deaths were observed.
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Affiliation(s)
- Tomás José González-López
- Department of Hematology, Hospital Universitario de Burgos, Burgos, Spain.,Department of Health Sciences, University of Burgos, Burgos, Spain
| | | | - Isidro Jarque
- Department of Hematology, Hospital Universitario La Fé, Valencia, Spain
| | - Silvia Bernat
- Department of Hematology, Hospital de La Plana, Castellón, Spain
| | - Fernando Fernández-Fuertes
- Department of Hematology, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Isabel Caparrós
- Department of Hematology, Hospital Clínico de Málaga, Málaga, Spain
| | - Inmaculada Soto
- Department of Hematology, Hospital Universitario Central de Asturias, Oviedo (Asturias), Spain
| | | | - Estefanía Bolaños
- Department of Hematology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Gloria Pérez-Rus
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Cristina Pascual
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Elsa López-Ansoar
- Department of Hematology, Complejo Hospitalario Universitario de Orense, Orense, Spain
| | - Marta Gómez-Nuñez
- Department of Hematology, Hospital Parc Taulí, Sabadell (Barcelona), Spain
| | | | - Pavel Olivera
- Department of Hematology, Hospital Universitario Vall de Hebron, Barcelona, Spain
| | - Maria Yera Cobo
- Department of Hematology, Hospital Puerta del Mar, Cádiz, Spain
| | | | | | - Erik de Cabo
- Department of Hematology, Hospital del Bierzo, Ponferrada (León), Spain
| | | | - Germán Perdomo
- Department of Health Sciences, University of Burgos, Burgos, Spain
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6
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Geneviève LD, Martani A, Mallet MC, Wangmo T, Elger BS. Factors influencing harmonized health data collection, sharing and linkage in Denmark and Switzerland: A systematic review. PLoS One 2019; 14:e0226015. [PMID: 31830124 PMCID: PMC6907832 DOI: 10.1371/journal.pone.0226015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The digitalization of medicine has led to a considerable growth of heterogeneous health datasets, which could improve healthcare research if integrated into the clinical life cycle. This process requires, amongst other things, the harmonization of these datasets, which is a prerequisite to improve their quality, re-usability and interoperability. However, there is a wide range of factors that either hinder or favor the harmonized collection, sharing and linkage of health data. OBJECTIVE This systematic review aims to identify barriers and facilitators to health data harmonization-including data sharing and linkage-by a comparative analysis of studies from Denmark and Switzerland. METHODS Publications from PubMed, Web of Science, EMBASE and CINAHL involving cross-institutional or cross-border collection, sharing or linkage of health data from Denmark or Switzerland were searched to identify the reported barriers and facilitators to data harmonization. RESULTS Of the 345 projects included, 240 were single-country and 105 were multinational studies. Regarding national projects, a Swiss study reported on average more barriers and facilitators than a Danish study. Barriers and facilitators of a technical nature were most frequently reported. CONCLUSION This systematic review gathered evidence from Denmark and Switzerland on barriers and facilitators concerning data harmonization, sharing and linkage. Barriers and facilitators were strictly interrelated with the national context where projects were carried out. Structural changes, such as legislation implemented at the national level, were mirrored in the projects. This underlines the impact of national strategies in the field of health data. Our findings also suggest that more openness and clarity in the reporting of both barriers and facilitators to data harmonization constitute a key element to promote the successful management of new projects using health data and the implementation of proper policies in this field. Our study findings are thus meaningful beyond these two countries.
