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Lu W, Stephens L, Shmookler A, O'Brien K, Karp JK, Hermelin D, Bakhtary S, Almozain N, George M, Fung M. Rh immune globulin immunoprophylaxis after RhD-positive red cell exposure in RhD-negative patients via transfusion: A survey of practices. Transfusion 2024; 64:839-845. [PMID: 38534065 DOI: 10.1111/trf.17812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/07/2024] [Accepted: 03/14/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Current Association for the Advancement of Blood & Biotherapies (AABB) standards require transfusion services to have a policy on Rh immune globulin (RhIG) immunoprophylaxis for when RhD-negative patients are exposed to RhD-positive red cells. This is a survey of AABB-accredited transfusion services in the United States (US) regarding institutional policies and practices on RhIG immunoprophylaxis after RhD-negative patients receive RhD-positive (i.e., RhD-incompatible) packed red blood cell (pRBC) and platelet transfusions. RESULTS Approximately half of the respondents (50.4%, 116/230) have policies on RhIG administration after RhD-incompatible pRBC and platelet transfusions, while others had policies for only pRBC (13.5%, 31/230) or only platelet (17.8%, 41/230) transfusions, but not both. In contrast, 18.3% (42/230) report that their institution has no written policies on RhIG immunoprophylaxis after RhD-incompatible transfusions. Most institutions (70.2%, 99/141) do not have policies addressing safety parameters to mitigate the risk of hemolysis associated with the high dose of RhIG required to prevent RhD alloimmunization after RhD-incompatible pRBC transfusions. DISCUSSION With approximately half of US AABB-accredited institutions report having policies on RhIG immunoprophylaxis after both RhD-incompatible pRBC and platelet transfusions, some institutions may not be in compliance with AABB standards. Further, most with policies on RhIG immunoprophylaxis after RhD-incompatible pRBC transfusion do not have written safeguards to mitigate the risk of hemolysis associated with the high dose of RhIG required. CONCLUSION This survey underscores the diverse and inadequate institutional policies on RhIG immunoprophylaxis after RhD exposure in Rh-negative patients via transfusion. This observation identifies an opportunity to improve transfusion safety.
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Affiliation(s)
- Wen Lu
- Department of Laboratory Medicine and Pathology, Center for Regenerative Biotherapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Laura Stephens
- Department of Pathology, University of California San Diego, San Diego, California, USA
| | - Aaron Shmookler
- Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Kerry O'Brien
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Julie Katz Karp
- Department of Pathology and Genomic Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Daniela Hermelin
- ImpactLife, Davenport, Iowa, USA
- Department of Pathology, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Nour Almozain
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Melissa George
- Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Mark Fung
- Department of Pathology and Laboratory Medicine, University of Vermont, Burlington, Vermont, USA
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Bussel JB. Why should intramuscular anti-D be different from intravenous anti-D? Br J Haematol 2023; 200:275-276. [PMID: 36408739 DOI: 10.1111/bjh.18524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 10/08/2022] [Indexed: 11/22/2022]
Abstract
For reasons of safety the use of intravenous anti D to treat ITP has largely been abandoned because of the risk it incurs of intravascular haemolysis. Intramuscular delivery of anti-D could be a safer approach and deserves to be further evaluated. IV anti-D was a mainstay of ITP treatment in the United States in the 1990's until the development of intravascular hemolysis (IVH) and its serious even fatal consequences was appreciated. Subsequently, treatment of patients with ITP with IV anti-D has become very rare given other alternatives and the IVH risk. IM anti-D does not carry a risk for IVH and it should be re-evaluated and reconsidered as an option for D+ DAT-negative not splenectomized adults who do not have a long duration of ITP and require maintenance treatment. Commentary on: Lakhwani, et al. Intramuscular Anti-D treatment for immune thrombocytopenia: A single centre experience. Br J Haematol 2023;200:353-357.
