1
|
Wang ZJ, Chen HB, Zhou F, Yu H, Wu XY, Shen YQ, Qiu YN, Jin RM. A New Immunosuppressive Therapy for Very Severe Aplastic Anemia in Children with Autoantibodies. Curr Med Sci 2022; 42:379-386. [PMID: 35258748 DOI: 10.1007/s11596-022-2519-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 10/11/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE At present, a number of very severe aplastic anemia (VSAA) patients cannot receive hematopoietic stem cell transplantation (HSCT) or standard immunosuppressive therapy (IST) due to the high cost of therapy, shortage of sibling donors, and lack of resources to support the HSCT. In addition, some VSAA patients with autoantibodies have no life-threatening infections or bleeding at the time of initial diagnosis. Considering the disease condition, economics and other factors, the present study designed a new and relatively mild treatment strategy: cyclosporine A plus pulsed high-dose prednisone (CsA+HDP). METHODS The present study retrospectively analyzed 11 VSAA patients, who were treated with CsA+HDP in our hospital from August 2017 to August 2019. RESULTS The median follow-up time for these patients was 24.9 months. The overall response rate was 54.5% (6/11) at six months after the initiation of IST and 81.8% (9/11) at deadline. Five patients achieved complete remission and four patients met the criteria for partial response at the last follow-up. The median time to response for responders was 110 days. Three patients underwent HSCT due to the poor effect of CsA+HDP or to find a suitable transplant donor. Recurrence and clonal evolution were not found in any of these patients. The estimated 3-year overall survival rate and 3-year failure-free survival rate were 100.0% and 72.7%, respectively. In addition, the results revealed that the cyclosporine-prednisone-associated toxicity was mild and well-tolerated by most patients. CONCLUSION The novel CsA+HDP regimen has good therapeutic effect and safety for VSAA patients with autoantibodies, who have no serious life-threatening infections or bleeding at the time of initial diagnosis.
Collapse
Affiliation(s)
- Zhong-Jian Wang
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Hong-Bo Chen
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Fen Zhou
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Hui Yu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiao-Yan Wu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ya-Qing Shen
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yi-Ning Qiu
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Run-Ming Jin
- Department of Pediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| |
Collapse
|
2
|
Singh G, Bansal D, Wright NAM. Immune Thrombocytopenia in Children: Consensus and Controversies. Indian J Pediatr 2020; 87:150-157. [PMID: 31927692 DOI: 10.1007/s12098-019-03155-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/05/2019] [Indexed: 01/19/2023]
Abstract
Newly diagnosed immune thrombocytopenia (ITP) is a relatively common disorder of childhood that does not require an exhaustive laboratory workup for diagnosis. A history and physical exam with a review of the peripheral smear are crucial for excluding secondary causes of thrombocytopenia. Several guidelines have been published to guide physicians in the management of ITP. However, the decision for treatment can be arduous. The management strategy should not be focussed on the platelet count but the severity of bleeding symptoms. Agents for treating acute ITP, including corticosteroids, immunoglobulin and anti-D immunoglobulin, do not seem to have a significant impact on the natural history of the disease. The majority of children with ITP do not need therapy and have a spontaneous resolution of the disease. Some children can develop chronic ITP that is not commonly life-threatening but can lead to impaired quality of life. Traditional therapies such as rituximab and splenectomy for chronic ITP are not without significant adverse effects. Thrombopoietin receptor agonists are newer agents for the treatment of chronic ITP and hold promise, however, their cost currently precludes use in most of the patients in low-middle-income countries. This review compares and contrasts the specific treatments available for the treatment of ITP to help the reader make a balanced choice. This review, based on a series of case examples, will help physicians in making decisions about choosing a practical management strategy for patients with newly diagnosed as well as chronic ITP.