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Affiliation(s)
| | - Andrea Martani
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | | | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Bernice Simone Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
- University Center of Legal Medicine, University of Geneva, Geneva, Switzerland
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7
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De Back TR, Kater AP, Tonino SH. Autoimmune cytopenias in chronic lymphocytic leukemia: a concise review and treatment recommendations. Expert Rev Hematol 2018; 11:613-624. [DOI: 10.1080/17474086.2018.1489720] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Tim R. De Back
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Arnon P. Kater
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne H. Tonino
- Department of Hematology and Lymphoma and Myeloma Center (LYMMCARE), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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8
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Guitton Z, Terriou L, Lega JC, Nove-Josserand R, Hie M, Amoura Z, Bussel JB, Hamidou M, Rosenthal E, Lioger B, Chauveau D, Chaminade A, Magy-Bertrand N, Michel M, Audia S, Godeau B, Mahevas M. Risk of thrombosis with anti-phospholipid syndrome in systemic lupus erythematosus treated with thrombopoietin-receptor agonists. Rheumatology (Oxford) 2018; 57:1432-1438. [DOI: 10.1093/rheumatology/key119] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Indexed: 12/26/2022] Open
Affiliation(s)
- Zelie Guitton
- Département de Médecine Interne et Immunologie Clinique, CHU Lille, Lille, France
| | - Louis Terriou
- Département de Médecine Interne et Immunologie Clinique, CHU Lille, Lille, France
| | | | | | - Miguel Hie
- Department of Internal Medicine, Pitie-Salpetriere University Hospital, Paris, France
| | - Zahir Amoura
- Department of Internal Medicine, Pitie-Salpetriere University Hospital, Paris, France
| | | | - Mohamed Hamidou
- Department of Internal Medicine, Hôtel Dieu University Hospital, Nantes, France
| | - Eric Rosenthal
- Weill Department of Medicine, Internal Medecine, CHRU Nice, Nice, France
| | - Bertrand Lioger
- Department of Internal Medicine, Bretonneau University Hospital, Tours, France
| | | | | | | | - Marc Michel
- Internal Medicine, French Referral Centre for Adult Immune Cytopenia, Henri Mondor Hospital, AP-HP, UPEC University, Créteil, France
| | - Sylvain Audia
- Department of Internal Medicine, Dijon University Hospital, Dijon, France
| | - Bertrand Godeau
- Internal Medicine, French Referral Centre for Adult Immune Cytopenia, Henri Mondor Hospital, AP-HP, UPEC University, Créteil, France
| | - Matthieu Mahevas
- Internal Medicine, French Referral Centre for Adult Immune Cytopenia, Henri Mondor Hospital, AP-HP, UPEC University, Créteil, France
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9
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Barcellini W, Fattizzo B. Autoimmune hemolytic anemia - progress in emerging treatment options. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1452734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Wilma Barcellini
- Hematology Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Bruno Fattizzo
- Hematology Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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10
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Santoro C, Volpicelli P, Baldacci E, Ferrara G, Di Rocco A, Ferretti A, Porrazzo M, Mazzucconi MG. Repeated successful use of eltrombopag in chronic primary immune thrombocytopenia: description of an intriguing case. Clin Case Rep 2017; 5:1385-1388. [PMID: 28781864 PMCID: PMC5538052 DOI: 10.1002/ccr3.920] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 11/21/2022] Open
Abstract
Thrombopoietin receptor agonists (TPO‐RAs) are used as effective alternative treatments in ITP patients unresponsive to first‐/second‐line therapies. TPO‐RAs can also be used to normalize platelet count to safely perform invasive procedures and chemotherapy, in case of malignancies. In few responsive patients, TPO‐RAs can be suspended maintaining a sustained response.
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Affiliation(s)
- Cristina Santoro
- Hematology Department of Cellular Biotechnology and Hematology "Sapienza" University of Rome Italy
| | - Paola Volpicelli
- Hematology Department of Cellular Biotechnology and Hematology "Sapienza" University of Rome Italy
| | - Erminia Baldacci
- Hematology Department of Cellular Biotechnology and Hematology "Sapienza" University of Rome Italy
| | - Grazia Ferrara
- Hematology Department of Cellular Biotechnology and Hematology "Sapienza" University of Rome Italy
| | - Alice Di Rocco
- Hematology Department of Cellular Biotechnology and Hematology "Sapienza" University of Rome Italy
| | - Antonietta Ferretti
- Hematology Department of Cellular Biotechnology and Hematology "Sapienza" University of Rome Italy
| | - Marika Porrazzo
- Hematology Department of Cellular Biotechnology and Hematology "Sapienza" University of Rome Italy
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11
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González-López TJ, Alvarez-Román MT, Pascual C, Sánchez-González B, Fernández-Fuentes F, Pérez-Rus G, Hernández-Rivas JA, Bernat S, Bastida JM, Martínez-Badas MP, Martínez-Robles V, Soto I, Olivera P, Bolaños E, Alonso R, Entrena L, Gómez-Nuñez M, Alonso A, Yera Cobo M, Caparrós I, Tenorio M, Arrieta-Cerdán E, Lopez-Ansoar E, García-Frade J, González-Porras JR. Use of eltrombopag for secondary immune thrombocytopenia in clinical practice. Br J Haematol 2017; 178:959-970. [PMID: 28573819 DOI: 10.1111/bjh.14788] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/04/2017] [Indexed: 01/16/2023]
Abstract
Eltrombopag is a second-line treatment in primary immune thrombocytopenia (ITP). However, its role in secondary ITP is unknown. We evaluated the efficacy and safety of eltrombopag in secondary ITP in daily clinical practice. Eighty-seven secondary ITP patients (46 with ITP secondary to autoimmune syndromes, 23 with ITP secondary to a neoplastic disease subtype: lymphoproliferative disorders [LPDs] and 18 with ITP secondary to viral infections) who had been treated with eltrombopag were retrospectively evaluated. Forty-four patients (38%) had a platelet response, including 40 (35%) with complete responses. Median time to platelet response was 15 days (95% confidence interval, 7-28 days), and was longer in the LPD-ITP group. Platelet response rate was significantly lower in the LPD-ITP than in other groups. However, having achieved response, there were no significant differences between the durable response of the groups. Forty-three patients (49·4%) experienced adverse events (mainly grade 1-2), the commonest being hepatobiliary laboratory abnormalities. There were 10 deaths in this case series, all of which were related to pre-existing medical conditions. In routine clinical practice, eltrombopag is effective and well-tolerated in unselected patients with ITP secondary to both immune and infectious disorders. However, the response rate in LPD-ITP is low.
