Platelet count or bleeding as the outcome in ITP trials?

Current Understanding of Immune Thrombocytopenia: A Review of Pathogenesis and Treatment Options

The management of immune thrombocytopenia (ITP) and the prediction of patient response to therapy still represent a significant and constant challenge in hematology. ITP is a heterogeneous disease with an unpredictable evolution. Although the pathogenesis of ITP is currently better known and its etiology has been extensively studied, up to 75% of adult patients with ITP may develop chronicity, which represents a significant burden on patients' quality of life. A major risk of ITP is bleeding, but knowledge on the exact relationship between the degree of thrombocytopenia and bleeding symptoms, especially at a lower platelet count, is lacking. The actual management of ITP is based on immune suppression (corticosteroids and intravenous immunoglobulins), or the use of thrombopoietin receptor agonists (TPO-RAs), rituximab, or spleen tyrosine kinase (Syk) inhibitors. A better understanding of the underlying pathology has facilitated the development of a number of new targeted therapies (Bruton's tyrosine kinase inhibitors, neonatal Fc receptors, strategies targeting B and plasma cells, strategies targeting T cells, complement inhibitors, and newer TPO-RAs for improving megakaryopoiesis), which seem to be highly effective and well tolerated and result in a significant improvement in patients' quality of life. The disadvantage is that there is a lack of knowledge of the predictive factors of response to treatments, which would help in the development of an optimized treatment algorithm for selected patients.

Sufficient vitamin D is favorable for children with persistent and chronic immune thrombocytopenia

Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia in the absence of other disorders. Vitamin D (VD) has been shown to modulate the immune system and its deficiency is linked to many immunological disorders. Supplementation with VD in ITP has promising results. This work aims at evaluating VD values in children with persistent and chronic ITP and the effect of its deficiency on disease severity and treatment response. A case-control study including 50 persistent and chronic ITP patients and 50 healthy controls was conducted. 25 OH vitamin D level was determined using ELISA technique. VD median value was significantly higher among the control group than that of the patients' group (28 vs 21.5 and p = 0.002). Severe deficiency was detected significantly more among the patients' group than the control group (12 (24%) vs 3 (6%), p = 0.048) respectively. Forty-four percent of complete responders belong to sufficient VD category ((15/34) ~ 44% (p = 0.005)) representing all patients with sufficient VD status (n = 15). Also, a positive correlation between serum level of vitamin D and mean PLT count was observed (r = 0.316, p value = 0.025). Sufficient vitamin D was associated with better treatment response and less disease severity. Vitamin D supplementation may be a new therapeutic option for chronic ITP.

Utilization of an ITP quality improvement pathway improves adherence to management guidelines

Despite availability of epidemiologic studies and national guidelines for the management of newly diagnosed pediatric immune thrombocytopenia (ITP), practice variation exists among and within hematology practices. We previously described the development of an ITP pathway guiding management based on bleeding symptoms. Over an 8-year period, integration of this iterative ITP pathway into management of newly diagnosed ITP increased observation rates in children with no or mild bleeding symptoms and improved consistency of laboratory evaluation and treatment strategies without increasing adverse outcomes. This quality improvement initiative has been sustainable, acceptable to providers, and increased adherence to guidelines.

Immune Thrombocytopenia: Characteristics of the Population and Treatment Methods-One-Center Experience

BACKGROUND

 Immune thrombocytopenia (ITP) is a disease with variable clinical presentation, requiring different treatment lines.

AIM

 The study aimed to characterize a group of ITP patients in terms of clinical picture and disease treatment, as well as to present the current standard of care of ITP in Poland, in the context of local and international guidelines.

MATERIALS AND METHODS

 The study included adult patients diagnosed with ITP, treated at the Department of Haematology of the Jagiellonian University Hospital in Krakow from January 2006 to January 2021. Patient characteristics, clinical manifestation of ITP, and treatment methods were analyzed.

RESULTS

 A total of 245 ITP patients were included. 57.1% of them were asymptomatic at diagnosis. Most common symptoms were thrombocytopenic purpura (68.2%), followed by epistaxis (34.7%) and gum bleeds (19.2%). Life-threatening bleedings were noted in three cases (1.2%). 23.2% of patients did not require treatment. Prednisone was the most commonly used first-line therapy (75.5% of patients). Treatment with eltrombopag and romiplostim was used in 40.4 and 8.5% of patients requiring second-line therapy, respectively. 14.3% of all patients ultimately underwent splenectomy, including 51.5% of those who needed second-line treatment. The initial response rate was 74.3%; however, post-splenectomy relapses occurred in 22.9% of patients.