Collapse
Affiliation(s)
- Gurpreet Singh
- Division of Hematology/Immunology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 28 Oki Dr Nw, Calgary, T3B 6A8, Canada
| | - Deepak Bansal
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nicola A M Wright
- Division of Hematology/Immunology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 28 Oki Dr Nw, Calgary, T3B 6A8, Canada.
| |
Collapse
|
3
|
Shah SJ, Etzl MM. Eltrombopag in long-term management of pediatric thrombocytopenia. Clin Case Rep 2019; 7:196-201. [PMID: 30656041 PMCID: PMC6333124 DOI: 10.1002/ccr3.1916] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 09/19/2018] [Accepted: 09/28/2018] [Indexed: 01/19/2023] Open
Abstract
Eltrombopag is a thrombopoietin receptor agonist that may be effective in a broad range of thrombocytopenias of distinct etiology. We have observed rapid, robust, and sustained responses to eltrombopag in two young patients with refractory thrombocytopenia, one with primary immune thrombocytopenia and the other with Evans syndrome.
Collapse
|
4
|
O'Brien SH, Despotovic JM, Neunert CE. Intravenous Immunoglobulin Versus Anti-D Immunoglobulin: When Better Treatment May Not Be the Best Treatment. J Pediatr 2019; 204:11-13. [PMID: 30274924 DOI: 10.1016/j.jpeds.2018.08.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Sarah H O'Brien
- Center for Innovation in Pediatric Practice The Research Institute at Nationwide Children's Hospital; Division of Pediatric Hematology/Oncology Nationwide Children's Hospital/The Ohio State University Columbus, Ohio.
| | - Jenny M Despotovic
- Texas Children's Hematology Center Baylor College of Medicine Houston, Texas
| | - Cindy E Neunert
- Department of Pediatrics Columbia University Medical Center New York, New York
| |
Collapse
|
5
|
A Quality Improvement Bundle to Improve Informed Choice for Children With Typical, Newly Diagnosed Immune Thrombocytopenia. J Pediatr Hematol Oncol 2018; 40:e537-e543. [PMID: 30028824 DOI: 10.1097/mph.0000000000001247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IVIG has been the predominant therapy for the initial management of children with newly diagnosed immune thrombocytopenia at our hospital. With current guidelines supporting more conservative management, we undertook a quality improvement initiative to lead practice change. Over a 2-year time period (2013 to 2015), we strove to decrease use of hospital resources (use of IVIG, length of stay) while optimizing family satisfaction. An interdisciplinary working group was struck and a quality improvement bundle was implemented. The bundle comprised a patient information sheet; an evidence-informed, consensus-based protocol; and promotion of shared decision-making via stakeholder engagement and education. Data were collected prospectively; baseline data from a 2007 to 2009 audit were used for comparison. In total, 27 patients were included. Mean initial platelet count was 4×10/L. Bleeding was classified as none or mild in 56% of patients. IVIG use decreased from 88% to 55% of patients, corticosteroid prescription increased from 6% to 15%, and observation increased from 6% to 30% of patients. Hospital length of stay decreased from 47 to 36 hours. Family satisfaction was stable across treatment groups. Through introduction of a quality improvement initiative, we were able to improve family-centered care and decrease use of hospital resources.