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Affiliation(s)
| | | | - Cristina Pascual
- Department of Haematology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Fernando Fernández-Fuentes
- Department of Haematology, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Gloria Pérez-Rus
- Department of Haematology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Silvia Bernat
- Department of Haematology, Hospital de La Plana, Castellón, Spain
| | - José M Bastida
- Department of Haematology, IBSAL-Hospital Universitario de Salamanca, Salamanca, Spain
| | | | | | - Inmaculada Soto
- Department of Haematology, Hospital Universitario Central de Asturias, Oviedo (Asturias), Spain
| | - Pavel Olivera
- Department of Haematology, Hospital Universitario Valle de Hebron, Barcelona, Spain
| | - Estefanía Bolaños
- Department of Haematology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Rafael Alonso
- Department of Haematology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Laura Entrena
- Department of Haematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Marta Gómez-Nuñez
- Department of Haematology, Parc Sanitari Taulí, Sabadell (Barcelona), Spain
| | - Arancha Alonso
- Department of Haematology, Hospital Universitario Quirón Madrid, Madrid, Spain
| | - María Yera Cobo
- Department of Haematology, Hospital Puerta del Mar, Cádiz, Spain
| | - Isabel Caparrós
- Department of Haematology, Hospital Clínico de Málaga, Malaga, Spain
| | - María Tenorio
- Department of Haematology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Elsa Lopez-Ansoar
- Department of Haematology, Complejo Hospitalario Universitario de Orense, Orense, Spain
| | - Javier García-Frade
- Department of Haematology, Hospital Universitario Río Hortega, Valladolid, Spain
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12
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Virot E, Duclos A, Adelaide L, Miailhes P, Hot A, Ferry T, Seve P. Autoimmune diseases and HIV infection: A cross-sectional study. Medicine (Baltimore) 2017; 96:e5769. [PMID: 28121924 PMCID: PMC5287948 DOI: 10.1097/md.0000000000005769] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
To describe the clinical manifestations, treatments, prognosis, and prevalence of autoimmune diseases (ADs) in human immunodeficiency virus (HIV)-infected patients.All HIV-infected patients managed in the Infectious Diseases Department of the Lyon University Hospitals, France, between January 2003 and December 2013 and presenting an AD were retrospectively included.Thirty-six ADs were found among 5186 HIV-infected patients which represents a prevalence of 0.69% including immune thrombocytopenic purpura (n = 15), inflammatory myositis (IM) (n = 4), sarcoidosis (n = 4), Guillain-Barré syndrome (GBS) (n = 4), myasthenia gravis (n = 2), Graves' disease (n = 2), and 1 case of each following conditions: systemic lupus erythematosus, rheumatoid arthritis, autoimmune hepatitis, Hashimoto thyroiditis and autoimmune hemolytic anemia. One patient presented 2 ADs. Thirty patients were known to be HIV-infected when they developed an AD. The AD preceded HIV infection in 2 patients. GBS and HIV infection were diagnosed simultaneously in 3 cases. At AD diagnosis, CD4 T lymphocytes count were higher than 350/mm in 63% of patients, between 200 and 350/mm in 19% and less than 200/mm in 19%. Twenty patients benefited from immunosuppressant treatments, with a good tolerance.ADs during HIV infection are uncommon in this large French cohort. Immune thrombocytopenic purpura, sarcoidosis, IM, and GBS appear to be more frequent than in the general population. Immunosuppressant treatments seem to be effective and well tolerated.
