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Wang Y, Sheng L, Han F, Guo Q, Zhang Z, Hou Y, Feng Q, Zhou H, Ji X, Peng J, Hou M, Xu M. Efficacy and safety of treatments in newly diagnosed adult primary immune thrombocytopenia: A systematic review and network meta-analysis. EClinicalMedicine 2023; 56:101777. [PMID: 36578882 PMCID: PMC9791309 DOI: 10.1016/j.eclinm.2022.101777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Immune thrombocytopenia is an autoimmune disease characterised by decreased platelet count. In recent years, novel therapeutic regimens have been investigated in randomised controlled trials (RCTs). We aimed to compare the efficacy and safety of different treatments in newly diagnosed adult primary immune thrombocytopenia. METHODS We did a systematic review and network meta-analysis of RCTs involving treatments for newly diagnosed primary immune thrombocytopenia. PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched up to April 31, 2022. The primary outcomes were 6-month sustained response and early response. Secondary outcome was grade 3 or higher adverse events. This study is registered with PROSPERO (CRD42022296179). FINDINGS Eighteen RCTs (n = 1944) were included in this study. Pairwise meta-analysis showed that the percentage of patients achieving early response was higher in the dexamethasone-containing doublet group than in the dexamethasone group (79.7% vs 68.7%, odds ratio [OR] 1.82, 95% CI 1.10-3.02). The difference was more profound for sustained response (60.5% vs 37.4%, OR 2.57, 95% CI 1.95-3.40). Network meta-analysis showed that dexamethasone plus recombinant human thrombopoietin ranked first for early response, followed by dexamethasone plus oseltamivir or tacrolimus. Rituximab plus prednisolone achieved highest sustained response, followed by dexamethasone plus all-trans retinoic acid or rituximab. Rituximab plus dexamethasone showed 15.3% of grade 3 or higher adverse events, followed by prednis(ol)one (4.8%) and all-trans retinoic acid plus dexamethasone (4.7%). INTERPRETATION Our findings suggested that compared with monotherapy dexamethasone or prednis(ol)one, the combined regimens had better early and sustained responses. rhTPO plus dexamethasone ranked top in early response, while rituximab plus corticosteroids obtained the best sustained response, but with more adverse events. Adding oseltamivir, all-trans retinoic acid or tacrolimus to dexamethasone reached equally encouraging sustained response, without compromising safety profile. Although this network meta-analysis compared all the therapeutic regimens up to date, more head-to-head RCTs with larger sample size are warranted to make direct comparison among these strategies. FUNDING National Natural Science Foundation of China, Major Research Plan of National Natural Science Foundation of China, Shandong Provincial Natural Science Foundation and Young Taishan Scholar Foundation of Shandong Province.
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Key Words
- AEs, adverse events
- ASH, American Society of Hematology
- All-trans retinoic acid
- Anti-D, Rho(D) immune globulin
- CI, confidence interval
- CrI, credible intervals
- DEX, dexamethasone
- Dexamethasone
- ITP, primary immune thrombocytopenia
- IVIg, intravenous immunoglobulin
- NMA, network meta-analysis
- Network meta-analysis
- OR, odds ratio
- OSE, oseltamivir
- Oseltamivir
- PRD, prednis(ol)one
- Prednis(ol)one
- Primary immune thrombocytopenia
- QoL, quality of life
- RA, all-trans retinoic acid
- RCTs, randomised controlled trials
- RTX, rituximab
- Randomized controlled trials
- Rituximab
- SUCRA, the surface under the cumulative ranking curve
- TAC, tacrolimus
- TPO-RAs, thrombopoietin receptor agonists
- Tacrolimus
- mPRD, methylprednisolone
- rhTPO
- rhTPO, recombinant human thrombopoietin
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Affiliation(s)
- Yun Wang
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Lei Sheng
- Department of General Surgery, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Fengjiao Han
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Qiuyu Guo
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Zihan Zhang
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Qi Feng
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Hai Zhou
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Xuebin Ji
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
- Advanced Medical Research Institute, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
- Corresponding author. Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Wenhuaxi Road, Jinan, China.
| | - Miao Xu
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
- Corresponding author. Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Wenhuaxi Road, Jinan, China.