Collapse
|
6
|
Graham R, Rose MJ. Breaking Down Blood: Pediatric Immune Thrombocytopenia and Autoimmune Hemolytic Anemia in the Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
7
|
Affiliation(s)
- Abdulgabar Salama
- Charité - Universitätsmedizin Berlin, Germany - Institute of Transfusion Medicine, Berlin, Germany
| |
Collapse
|
8
|
[Clinical study of pulsed high- dose dexamethasone treatment in 38 children with primary immune thrombocytopenic purpura]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:912-915. [PMID: 27801328 PMCID: PMC7364867 DOI: 10.3760/cma.j.issn.0253-2727.2016.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
目的 探讨大剂量地塞米松(HDD)静脉滴注,对原发免疫性血小板减少症(ITP)患儿的疗效及安全性。 方法 2013年9月至2014年9月38例一线治疗无效的ITP患儿接受HDD治疗。用药方案:地塞米松0.6 mg·kg−1·d−1×4 d(最大剂量40 mg/d),冲击治疗每疗程间隔28 d,共6个疗程。 结果 ①38例患儿中男26例,女12例,中位月龄为54(6~151)个月,中位病程为6(1~72)个月;新诊断ITP 9例,持续性ITP 13例,慢性ITP 16例;治疗前中位PLT为16.3(1.0~30.0)×109/L。②中位随访时间180(90~554)d, 17例(44.7%)获得治疗反应[完全反应(CR)7例(18.4%),有效(R)10例(26.3%)],中位起效时间为80.5(23~245)d; 17例获得CR/R患儿中3例失效复发,中位反应持续时间为63(37~67)d; 21例(55.3%)无效(NR),但其中18例(85.7%)患儿出血症状好转。③用药过程中仅1例患儿出现轻度可逆性不良反应。④CR/R组患儿外周血CD4+CD25+Foxp3+T细胞比例高于NR组[(7.54±1.50)%对(5.69±1.95)%,P=0.049]。单因素分析显示骨髓巨核细胞<300个患儿HDD疗效较好(P=0.049)。 结论 HDD冲击治疗是ITP患儿一种比较理想的二线治疗选择;骨髓巨核细胞计数<300个、CD4+CD25+Foxp3+T细胞比例高的患儿可能更适用于该疗法。
Collapse
|
9
|
Yacobovich J, Abu-Ahmed S, Steinberg-Shemer O, Goldberg T, Cohen M, Tamary H. Anti-D treatment for pediatric immune thrombocytopenia: Is the bad reputation justified? Semin Hematol 2016; 53 Suppl 1:S64-6. [DOI: 10.1053/j.seminhematol.2016.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
10
|
Ayçiçek A. Platelet Levels of High- and Mega-Dose Methylprednisolone Treatment in Acute Immune Thrombocytopenia. Turk J Haematol 2015; 32:186-7. [PMID: 26316491 PMCID: PMC4451491 DOI: 10.4274/tjh.2014.0436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Ali Ayçiçek
- Kanuni Sultan Süleyman Research and Education Hospital, Clinic of Pediatric Hematology/Oncology, İstanbul, Turkey E-mail:
| |
Collapse
|
11
|
Sruamsiri R, Dilokthornsakul P, Pratoomsoot C, Chaiyakunapruk N. A cost-effectiveness study of intravenous immunoglobulin in childhood idiopathic thrombocytopenia purpura patients with life-threatening bleeding. PHARMACOECONOMICS 2014; 32:801-813. [PMID: 24849397 DOI: 10.1007/s40273-014-0171-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Although the international guideline recommends intravenous immunoglobulin (IVIG) as the first-line treatment for childhood idiopathic thrombocytopenia purpura (ITP) with life-threatening bleeding, ITP patients may not be able to access IVIG because of the limitation in health benefit packages especially in developing countries. There remains an important policy question as to whether IVIG used as a first-line treatment is worth the money spent. Thus, the objective of this study was to perform a cost-effectiveness analysis of adding IVIG to the standard treatment of platelet transfusion and corticosteroids, for the treatment of childhood ITP with life-threatening bleeding in the context of Thailand. METHODS A cost-effectiveness analysis using a hybrid model consisting of a decision tree and Markov models was conducted with a societal perspective. The effectiveness and utility parameters were determined by systematic reviews, while costs and mortality parameters were determined using a retrospective electronic hospital database analysis. All costs were presented in 2012 US$. The discount rate of 3 % was applied for both costs and outcomes. One-way and probabilistic sensitivity analyses were also performed. RESULTS The incremental cost-effectiveness ratio (ICER) was $3,172 per quality-adjusted life-year gained ($/QALY) for the addition of IVIG versus standard treatment alone. The probability of response to corticosteroids was the most influential parameter on ICER. According to the willingness-to-pay of Thailand, of approximately $3,861/QALY, the probability of IVIG being cost effective was 33 %. CONCLUSIONS The addition of IVIG to standard treatment in the treatment of childhood ITP with life-threatening bleeding is possibly a cost-effective intervention in Thailand. However, our findings were highly sensitive. Policy makers may consider our findings as part of the information for their decision making.