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Affiliation(s)
- James B Bussel
- Pediatric Hematology-Oncology, Weill-Cornell Medical College, New York, New York, USA
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3
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Real-world experience of anti-D immunoglobulin in immune thrombocytopenia. Ann Hematol 2022; 101:1173-1179. [PMID: 35396605 DOI: 10.1007/s00277-022-04829-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 03/29/2022] [Indexed: 12/14/2022]
Abstract
In developing countries, anti-D has been used in immune thrombocytopenia (ITP) as a cheaper alternative to human immunoglobulin. We aim to analyze the response and safety profile of anti-D in patients with severe ITP. A retrospective study was conducted at a tertiary care hospital in Northern India. Patients received a single intravenous infusion of 75 μg/kg anti-D. In total, 36 patients (20 females) were included in this study. The median duration from ITP diagnosis to anti-D therapy was 235 days (range 1-1613 days). Four (11.1%) patients received anti-D as an upfront treatment. The patients' platelet counts rose significantly by the end of day three and continued to be significantly high until day 30 of receiving anti-D (p ≤ 0.001). The overall response rate (ORR) by day seven was 88.89%. There was no effect of age, sex, duration of disease, prior therapy, and platelet count on the ORR. Patients were followed up for a median duration of 52 days (longest follow-up: 3080 days). Six (6/36, 16.67%) patients continued to be in remission till the last follow-up. The hemoglobin fall was statistically significant on day three and day seven (p < 0.001 and p = 0.001) and got normalized by day 30. We observed equally good ORR in mixed populations and different phases of ITP along with long-term sustained response. The study demonstrates a quick and high response rate along with good safety profile to anti-D in all forms of ITP.
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An Update on Pediatric Immune Thrombocytopenia (ITP): Differentiating Primary ITP, IPD, and PID. Blood 2021; 140:542-555. [PMID: 34479363 DOI: 10.1182/blood.2020006480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/20/2021] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is the most common acquired thrombocytopenia in children and is caused by both immune-mediated decreased platelet production and increased platelet destruction. In the absence of a diagnostic test, ITP must be differentiated from other thrombocytopenic disorders, including inherited platelet disorders (IPD). In addition, a diagnosis of secondary ITP due to a primary immune deficiency (PID) with immune dysregulation may not be apparent at diagnosis but can alter management and should be considered in an expanding number of clinical scenarios. The diagnostic evaluation of children with thrombocytopenia will vary based on the clinical history and laboratory features. Access to genotyping has broadened the ability to specify the etiology of thrombocytopenia, while increasing access to immunophenotyping, functional immunologic and platelet assays, and biochemical markers has allowed for more in-depth evaluation of patients. With this greater availability of testing, diagnostic algorithms in patients with thrombocytopenia have become complex. In this article, we highlight the diagnostic evaluation of thrombocytopenia in children with a focus on ITP, including consideration of underlying genetic and immune disorders, and utilize hypothetical patient cases to describe disease manifestations and strategies for treatment of pediatric ITP.
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5
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Shimano KA, Grace RF, Despotovic JM, Neufeld EJ, Klaassen RJ, Bennett CM, Ma C, London WB, Neunert C. Phase 3 randomised trial of eltrombopag versus standard first-line pharmacological management for newly diagnosed immune thrombocytopaenia (ITP) in children: study protocol. BMJ Open 2021; 11:e044885. [PMID: 34452956 PMCID: PMC8404450 DOI: 10.1136/bmjopen-2020-044885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Immune thrombocytopaenia (ITP) is an acquired disorder of low platelets and risk of bleeding. Although many children can be observed until spontaneous remission, others require treatment due to bleeding or impact on health-related quality of life. Standard first-line therapies for those who need intervention include corticosteroids, intravenous immunoglobulin and anti-D globulin, though response to these agents may be only transient. Eltrombopag is an oral thrombopoietin receptor agonist approved for children with chronic ITP who have had an insufficient response to corticosteroids, intravenous immunoglobulin or splenectomy. This protocol paper describes an ongoing open-label, randomised trial comparing eltrombopag to standard first-line management in children with newly diagnosed ITP. METHODS AND ANALYSIS Randomised treatment assignment is 2:1 for eltrombopag versus standard first-line management and is stratified by age and by prior treatment. The primary endpoint of the study is platelet response, defined as ≥3 of 4 weeks with platelets >50×109/L during weeks 6-12 of therapy. Secondary outcomes include number of rescue therapies needed during the first 12 weeks, proportion of patients who do not need ongoing treatment at 12 weeks and 6 months, proportion of patients with a treatment response at 1 year, and number of second-line therapies used in weeks 13-52, as well as changes in regulatory T cells, iron studies, bleeding, health-related quality of life and fatigue. A planned sample size of up to 162 randomised paediatric patients will be enrolled over 2 years at 20 sites. ETHICS AND DISSEMINATION The study has been approved by the centralised Baylor University Institutional Review Board. The results are expected to be published in 2023. TRIAL REGISTRATION NUMBER NCT03939637.