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Affiliation(s)
- Emilie Virot
- Département de Médecine Interne, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
| | - Antoine Duclos
- Pôle Information Médicale Evaluation Recherche des Hospices Civils de Lyon
| | - Leopold Adelaide
- Département de Maladies Infectieuses, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
| | - Patrick Miailhes
- Département de Maladies Infectieuses, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
| | - Arnaud Hot
- Université de Lyon, Université Lyon 1
- Département de Médecine Interne, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Tristan Ferry
- Département de Maladies Infectieuses, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
- Université de Lyon, Université Lyon 1
| | - Pascal Seve
- Département de Médecine Interne, Hôpital de la Croix-Rousse, Hospices Civils de Lyon
- Université de Lyon, Université Lyon 1
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13
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Abstract
Secondary autoimmune cytopenias in chronic lymphocytic leukemia are distinct clinical entities that require specific management. These autoimmune disorders have a complex pathogenesis that involves both the leukemic cells and the immune environment in which they exist. The mechanism is not the same in all cases, and to varying degrees involves the chronic lymphocytic leukemia (CLL) cells in antibody production, antigen presentation, and stimulation of T cells and bystander polyclonal B cells. Diagnosis of autoimmune cytopenias can be challenging as it is difficult to differentiate between autoimmunity and bone marrow failure due to disease progression. There is a need to distinguish these causes, as prognosis and treatment are not the same. Evidence regarding treatment of secondary autoimmune cytopenias is limited, but many effective options exist and treatment can be selected with severity of disease and patient factors in mind. With new agents to treat CLL coming into widespread clinical use, it will be important to understand how these will change the natural history and treatment of autoimmune cytopenias.
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Affiliation(s)
- Kerry A Rogers
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Jennifer A Woyach
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH.
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14
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González-López TJ, Alvarez-Román MT, Pascual C, Sánchez-González B, Fernández-Fuentes F, Jarque I, Pérez-Rus G, Pérez-Crespo S, Bernat S, Hernández-Rivas JA, Andrade MM, Cortés M, Gómez-Nuñez M, Olivera P, Martínez-Robles V, Fernández-Rodríguez A, Fuertes-Palacio MA, Fernández-Miñano C, de Cabo E, Fisac R, Aguilar C, Bárez A, Peñarrubia MJ, García-Frade LJ, González-Porras JR. Eltrombopag safety and efficacy for primary chronic immune thrombocytopenia in clinical practice. Eur J Haematol 2016; 97:297-302. [PMID: 26709028 DOI: 10.1111/ejh.12725] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Eltrombopag is effective and safe in chronic immune thrombocytopenia (ITP). However, clinical trials may not accurately reflect what happens in clinical practice. We evaluated the efficacy and safety of eltrombopag in primary chronic ITP in a real-world setting. METHODS A total of 164 primary patients with chronic ITP from 40 Spanish centers, who had been treated with eltrombopag, were retrospectively evaluated. RESULTS The median age of our cohort (72% women) was 63 yr (interquartile range, IQR, 45-75 yr). The median time with ITP diagnosis was 81 months (IQR, 30-192 months). The median number of therapies prior to eltrombopag was 3 (IQR, 2-4). At the time of eltrombopag start, 45 patients (30%) were receiving concomitant treatment for ITP. Forty-six patients (30%) had bleeding signs/symptoms the month before the treatment started. The median platelet count at eltrombopag initiation was 22 × 10(9) /L (IQR, 8-39 × 10(9) /L). A total of 135 patients (88.8%) achieved a platelet response. The median time to platelet response was 12 d (95% CI, 9-13 d). Maintained platelet response rate during the 15-month period under examination was 75.2%. Twenty-eight patients (18.4%) experienced adverse events, mainly grades 1-2. CONCLUSION Eltrombopag is highly effective and well tolerated in unselected patients with primary chronic ITP.