Collapse
MESH Headings
- Child
- Cost-Benefit Analysis
- Decision Trees
- Drug Costs
- Health Care Costs
- Hemorrhage/economics
- Hemorrhage/etiology
- Hemorrhage/mortality
- Hemorrhage/prevention & control
- Hospitalization/economics
- Humans
- Immunoglobulins, Intravenous/economics
- Immunoglobulins, Intravenous/therapeutic use
- Markov Chains
- Models, Economic
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/economics
- Purpura, Thrombocytopenic, Idiopathic/mortality
- Quality-Adjusted Life Years
- Severity of Illness Index
- Thailand
Collapse
Affiliation(s)
- Rosarin Sruamsiri
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Center of Pharmaceutical Outcomes Research, Naresuan University, Phitsanulok, Thailand
| | | | | | | |
Collapse
|
12
|
Thompson JC, Klima J, Despotovic JM, O'Brien SH. Anti-D immunoglobulin therapy for pediatric ITP: before and after the FDA's black box warning. Pediatr Blood Cancer 2013; 60:E149-51. [PMID: 23813881 DOI: 10.1002/pbc.24633] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 05/15/2013] [Indexed: 01/19/2023]
Abstract
In March 2010, the Food and Drug Administration (FDA) issued a black box warning for anti-D immunoglobulin (anti-D), an approved treatment for immune thrombocytopenia (ITP). It is unknown if and how clinical practice at U.S children's hospitals has since changed. We sought to describe inpatient anti-D usage, laboratory monitoring, and anti-D complications before and after the FDA warning. Using the Pediatric Health Information System, we collected data from 41 children's hospitals. There was a modest but statistically significant decrease in anti-D usage from pre-warning to post-warning. Severe complication rates were very low and did not change appreciably.
Collapse
Affiliation(s)
- Joel C Thompson
- Pediatric Residency Program, Nationwide Children's Hospital, Columbus, Ohio
| | | | | | | |
Collapse
|
13
|
Kime C, Klima J, Rose MJ, O'Brien SH. Patterns of inpatient care for newly diagnosed immune thrombocytopenia in US children's hospitals. Pediatrics 2013; 131:880-5. [PMID: 23569091 DOI: 10.1542/peds.2012-2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Although recent evidence-based guidelines for the management of immune thrombocytopenia (ITP) recommend a conservative, observation-based approach for the majority of patients with newly diagnosed pediatric ITP, current practice patterns are unknown. This study used the Pediatric Health Information System database to examine patterns of inpatient care in newly diagnosed ITP in freestanding US children's hospitals and to examine geographic differences in care. METHODS Data were extracted from Pediatric Health Information System for all newly diagnosed ITP admissions aged 1 to 18 years discharged between January 2008 and December 2010. Clinical data obtained included age, gender, length of stay, diagnoses, medications, and discharge status. RESULTS We identified 2314 unique patients meeting the study diagnosis of newly diagnosed ITP. Noncutaneous bleeding occurred in 12% of patients (intracranial hemorrhage 0.6%), with epistaxis the most commonly reported symptom. Ninety percent of hospitalized patients received ITP-directed therapy, with intravenous immunoglobulin G the most commonly used therapy (78% of patients). We identified significant variation by geographic region in treatment strategies, length of stay, hospital charges, and likelihood of readmission. CONCLUSIONS A substantial number of children with newly diagnosed ITP continue to be hospitalized and receive intravenous medications, although the majority of these patients do not have clinical bleeding events during the admission. By using these results as a backdrop, future studies will be able to identify if the number of ITP admissions, costs of care, and geographic variability in care decrease with the dissemination and implementation of recently published guidelines.