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Affiliation(s)
- Kristin A Shimano
- UCSF Benioff Children's Hospital, San Francisco, California, USA
- Pediatrics, UCSF, San Francisco, California, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Jenny M Despotovic
- Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Ellis J Neufeld
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Carolyn M Bennett
- Pediatrics, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Clement Ma
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Wendy B London
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
- Biostatistics, Harvard Medical School, Boston, Massachusetts, USA
| | - Cindy Neunert
- Pediatrics, Columbia University Medical School, New York, New York, USA
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6
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Song F, Al-Samkari H. Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice. J Blood Med 2021; 12:653-664. [PMID: 34345191 PMCID: PMC8323851 DOI: 10.2147/jbm.s259101] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune process resulting in increased destruction and inadequate production of platelets that can result in bleeding, fatigue, and reduced health-related quality of life. While treatment is not required for many patients with ITP, the occurrence of bleeding manifestations, severe thrombocytopenia, and requirement for invasive procedures are among the reasons necessitating initiation of therapy. Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are typical first-line and rescue treatments, but these agents typically do not result in a durable remission in adult patients. Most patients requiring treatment therefore require subsequent line therapies, such as thrombopoietin receptor agonists (TPO-RAs), rituximab, fostamatinib, splenectomy, or a number of other immunosuppressive agents. In this focused review, we discuss management of adult ITP in the acute and chronic settings.
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Affiliation(s)
- Fei Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA.,Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
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7
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Immune thrombocytopenia: A review of upfront treatment strategies. Blood Rev 2021; 49:100822. [PMID: 33736875 DOI: 10.1016/j.blre.2021.100822] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/06/2021] [Accepted: 02/24/2021] [Indexed: 01/19/2023]
Abstract
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.
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8
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American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv 2020; 3:3829-3866. [PMID: 31794604 DOI: 10.1182/bloodadvances.2019000966] [Citation(s) in RCA: 591] [Impact Index Per Article: 147.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/21/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Despite an increase in the number of therapies available to treat patients with immune thrombocytopenia (ITP), there are minimal data from randomized trials to assist physicians with the management of patients. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the management of ITP. METHODS In 2015, ASH formed a multidisciplinary guideline panel that included 8 adult clinical experts, 5 pediatric clinical experts, 2 methodologists with expertise in ITP, and 2 patient representatives. The panel was balanced to minimize potential bias from conflicts of interest. The panel reviewed the ASH 2011 guideline recommendations and prioritized questions. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence (up to May 2017) and formulate recommendations. RESULTS The panel agreed on 21 recommendations covering management of ITP in adults and children with newly diagnosed, persistent, and chronic disease refractory to first-line therapy who have non-life-threatening bleeding. Management approaches included: observation, corticosteroids, IV immunoglobulin, anti-D immunoglobulin, rituximab, splenectomy, and thrombopoietin receptor agonists. CONCLUSIONS There was a lack of evidence to support strong recommendations for various management approaches. In general, strategies that avoided medication side effects were favored. A large focus was placed on shared decision-making, especially with regard to second-line therapy. Future research should apply standard corticosteroid-dosing regimens, report patient-reported outcomes, and include cost-analysis evaluations.