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Affiliation(s)
| | | | - Cristina Pascual
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Fernando Fernández-Fuentes
- Department of Hematology, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Isidro Jarque
- Department of Hematology, Hospital Universitario La Fé, Valencia, Spain
| | - Gloria Pérez-Rus
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Susana Pérez-Crespo
- Department of Hematology, Hospital de Santiago de Compostela, Santiago de Compostela (La Coruña), Spain
| | - Silvia Bernat
- Department of Hematology, Hospital de La Plana, Castellón, Spain
| | | | - Marcio M Andrade
- Department of Hematology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Montserrat Cortés
- Department of Hematology, Fundació Hospital Asil de Granollers, Granollers (Barcelona), Spain
| | - Marta Gómez-Nuñez
- Department of Hematology, Hospital Parc Taulí, Sabadell (Barcelona), Spain
| | - Pavel Olivera
- Department of Hematology, Hospital Universitario Vall de Hebron, Barcelona, Spain
| | | | | | | | | | - Erik de Cabo
- Department of Hematology, Hospital del Bierzo, Ponferrada (León), Spain
| | - Rosa Fisac
- Department of Hematology, Hospital de Segovia, Segovia, Spain
| | - Carlos Aguilar
- Department of Hematology, Hospital de Soria, Soria, Spain
| | - Abelardo Bárez
- Department of Hematology, Hospital de Avila, Avila, Spain
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15
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Magnano L, Enríquez H, Esteve J, Cervera R, Espinosa G. Effectiveness of thrombopoietin-receptor agonists in the treatment of refractory immune thrombocytopenia associated to systemic lupus erythematosus. J Rheumatol 2015; 41:1895-6. [PMID: 25179983 DOI: 10.3899/jrheum.140080] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
| | | | | | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain.
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16
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Abstract
Thrombocytopenia is a frequent complication of cancer and its treatment. The causes of thrombocytopenia in cancer patients can be diverse and multifactorial. Systemic chemotherapy is the most frequent cause of thrombocytopenia. The degree and duration thrombocytopenia depends upon whether the chemotherapeutic treatment is myeloablative, as used in stem cell transplants, or non-myeloablative, as typically used in solid non-hematologic malignancies. Additional causes of significant thrombocytopenia include tumor involvement of bone marrow and spleen; microangiopathic disorders such as disseminated intravascular coagulation, thrombotic thrombocytopenic purpura or hemolytic uremia syndrome. Lymphoproliferative malignancies can also be associated with secondary immune thrombocytopenia. Due to the broad differential diagnosis associated with cancer related thrombocytopenia, a careful diagnostic evaluation is indicated. The goal of treatment should be to maintain a safe platelet count to allow effective treatment of the underlying malignancy, prevent bleeding complications and to minimize the use of platelet product transfusion.
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17
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Kowalczyk M, Rubinstein PG, Aboulafia DM. Initial Experience with the Use of Thrombopoetin Receptor Agonists in Patients with Refractory HIV-Associated Immune Thrombocytopenic Purpura: A Case Series. J Int Assoc Provid AIDS Care 2014; 14:211-6. [PMID: 25504472 DOI: 10.1177/2325957414557266] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
HIV-associated immune thrombocytopenic purpura (ITP) has decreased in incidence 10-fold since the advent of highly active antiretroviral therapy (HAART). For patients with detectable HIV viral loads, first-line treatment approaches involve optimizing HAART followed by standard ITP options used to treat those without HIV infection. In the general population, the thrombopoetin receptor agonists (TRAs), eltrombopag and romiplostim, are effective when used as salvage ITP therapy. In addition, eltrombopag has been used effectively in patients with thrombocytopenia secondary to hepatitis C--a virus seen commonly in HIV-infected patients, especially in those who also have a history of intravenous drug use. There are, however, few reports or studies of TRAs use in those with HIV infection. Herein, we describe 5 cases of refractory HIV-associated ITP managed with TRAs. Although platelet counts improved for all patients, 2 patients succumbed to thromboembolic complications. Our initial experience, as well as our findings from a Medline review, supports the potential utility of TRA as salvage therapy in the treatment of HIV-related ITP; however, we recommend caution in the use of these agents in those who are at highest risk of thrombosis. Additional studies are needed to determine the efficacy and, more importantly, the safety of TRAs in treatment of HIV-associated ITP.