Collapse
Affiliation(s)
- Courtney Kime
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | | | | | | |
Collapse
|
14
|
Iskedjian M, Tinmouth AT, Arnold DM, Deuson R, Isitt JJ, Mikhael J. Elicitation of utility scores in Canada for immune thrombocytopenia treated with romiplostim or watch and rescue. J Med Econ 2012; 15:313-31. [PMID: 22136485 DOI: 10.3111/13696998.2011.646045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The objective of this study was to obtain utilities, or preference-based quality-of-life values, from the Canadian general public, for potential health states experienced by immune thrombocytopenia (ITP) patients receiving either romiplostim (a new thrombopoietin mimetic agent) or 'watch and rescue' therapy. Utilities are needed to conduct a cost-utility analysis of romiplostim for formulary and reimbursement decisions. METHODS An electronic Time Trade-off (TTO) survey was developed and administered to a sample of the general public in Canada, with 12 distinct health states derived from two randomized clinical trials of romiplostim vs watch and rescue treatment. Two pilot tests assessed interpretability and respondent burden. In the final survey, each subject was administered the TTO for four randomly-selected health states. Descriptive statistics were computed for utility scores, and differences between health states were evaluated with an analysis of variance model. RESULTS Eight hundred and twenty-one adults completed the TTO survey. Mean age was 36.4 (SD = 15) years; 63% were female. Mean (SD) utility scores ranged from 0.476 (0.271) for the most severe health state (significant bleeding) to 0.633 (0.282) for the least severe health state depicting successful treatment with romiplostim. Statistical significance was found on the mean difference between the most severe health state and five other health states (p < 0.05). After adjusting utilities for matching Canadian demographic parameters, no substantial difference was found between original utility scores and adjusted scores. CONCLUSIONS This study provides evidence of the Canadian general public's preference for 12 ITP health states pertaining to romiplostim treatment or watch and rescue. This study had a number of limitations, the main ones being the lack of perfect match in demographics between this sample and the Canadian population, as well as the fact that the scenario descriptions were based on both published literature and expert opinion. Despite those limitations, the obtained utility scores may be used in cost-utility models of romiplostim as a treatment for ITP patients in Canada.
Collapse
Affiliation(s)
- M Iskedjian
- PharmIdeas Research and Consulting Inc, Oakville, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|
15
|
Lehmann HP, Dambita N, Buchanan GR, Casella JF. Decision Modeling of Disagreements. Med Decis Making 2011; 31:805-15. [DOI: 10.1177/0272989x11400417] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose. To identify core disagreements between pediatric hematologists who would treat children with idiopathic thrombocytopenic purpura (ITP) on initial presentation (“Treaters”) and those who would treat by observation (“Observers”), to determine whether each group’s preferred stance was consistent with each individual’s detailed perceptions, and to identify key variables in each stance. Methods. A decision model was constructed in collaboration with experts, and a detailed questionnaire was presented to a nationally representative committee of 25 pediatric hematologists. A full decision tree was specified for each respondent. Results. Nineteen (76%) experts responded; based on preference for initial treatment, 9 were Treaters and 10 Observers. Of the 30 probability/effectiveness variables, 8—almost all concerning treatment effectiveness—had at least one statistically-significant difference between the 2 groups regarding low, best, or high estimates. To convince Observers that treatment is effective would take a clinical trial with between 39 000 and 87 000 participants; to convince Treaters that treatment is not effective enough, between 97 000 and 114 000 participants. Observers’ calculated numbers needed to treat (NNTs) of about 150 000 are more consistent ( P = 0.0023) with their elicited maximum NTTs of about 500. Conclusion. Physicians not specifically trained provided enough data to specify complete individual decision models. From the estimates provided, no practical clinical trial could convince hematologists who would treat children on initial presentation with ITP just to simply observe them or could convince those who would just observe to instead treat with available agents. Perceived burdens could be better characterized, perhaps by including parental perceptions and preferences.