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9
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Crow AR, Kapur R, Koernig S, Campbell IK, Jen CC, Mott PJ, Marjoram D, Khan R, Kim M, Brasseit J, Cruz-Leal Y, Amash A, Kahlon S, Yougbare I, Ni H, Zuercher AW, Käsermann F, Semple JW, Lazarus AH. Treating murine inflammatory diseases with an anti-erythrocyte antibody. Sci Transl Med 2020; 11:11/506/eaau8217. [PMID: 31434758 DOI: 10.1126/scitranslmed.aau8217] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 02/08/2019] [Accepted: 07/11/2019] [Indexed: 12/13/2022]
Abstract
Treatment of autoimmune and inflammatory diseases typically involves immune suppression. In an opposite strategy, we show that administration of the highly inflammatory erythrocyte-specific antibody Ter119 into mice remodels the monocyte cellular landscape, leading to resolution of inflammatory disease. Ter119 with intact Fc function was unexpectedly therapeutic in the K/BxN serum transfer model of arthritis. Similarly, it rapidly reversed clinical disease progression in collagen antibody-induced arthritis (CAIA) and collagen-induced arthritis and completely corrected CAIA-induced increase in monocyte Fcγ receptor II/III expression. Ter119 dose-dependently induced plasma chemokines CCL2, CCL5, CXCL9, CXCL10, and CCL11 with corresponding alterations in monocyte percentages in the blood and liver within 24 hours. Ter119 attenuated chemokine production from the synovial fluid and prevented the accumulation of inflammatory cells and complement components in the synovium. Ter119 could also accelerate the resolution of hypothermia and pulmonary edema in an acute lung injury model. We conclude that this inflammatory anti-erythrocyte antibody simultaneously triggers a highly efficient anti-inflammatory effect with broad therapeutic potential.
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Affiliation(s)
- Andrew R Crow
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Rick Kapur
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada.,Department of Hematology and Transfusion Medicine, Lund University, Lund 221 84, Sweden.,Department of Experimental Immunohematology, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, 1066 CX Amsterdam, Netherlands
| | - Sandra Koernig
- CSL Limited, Bio21 Institute, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Ian K Campbell
- CSL Limited, Bio21 Institute, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Chao-Ching Jen
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Patrick J Mott
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Danielle Marjoram
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Ramsha Khan
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Michael Kim
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Jennifer Brasseit
- CSL Behring, Research, CSL Biologics Research Center, Bern, Switzerland
| | - Yoelys Cruz-Leal
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Alaa Amash
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Simrat Kahlon
- Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Issaka Yougbare
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada
| | - Heyu Ni
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada.,Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada.,Department of Physiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Adrian W Zuercher
- CSL Behring, Research, CSL Biologics Research Center, Bern, Switzerland
| | - Fabian Käsermann
- CSL Behring, Research, CSL Biologics Research Center, Bern, Switzerland
| | - John W Semple
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada.,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada.,Department of Hematology and Transfusion Medicine, Lund University, Lund 221 84, Sweden.,Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada.,Department of Pharmacology, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Alan H Lazarus
- Canadian Blood Services Centre for Innovation, Ottawa, Ontario K1G 4J5, Canada. .,Department of Laboratory Medicine and Keenan Research Centre for Biomedical Science of St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Toronto Platelet Immunobiology Group, Toronto, Ontario, M5B 1T8 Canada.,Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario M5B 1W8, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada
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11
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Acero-Garcés DO, García-Perdomo HA. First Line Treatments for Newly Diagnosed Primary Immune Thrombocytopenia in Children: A Systematic Review and Network Meta-analysis. Curr Pediatr Rev 2020; 16:61-70. [PMID: 31656149 DOI: 10.2174/1573396315666191023122542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 07/09/2019] [Accepted: 09/27/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND The first-line interventions in immune thrombocytopenia (ITP) include intravenous polyclonal immunoglobulins (IVIg), corticosteroids and anti-D immunoglobulin (anti-D). OBJECTIVE We aimed to compare the effectiveness and safety of first line treatments for newlydiagnosed primary ITP in children to increase the platelet count. METHODS We searched MEDLINE, EMBASE, LILACS and the Cochrane Central register of Controlled Trials (CENTRAL); and included the clinical trials. We performed the statistical analysis in R. RESULTS We included 12 studies for meta-analysis. Compared with IVIG 2g/kg, response rates were lower for prednisone 2mg/kg at 72 hours [RR 0.04 (95% CI 0.0 to 0.68)] and at 7 days [RR 0.23 (95% CI 0.08 to 0.67)]; at 48 hours, methylprednisolone 30mg/kg also showed lower response rates [RR 0.72 (95% CI 0.52 to 0.99)]. IVIG 2g/kg and 2.5g/kg had less adverse effects than Anti- D, methylprednisolone and IVIG 0.8g/kg. For rising platelet count, no statistical differences were found at 24 hours or in 7 days; at 48 hours, IVIG 2g/kg showed better results than Anti-D 75μg/kg [MD -58.84 (95% CI -87.02 to -25.66)]. After a month, platelet count with IVIG 2g/kg was higher than Anti-D 50 and 75μg/kg [-82.03 (95% CI -102.60 to -61.46) and -78.77 (95% CI -97.80 to - 59.74), respectively], but lower than methylprednisolone 50mg/kg [MD 118 (95% CI 3.88 to 232.12)]. CONCLUSION The total platelet count rises higher in early and late phases with IVIG than Anti-D, but in long term it is higher with methylprednisolone. Additionally, IVIG causes less adverse effects than Anti-D and corticosteroids.