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Affiliation(s)
- Mark Kowalczyk
- Department of Hematology/Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Paul G Rubinstein
- Section of Hematology/Oncology, Stroger Hospital of Cook County, Ruth M. Rothstein CORE Center, Rush University Medical Center, Chicago, IL, USA
| | - David M Aboulafia
- Department of Hematology/Oncology, Virginia Mason Medical Center, Seattle, WA, USA Division of Hematology, The University of Washington School of Medicine, Seattle WA, USA
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18
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Visco C, Barcellini W, Maura F, Neri A, Cortelezzi A, Rodeghiero F. Autoimmune cytopenias in chronic lymphocytic leukemia. Am J Hematol 2014; 89:1055-62. [PMID: 24912821 DOI: 10.1002/ajh.23785] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 05/28/2014] [Accepted: 06/06/2014] [Indexed: 12/20/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is frequently complicated by secondary autoimmune cytopenias (AIC) represented by autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), pure red cell aplasia, and autoimmune granulocytopenia. The distinction of immune cytopenias from cytopenias due to bone marrow infiltration, usually associated with a worse outcome and often requiring a different treatment, is mandatory. AIHA and ITP are more frequently found in patients with unfavorable biological risk factors for CLL. AIC secondary to CLL respond less favorably to standard treatments than their primary forms, and treating the underlying CLL with chemotherapy or monoclonal antibodies may ultimately be necessary.
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Affiliation(s)
- Carlo Visco
- Department of Cell Therapy and Hematology; Ospedale San Bortolo Vicenza
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
| | - Francesco Maura
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Antonino Neri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
| | - Agostino Cortelezzi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
- Department of Clinical Sciences and Community Health; University of Milan; Milan
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19
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Jolliffe E, Romeril K. Eltrombopag for resistant immune thrombocytopenia secondary to chronic lymphocytic leukaemia. Intern Med J 2014; 44:697-9. [DOI: 10.1111/imj.12468] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 04/03/2014] [Indexed: 11/28/2022]
Affiliation(s)
- E. Jolliffe
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
| | - K. Romeril
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
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20
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Tandra P, Krishnamurthy J, Bhatt VR, Newman K, Armitage JO, Akhtari M. Autoimmune cytopenias in chronic lymphocytic leukemia, facts and myths. Mediterr J Hematol Infect Dis 2013; 5:e2013068. [PMID: 24363883 PMCID: PMC3867225 DOI: 10.4084/mjhid.2013.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 10/31/2013] [Indexed: 12/21/2022] Open
Abstract
CLL has been defined as presence of more than 5000 small mature appearing monoclonal B lymphocytes with a specific immunophenotype in peripheral blood. It is a well-known fact that CLL is associated with autoimmune cytopenias. CLL cells are CD5(+) B lymphocytes, and usually are not the "guilty" cells which produce autoantibodies. T cell defect is another characteristic of CLL and the total number of T cells is increased, and there is inversion of the CD4/CD8 ratio. Autoimmune hemolytic anemia (AIHA) is the most common autoimmune complication of CLL and has been reported in 10-25% of CLL patients. However, the stage-adjusted estimated rate of AIHA in CLL is about 5%. Conversely, CLL is three times more common in patients who present with AIHA. Direct agglutinin test (DAT) is positive in 7-14% of CLL patients but AIHA may also occur in DAT negative patients. Autoimmune thrombocytopenia (AIT) is the second most common complication of CLL and has been reported in 2-3% of patients. DAT is positive in AIT but presence of antiplatelet antibodies is neither diagnostic nor reliable. Autoimmune neutropenia (AIN) and pure red cell aplasia (PRCA) are very rare complications of CLL and like other autoimmune complications of CLL may occur at any clinical stage. It is believed that most case reports of AIN and PRCA in CLL actually belong to large granular lymphocytic leukemia (LGL). Non-hematologic autoimmune complications of CLL including cold agglutinin disease (CAD), paraneoplastic pemphigus (PNP), acquired angioedema, and anti-myelin associated globulin are rare. Before starting any treatment, clinicians should distinguish between autoimmune cytopenias and massive bone marrow infiltration since autoimmune complications of CLL are not necessarily equal to advanced disease with poor prognosis. According to IWCLL guideline, steroids are the mainstay of treatment of simple autoimmunity. Intravenous immunoglobulin (IVIg), cyclosporine, and rituximab are used in complex, steroid refractory cases. Monotherapy with purine analogues and alkylating agents should be avoided as they may increase CLL associated autoimmune complications.
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Affiliation(s)
- Pavankumar Tandra
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Jairam Krishnamurthy
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Vijaya Raj Bhatt
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Kam Newman
- Dr. Kam Newman, Section of Transfusion Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue 6-1, Cleveland, OH 44195, USA
| | - James O Armitage
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Mojtaba Akhtari
- Division of Hematology and Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA
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