CONCLUSIONS

 ITP is a disease of mild clinical course, often asymptomatic. Chronic disease often requires multiple treatment lines and balancing between bleeding risk and treatment toxicity, based on individual risk-benefit assessment. Local access restrictions to thrombopoietin receptor agonists determined the treatment strategy.

Immune thrombocytopenia: A review of upfront treatment strategies

Immune thrombocytopenia (ITP), resulting from antibody-mediated platelet destruction combined with impaired platelet production, is a rare cause of thrombocytopenia in both children and adults. The decision to treat newly diagnosed patients is based on several factors, including the desire to increase platelet count to prevent bleeding, induce remission, and improve health-related quality of life (HRQoL). At present, standard first-line therapy is corticosteroids. While this treatment does increase the platelet count in many patients, a high percentage still relapse after discontinuation of therapy. For this reason, alteration or intensification of first-line therapy that results in superior long-term remission rates is desirable. The objective of this review is to outline different upfront strategies for newly diagnosed patients with ITP in an effort to potentially enhance remission rates and prevent relapse, taking into account an assessment of the risks and benefits of each approach. We primarily focus on adults with ITP, highlighting pediatric data and practice when applicable.

Real-world evidence on clinical outcomes in immune thrombocytopenia treated with thrombopoietin receptor agonists

Aim: Eltrombopag and romiplostim are US FDA approved for treatment of immune thrombocytopenia in patients with insufficient response to other treatments. Clinical or real-world data comparing outcomes of the two drugs are limited. Methods: This retrospective cross-sectional study sought information on bleeding-related episodes (BREs), adverse events (AEs) and other outcomes of eltrombopag or romiplostim treatment in immune thrombocytopenia. Results: Patients receiving eltrombopag experienced significantly reduced BREs, severe BREs, rescue medication use and platelet transfusions. Diarrhea and headache were significantly less frequent in patients receiving eltrombopag; other AEs occurred equally in both groups. Conclusion: There may be a potential advantage for the use of eltrombopag versus romiplostim in the practice settings studied, based on rates of BREs and AEs and rescue medication utilization.

Hypovitaminosis D Influences the Clinical Presentation of Immune Thrombocytopenia in Children with Newly Diagnosed Disease

Immune thrombocytopenia (ITP) is an acquired autoimmune disorder characterized by isolated thrombocytopenia defined as platelet count in peripheral blood <100 × 109/L. Hypovitaminosis D is very common in children with autoimmune diseases. To analyze whether hypovitaminosis D is associated with the clinical presentation of ITP in children, medical records of 45 pediatric patients with newly diagnosed immune thrombocytopenia in the coastal region of Croatia were evaluated. The severity of bleeding was assessed using two bleeding scores. Children with lower 25-hydroxyvitamin D (25(OH)D) values had higher values of the skin-mucosa-organ-gradation (SMOG) bleeding score and respectively more severe bleeding on diagnosis of ITP. With further analysis of the main domains of that score, we found that patients with a lower 25(OH)D value had more severe bleeding in the skin and organs. When 25(OH)D and ITP Bleeding Scale (IBLS) score were analyzed, a negative correlation was found, but it was not significant. Our findings suggest that hypovitaminosis D influences the severity of the clinical presentation of ITP in children on initial diagnosis of the disease. Therefore, therapy with 25(OH)D could be a new potential option for treatment of ITP. To investigate the connection between 25(OH)D and the incidence and severity of ITP, further studies, especially randomized controlled studies, are needed.

Proposal of treatment algorithm for immune thromocytopenia in adult patients of a hematology service at a referral center in Northeastern Brazil

Introduction

The management of adult (≥18 years) immune thrombocytopenia patients relies on platelet count, the risk of bleeding and presence of bleeding.

Objective

Confirming the diagnosis of immune thrombocytopenia and the start of therapy, our hematology service, a referral center, favors the establishment of this algorithm to treat those patients.