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Gervaso L, Dave H, Khorana AA. Venous and Arterial Thromboembolism in Patients With Cancer: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2021; 3:173-190. [PMID: 34396323 PMCID: PMC8352228 DOI: 10.1016/j.jaccao.2021.03.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in patients with cancer. Arterial thromboembolism, including myocardial infarction and stroke, is also prevalent. Risk differs in subgroups, with higher rates observed in specific cancers including pancreas, stomach, and multiple myeloma. Thromboprophylaxis is recommended for most patients with active cancer hospitalized for medical illnesses and after major cancer surgery. Outpatient thromboprophylaxis is not routinely recommended, but emerging data suggest that a high-risk population that benefits from pharmacological thromboprophylaxis can be identified using a validated risk tool. Direct oral anticoagulants are emerging as the preferred new option for the treatment of cancer-associated VTE, although low-molecular-weight heparin remains a standard for patients at high bleeding risk. Management of VTE beyond the first 6 months and challenging clinical situations including intracranial metastases and thrombocytopenia require careful management in balancing the benefits and risks of anticoagulation and remain major knowledge gaps in evidence.
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Key Words
- ASCO, American Society of Clinical Oncology
- ASH, American Society of Hematology
- AT, antithrombin
- ATE, arterial thromboembolism
- CAT, cancer-associated thrombosis
- CI, confidence interval
- CRNMB, clinically relevant nonmajor bleeding
- CVA, cerebrovascular event
- DOAC, direct oral anticoagulant
- DVT, deep venous thrombosis
- ESMO, European Society of Medical Oncology
- GI, gastrointestinal
- HR, hazard ratio
- ICH, intracranial hemorrhage
- ISTH, International Society on Thrombosis and Haemostasis
- KS, Khorana score
- LMWH, low-molecular-weight heparin
- MI, myocardial infarction
- MM, multiple myeloma
- NNT, number needed to treat
- PE, pulmonary embolism
- PPV, positive predictive value
- RAM, risk assessment model
- SPE, segmental pulmonary embolism
- SSC, Scientific and Standardization Committee
- SSPE, subsegmental pulmonary embolism
- UHF, unfractionated heparin
- VKA, vitamin K antagonist
- VTE, venous thromboembolism
- VVT, visceral vein thrombosis
- arterial thromboembolism
- cancer-associated thrombosis
- prophylaxis
- risk assessment models
- treatment
- venous thromboembolism
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Affiliation(s)
- Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, Istituto Europeo di Oncologia, European Institute of Oncology, Milan, Italy
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | - Heloni Dave
- Maharaja Sayajirao University, Medical College, Vadodara, Gujarat, India
| | - Alok A. Khorana
- Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
Apoptosis, especially the intrinsic mitochondrial cell death pathway, is regulated by the BCL-2 family of proteins. Defects in apoptotic machinery are one of the main mechanisms that cells employ to evade cell death and become cancerous. Targeting the apoptotic defects, either by direct inhibition of BCL-2 family proteins or through modulation of regulatory pathways, can restore cell sensitivity to cell death. This review will focus on the aspects of BCL-2 family proteins, their interactions with kinase pathways, and how novel targeted agents can help overcome the apoptotic blockades. Furthermore, functional assays, such as BH3 profiling, may help in predicting responses to chemotherapies and aid in the selection of combination therapies by determining the mitochondrial threshold for initiating cell death.
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Key Words
- ASH, American Society of Hematology
- ATAP, amphipathic tail-anchoring peptide
- Apoptosis
- BAD, BCL-2-associated death promoter protein
- BAK, BCL-2 homologous antagonist killer
- BAX, BCL-2-associated X protein
- BCL-2 family
- BCL-2, B-cell lymphoma 2
- BCL-w (BCL2L2), BCL-2-like protein 2
- BCL-xL, B-cell lymphoma X long
- BCR, B-cell receptor
- BFL-1 (BCL2A1), BCL-2-related protein A1
- BH3 profiling
- BH3, BCL-2 homology 3
- BID, BH3 interacting domain death agonist
- BIK, BCL-2-interacting killer
- BIM, BCL-2-interacting mediator of cell death
- BOK, BCL-2 related ovarian killer
- BTK, Bruton׳s tyrosine kinase
- CDK, cyclin-dependent kinase
- CHOP, cyclophosphamide, hydroxydaunorubicin, oncovin-vincristine and prednisone
- CLL, chronic lymphocytic leukemia
- CML, chronic myelogenous leukemia
- CR, complete response;EGFR, epidermal growth factor receptor
- Combination therapy
- ER, endoplasmic reticulum
- ERK, extracellular signal-regulated kinase
- FDA, U. S. Food and Drug Administration
- GSK-3, glycogen synthase kinase-3
- ITK, interleukin-2-inducible T-cell kinase
- MCL, myeloid cell leukemia
- MOMP, mitochondrial outer membrane permeabilization
- Mitochondrial priming
- NHL, non-Hodgkin lymphoma
- NIH, National Institutes of Health
- NSCLC, non-small cell lung cancer
- PI3K, phosphatidylinositol-3-kinase
- PUMA, p53 up-regulated modulator of apoptosis
- SLL, small lymphocytic lymphoma
- T-ALL, T-acute lymphocytic leukemia
- Targeted therapy
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