Collapse
Affiliation(s)
- Harold P. Lehmann
- Johns Hopkins University, Baltimore, Maryland (HPL, ND, JFC)
- University of Texas Southwestern Medical Center at Dallas (GRB)
| | - Nkossi Dambita
- Johns Hopkins University, Baltimore, Maryland (HPL, ND, JFC)
- University of Texas Southwestern Medical Center at Dallas (GRB)
| | - George R. Buchanan
- Johns Hopkins University, Baltimore, Maryland (HPL, ND, JFC)
- University of Texas Southwestern Medical Center at Dallas (GRB)
| | - James F. Casella
- Johns Hopkins University, Baltimore, Maryland (HPL, ND, JFC)
- University of Texas Southwestern Medical Center at Dallas (GRB)
| | | |
Collapse
|
16
|
Yadav D, Chandra J, Sharma S, Singh V. Short-course high-dose dexamethasone therapy for chronic idiopathic thrombocytopenic purpura in children. J Trop Pediatr 2010; 56:446-7. [PMID: 20388659 DOI: 10.1093/tropej/fmq022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
First-line therapies of acute and chronic idiopathic thrombocytopenic purpura (ITP) include intravenous immunoglobulin, IV anti-D and corticosteroids. A short-course high-dose dexamethasone (HDD-SC) therapy has recently been reported to be efficacious in acute ITP. The present study was conducted to assess the efficacy of HDD-SC in children with chronic ITP. Over a period of 10 months, 13 patients with chronic ITP were given HDD-SC (20 mg m(-2) IV daily for 4 days, four cycles repeated every 15 days). Of the 12 patients who could be evaluated, complete response was observed in 8 (66.6%) and moderate response in 2 (17%) patients, whereas 2 (17%) patients had no response. HDD-SC appears to be a safe and effective therapy in childhood ITP.
Collapse
Affiliation(s)
- Dinesh Yadav
- Division of Pediatric Hematology, Department of Pediatrics, Kalawati Saran Children's Hospital, New Delhi 110001, India.
| | | | | | | |
Collapse
|
17
|
Cooper JD, Smith KJ, Ritchey AK. A cost-effectiveness analysis of coagulation testing prior to tonsillectomy and adenoidectomy in children. Pediatr Blood Cancer 2010; 55:1153-9. [PMID: 20672369 DOI: 10.1002/pbc.22708] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The American Society of Pediatric Otolaryngology recommends pre-operative coagulation testing only when indicated by history or physical exam. Nevertheless, many surgeons test all children scheduled for tonsillectomy and/or adenoidectomy (T&A). Studies of pre-operative screening have had conflicting results. A decision analysis model was constructed to address the costs and health outcome states of pre-operative screening strategies in children. PROCEDURE A 14-day Markov model evaluated three strategies: (1) test all children for coagulation disorders; (2) test only those children with a pertinent history; and (3) perform no pre-operative testing. A literature search and a review of national databases estimated probabilities, costs, and utility data. Parameters then were varied widely in sensitivity analyses. Using a societal perspective and a cycle length of 1 day, we compared the strategies based on total costs and quality-adjusted life years (QALYs). RESULTS Total costs for the strategies were $3,200 for testing all children, $3,083 for testing only those with a history finding, and $3,077 for not testing. Total utilities were 0.02579, 0.02654, and 0.02659 QALYs, respectively. Cost-effectiveness ratios were most sensitive to variation in the cost of post-operative care and the probability of post-operative bleeding. The strategy of not testing was dominant in all sensitivity analyses. CONCLUSIONS Our results demonstrate that not performing preoperative testing is the most cost-effective strategy. This was persistent in sensitivity analyses, indicating that the model was robust. These data may be helpful to institutions and organizations to formulate policies regarding pre-operative coagulation for children without previous diagnoses of bleeding disorders.
Collapse
Affiliation(s)
- James D Cooper
- Division of Hematology/Oncology/BMT, Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15224, USA.
| | | | | |
Collapse
|
18
|
Neunert CE. Evaluating bleeding severity in immune thrombocytopenia (ITP). Ann Hematol 2010; 89 Suppl 1:47-50. [PMID: 20309688 DOI: 10.1007/s00277-010-0930-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 02/17/2010] [Indexed: 01/19/2023]
Abstract
Despite immune thrombocytopenia (ITP) being one of the most common conditions encountered by the pediatric hematologist, relatively few prospective investigations of ITP exist, and treatment approaches remain highly variable. The ideal prospective clinical trial would use a reduction in severe bleeding as an outcome; however, recent data shows that due to the rarity of severe bleeding events such a trial is not feasible due to the large number of children needed to be enrolled on such studies. Therefore, platelet count is often used a surrogate risk for bleeding severity and an increase in platelet count as the primary outcome in clinical trials. Reliance solely on the platelet count fails to account for relevant patient-related outcomes, among them bleeding severity. Bleeding assessment instruments published to date lack validity and reliability. Therefore, rigorous methods to design and analysis of patient-related outcome measurement tools need to be applied. Once designed appropriately, these measures can be applied to enhance research and help to guide treatment for those patients who truly need it.