Results

Presentation, recently diagnosed or recurrence – group 1: life-threatening bleeding: high-dose intravenous immunoglobulins with methylprednisolone or dexamethasone. Hospitalization and platelet transfusion are considered. Group 2: Platelets <30 × 10⁹/L with bleeding or risk factor for bleeding, or platelets <20 × 10⁹/L: prednisone or dexamethasone. No response, platelets <20 × 10⁹/L: replace corticoid or increase doses. If platelets continue <20 × 10⁹/L: immunization and splenectomy. Investigation of Helicobacter pylori, if positive: treatment for H. pylori. Chronic immune thrombocytopenia with platelets <20 × 10⁹/L we propose two new groups (A and B): Group A: <65 years, no or low surgical risk, patient declines maintenance therapy or patient intends to get pregnant: immunization and splenectomy. Group B: failure of splenectomy (refractory) or no splenectomy indication or history of exposure to malaria or babesiosis and no response to corticoids or corticoid dependence: choose thrombopoietin receptor agonists: eltrombopag or romiplostim. Patient at high risk for arterial or venous thrombosis: recommend rituximab. After rituximab or thrombopoietin receptor agonists, if platelets continue <20 × 10⁹/L: indicate immunosuppressants (azathioprine or cyclophosphamide), dapsone or mycophenolate mofetil or vinca alkaloids. The goals of treatment for chronic or refractory immune thrombocytopenia are to keep platelets >20 × 10⁹/L and stop bleeding.

Management of immune thrombocytopenia in elderly patients

Despite the improvement in understanding its pathogenesis and the introduction of novel treatment options, the management of primary immune thrombocytopenia (ITP) still remains challenging. Considering its increased incidence with aging and prolonged life-expectancy, ITP is often diagnosed in elderly patients, a subset that deserves some special precautions. Ensure the diagnosis is a crucial step, and carefully attention must be given in excluding other causes of thrombocytopenia, especially among older people that frequently suffer from many comorbidities. When it comes to treatment decision, it is worth keeping into account that the elderly have an increased risk of bleeding, thrombosis and infections, that they often require many concomitant therapies, including antiplatelet or anticoagulant agents, and that treatment-related toxicities are often increased and sometimes more dangerous that the disease itself. There are not dedicated guidelines, and only few specific studies. Steroids with or without IVIG remain the first-line treatment. Splenectomy is less effective than in youngers and burdened by an increased thrombotic and infectious risk. Rituximab is a good option in non-immunocompromised patients, but long-term remissions are few. Eltrombopag and romiplostim have a good safety and efficacy profile, and have become a prominent drug in this subset, even if they are associated with a possible increased risk of thrombosis, and long-term toxicity is unknown. Other drugs, such as dapsone and danazol, have a well-known efficacy and safety profile, and still represent a valid option among elderly patients.

Current and evolving treatment strategies in adult immune thrombocytopenia

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.

Start a fire, kill the bug: The role of platelets in inflammation and infection

Platelets are the main players in thrombosis and hemostasis; however they also play important roles during inflammation and infection. Through their surface receptors, platelets can directly interact with pathogens and immune cells. Platelets form complexes with neutrophils to modulate their capacities to produce reactive oxygen species or form neutrophil extracellular traps. Furthermore, they release microbicidal factors and cytokines that kill pathogens and influence the immune response, respectively. Platelets also maintain the vascular integrity during inflammation by a mechanism that is different from classical platelet activation. In this review we summarize the current knowledge about how platelets interact with the innate immune system during inflammation and infection and highlight recent advances in the field.

Platelets and vascular integrity

Platelets patrol the vasculature and adhere at sites of vascular damage after trauma to limit blood loss. In recent years, however, it has become clear that platelets also contribute to pathophysiologic processes such as thrombosis, atherosclerosis, stroke, sepsis and many more. An exciting new role for them is in non-classical hemostasis to prevent bleeding in the inflamed vasculature. Recent studies suggest that GPVI, CLEC-2, integrin αIIbβ3 (GPIIb/IIIa), and the content of platelet α- and dense granules are important players in this process. This review summarizes the current knowledge about how platelets prevent vascular integrity during inflammation in the skin, lung, and the ischemic brain and their organ-specific role.

Management of immune thrombocytopenia: Korean experts recommendation in 2017

Management options for patients with immune thrombocytopenia (ITP) have evolved substantially over the past decades. The American Society of Hematology published a treatment guideline for clinicians referring to the management of ITP in 2011. This evidence-based practice guideline for ITP enables the appropriate treatment of a larger proportion of patients and the maintenance of normal platelet counts. Korean authority operates a unified mandatory national health insurance system. Even though we have a uniform standard guideline enforced by insurance reimbursement, there are several unsolved issues in real practice in ITP treatment. To optimize the management of Korean ITP patients, the Korean Society of Hematology Aplastic Anemia Working Party (KSHAAWP) reviewed the consensus and the Korean data on the clinical practices of ITP therapy. Here, we report a Korean expert recommendation guide for the management of ITP.

Management of newly diagnosed immune thrombocytopenia: can we change outcomes?