Collapse
Affiliation(s)
- Cindy E Neunert
- Division of Hematology/Oncology, Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA,
| |
Collapse
|
19
|
Blanchette V, Bolton-Maggs P. Childhood Immune Thrombocytopenic Purpura: Diagnosis and Management. Hematol Oncol Clin North Am 2010; 24:249-73. [DOI: 10.1016/j.hoc.2009.11.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
20
|
Kane I, Ragucci D, Shatat IF, Bussel J, Kalpatthi R. Comparison of intravenous immune globulin and high dose anti-D immune globulin as initial therapy for childhood immune thrombocytopenic purpura. Br J Haematol 2010; 149:79-83. [PMID: 20096011 DOI: 10.1111/j.1365-2141.2009.08057.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This report documents our experience with intravenous immune globulin (IVIG) (1 g/kg, iv) and high-dose, anti-D immune globulin (anti-D) (75 microg/kg) as initial treatment for childhood immune thrombocytopenic purpura (ITP). The medical records of children diagnosed with ITP at a single institution between January 2003 and May 2008 were retrospectively reviewed. Participants received either IVIG or high-dose anti-D immune globulin as their initial treatment for ITP. For the 53 patients included for analysis, there was no statistical difference in efficacy between each group; however, patients who received anti-D experienced a higher rate of adverse drug reactions (ADRs), particularly chills and rigours, and 2 of 24 patients in the anti-D group developed severe anaemia requiring medical intervention. Patients who presented with mucosal bleeding had higher rates of treatment failure (32%) compared to those who presented with dry purpura (6%), regardless of treatment. Both IVIG and high-dose anti-D are effective first-line therapies for childhood ITP. However, we observed increased ADRs in the high-dose anti-D group in contrast to previously published reports. Further studies are needed to evaluate safety and premedications for high-dose anti-D and to determine the utility of using the presence of mucosal bleeding to predict treatment failure.
Collapse
Affiliation(s)
- Ian Kane
- Department of Pediatrics, MUSC Children's Hospital, Charleston, SC, USA
| | | | | | | | | |
Collapse
|
21
|
Neunert CE, Buchanan GR, Blanchette V, Barnard D, Young NL, Curtis C, Klaassen RJ. Relationships among bleeding severity, health-related quality of life, and platelet count in children with immune thrombocytopenic purpura. Pediatr Blood Cancer 2009; 53:652-4. [PMID: 19492316 DOI: 10.1002/pbc.21978] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Important outcomes for children with immune thrombocytopenic purpura (ITP) include health-related quality of life (HRQOL) and bleeding severity. A HRQOL instrument for children with ITP, the Kids' ITP Tools (KIT), was recently validated. Secondary analysis of the KIT database was performed to determine relationships among platelet count, bleeding severity and HRQOL. Bleeding severity grade correlated with platelet count in chronic ITP but not in acute ITP. Platelet count and bleeding severity failed to have any statistically significant correlations with the KIT scores. These findings suggest that relationships among outcome measures in children with ITP, using currently available instruments, remain poorly defined.
Collapse
Affiliation(s)
- Cindy E Neunert
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Controversy exists regarding management of children newly diagnosed with immune thrombocytopenic purpura (ITP). Drug treatment is usually administered to prevent severe hemorrhage, although the definition and frequency of severe bleeding are poorly characterized. Accordingly, the Intercontinental Childhood ITP Study Group (ICIS) conducted a prospective registry defining severe hemorrhage at diagnosis and during the following 28 days in children with ITP. Of 1106 ITP patients enrolled, 863 were eligible and evaluable for bleeding severity assessment at diagnosis and during the subsequent 4 weeks. Twenty-five children (2.9%) had severe bleeding at diagnosis. Among 505 patients with a platelet count less than or equal to 20 000/mm(3) and no or mild bleeding at diagnosis, 3 (0.6%), had new severe hemorrhagic events during the ensuing 28 days. Subsequent development of severe hemorrhage was unrelated to initial management (P = .82). These results show that severe bleeding is uncommon at diagnosis in children with ITP and rare during the next 4 weeks irrespective of treatment given. We conclude that it would be difficult to design an adequately powered therapeutic trial aimed at demonstrating prevention of severe bleeding during the first 4 weeks after diagnosis. This finding suggests that future studies of ITP management should emphasize other outcomes.
Collapse
|
23
|
Chen M, Zhang LL, Hu M, Gao J, Tong RS. Cost-effectiveness of Treatment for Acute Childhood Idiopathic Thrombocytopenic Purpura (ITP) – a Systematic Review. J Int Med Res 2008; 36:572-8. [PMID: 18534141 DOI: 10.1177/147323000803600324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The cost-effectiveness of treatment for acute paediatric idiopathic thrombocytopenic purpura (ITP) was assessed to provide evidence for health-care decision making and rational drug use. A systematic review of studies published between 1980 and 7 September 2007 on the clinical effects and economic profiles of treating ITP was undertaken. The quality of the studies was critically appraised and checklists were developed to assess methodological quality and transferability to the Chinese setting. Out of 174 studies, five (one Chinese; four USA) satisfied all the predefined criteria for inclusion and form the basis of this report. Methodological quality of most of the foreign studies was high, but transferability to other countries was low. Use of steroids provided additional life years and was cost-effective compared with intravenous immunoglobulin G and anti-D immunoglobulin. In comparison, the quality of the Chinese studies was low and long-term research rare. It was difficult to compare cost-effectiveness in different health-care settings and no life-time economic evaluations were available.
Collapse
Affiliation(s)
- M Chen
- Pharmaceutical Department, Women-children's Hospital of Sichuan University, Chengdu 610041, China
| | - L-L Zhang
- Pharmaceutical Department, Women-children's Hospital of Sichuan University, Chengdu 610041, China
| | - M Hu
- West China Pharmacy Faculty, Sichuan University, Chengdu 610041, China
| | - J Gao
- Blood Department, Women-children's Hospital of Sichuan University, Chengdu 610041, China
| | - R-S Tong
- Pharmaceutical Department, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu 610072, China
| |
Collapse
|
24
|
Blanchette V, Bolton-Maggs P. Childhood immune thrombocytopenic purpura: diagnosis and management. Pediatr Clin North Am 2008; 55:393-420, ix. [PMID: 18381093 DOI: 10.1016/j.pcl.2008.01.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by a low circulating platelet count caused by destruction of antibody-sensitized platelets in the reticuloendothelial system. ITP can be classified as childhood versus adult, acute versus chronic, and primary versus secondary. Persistence of thrombocytopenia defines the chronic form of the disorder. Secondary causes of ITP include collagen vascular disorders, immune deficiencies, and some chronic infections. This review focuses on the diagnosis and management of children who have acute and chronic ITP. Emphasis is placed on areas of controversy and new therapies.
Collapse
Affiliation(s)
- Victor Blanchette
- Division of Hematology/Oncology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | | |
Collapse
|
25
|
Abstract
Decision analysis is a simulation, model-based research technique in which investigators combine information from a variety of sources to create a mathematical model representing a clinical decision. This tool can be used to address many clinical dilemmas in pediatric hematology for which traditional clinical trials are unfeasible or impossible. This article outlines the basic steps of performing and analyzing a decision analysis tree and describes several decision analyses published in the field of pediatric hematology and how to evaluate and judge the decision analysis literature.
Collapse
Affiliation(s)
- Sarah H O'Brien
- Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| |
Collapse
|
26
|
|
27
|
Benesch M. How far should we go with cost-utility analysis when treating children with acute idiopathic thrombocytopenic purpura? Pediatr Blood Cancer 2008; 50:433. [PMID: 17458876 DOI: 10.1002/pbc.21231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|