Immune thrombocytopenia resulting from antibody-mediated platelet destruction combined with impaired platelet production is a common cause of thrombocytopenia. The decision to treat newly diagnosed patients is based on several factors including ceasing hemorrhagic manifestations, increasing the platelet count, prevention of bleeding, and inducing remission. Current standard first-line therapy is a course of corticosteroids. Although this treatment paradigm increases the platelet count in the majority of patients, a high percentage relapse after discontinuation of corticosteroid therapy. For this reason, intensification of first-line therapy that results in superior long-term remission rates would be desirable. This manuscript focuses primarily on adults with idiopathic thrombocytopenic purpura (ITP), highlighting pediatric data and practice when applicable. The primary aim is to outline upfront strategies for treatment-naive patients with ITP to enhance remission rates, taking into account assessment of the risks and benefits of these approaches.

Management of newly diagnosed immune thrombocytopenia: can we change outcomes?

Immune thrombocytopenia resulting from antibody-mediated platelet destruction combined with impaired platelet production is a common cause of thrombocytopenia. The decision to treat newly diagnosed patients is based on several factors including ceasing hemorrhagic manifestations, increasing the platelet count, prevention of bleeding, and inducing remission. Current standard first-line therapy is a course of corticosteroids. Although this treatment paradigm increases the platelet count in the majority of patients, a high percentage relapse after discontinuation of corticosteroid therapy. For this reason, intensification of first-line therapy that results in superior long-term remission rates would be desirable. This manuscript focuses primarily on adults with idiopathic thrombocytopenic purpura (ITP), highlighting pediatric data and practice when applicable. The primary aim is to outline upfront strategies for treatment-naive patients with ITP to enhance remission rates, taking into account assessment of the risks and benefits of these approaches.

Bleeding complications in immune thrombocytopenia

Bleeding manifestations in patients with immune thrombocytopenia (ITP) range from mild skin bruises to life-threatening intracranial hemorrhage (ICH). Severe bleeding is distinctly uncommon when the platelet count is >30 × 109/L and usually only occurs when the platelet count falls <10 × 109/L. Based on estimates from clinical studies, ITP registries and administrative databases, the frequency of ICH in patients with ITP is ∼0.5% in children and 1.5% in adults. Estimates of severe (non-ICH) bleeding are difficult to obtain because of the lack of standardized case definitions; the lack of a universally accepted, ITP-specific bleeding assessment tool; and the omission of reporting bleeding outcomes in many clinical studies. In practice, the presence of bleeding should dictate whether or not treatment is needed because many patients, especially children, can be safely managed with observation alone. Guiding principles for the management of ITP, based on the bleeding risk are: (1) Decide when treatment is needed and when it can safely be withheld; (2) for patients with chronic ITP, use the least toxic treatment at the lowest dose; (3) emergency treatment of severe thrombocytopenia-associated bleeding requires combination therapy; and (4) early aggressive therapy may result in durable platelet count responses.

Long-term safety and tolerability of romiplostim in patients with primary immune thrombocytopenia: a pooled analysis of 13 clinical trials

BACKGROUND AND OBJECTIVES

Thrombopoietin receptor agonists (TPOra) are the only treatments for immune thrombocytopenia (ITP) for which evidence of efficacy and safety from randomized, placebo-controlled trials is available. We sought to determine the long-term tolerability of the TPOra romiplostim, with a particular focus on thrombosis, bleeding, bone marrow (BM) reticulin, neoplasms/haematological malignancies and fatal events.

METHODS

Data from 13 romiplostim clinical trials in which 653 patients with ITP received romiplostim for up to 5 yr (921.5 patient-years) were pooled; subject incidence rates and exposure-adjusted event rates (per 100 patient-years) were calculated.

RESULTS

The rate of thrombotic events (6% of patients, 7.5 events per 100 patient-years) did not appear to increase over time; 9 events were associated with platelet counts >400 × 10(9) /L and 10 with romiplostim doses exceeding current recommendations. Serious and grade ≥3 bleeding each occurred in approximately 8% of patients (~11 events per 100 patient-years). Adverse events of BM reticulin were recorded for 12 patients (1.8%, 1.3 events per 100 patient-years, confirmed by bone biopsy in ten patients) and BM collagen for one patient (0.2%, 0.1 event per 100 patient-years, confirmed by trichrome staining). Neoplasms and haematological malignancies occurred in 2.1% and 0.8% of patients, respectively (2.2 and 0.7 events per 100 patient-years). Fatal events occurred in 3.7% of patients (2.6 events per 100 patient-years, four events treatment-related).

CONCLUSIONS

Romiplostim is the TPOra for which the longest duration of safety data is available. Our data demonstrate that long-term romiplostim treatment is well tolerated, with no new safety signals, even in patients treated for up to 5 yr.