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Affiliation(s)
- David O Acero-Garcés
- UROGIV Research Group, School of Medicine, Universidad del Valle, Cali, Colombia
| | - Herney A García-Perdomo
- UROGIV Research Group, School of Medicine, Universidad del Valle, Cali, Colombia.,School of Medicine, Universidad del Valle, Cali, Colombia
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12
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Hypovitaminosis D Influences the Clinical Presentation of Immune Thrombocytopenia in Children with Newly Diagnosed Disease. J Clin Med 2019; 8:jcm8111861. [PMID: 31684180 PMCID: PMC6912626 DOI: 10.3390/jcm8111861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 01/19/2023] Open
Abstract
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.
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Monteagudo E, Astigarraga I, Cervera Á, Dasí MA, Sastre A, Berrueco R, Dapena JL. Protocol for the study and treatment of primary immune thrombocytopenia: ITP-2018. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.anpede.2019.04.008] [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] Open
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14
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Güngör T, Arman Bilir Ö, Koşan Çulha V, Güngör A, Kara A, Azık FM, Yaralı HN. Retrospective evaluation of children with immune thrombocytopenic purpura and factors contributing to chronicity. Pediatr Neonatol 2019; 60:411-416. [PMID: 30470618 DOI: 10.1016/j.pedneo.2018.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 08/04/2018] [Accepted: 10/25/2018] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE Immune thrombocytopenic purpura (ITP) is the most common cause of acquired thrombocytopenia children. The aim of this retrospective study is to describe presenting features and clinical characteristics of ITP and evaluate clinical course, treatment modalities, and complications and determine the effects of preceding infection history, age, gender, treatment modality, and admission platelet count on chronicity. METHOD Two hundred and eleven patients who were diagnosed ITP and followed-up in Department of Pediatric Hematology, Ankara Children Hematology Oncology Education and Research Hospital between January 2008 and September 2012 were included. Age of the patients, gender, date of admission, date of diagnosis, complaint in the application, previous infection and laboratory tests were recorded. RESULTS Mean age of the patients on diagnosis was 5.4 ± 4.1 years. The female/male ratio was 1.03. The clinical courses were determined as acute or chronic in 72% and 28% of patients respectively. Mean age at diagnosis was significantly higher in chronic ITP (p < 0.01). Chronic course was significantly higher in female patients (p < 0.05). The most frequent complaint was bruises on the skin (68%). The most common physical examination findings were petechiae, purpura and ecchymosis (89%). Patients with a history of past infection (53.6%) and who had serologically positive infection (15.6%) frequently had acute course (p < 0.01). The most common serologically positive infection was Rubella. The mean platelet count was significantly higher in chronic ITP (p < 0.01). In the initial treatment of patients admitted in the acute phase, megadose methylprednisolone (MDMP) was used in 31% of patients, intravenous immune globulin (IVIG) in 55% of patients and anti-D in 2% of patients while 12% did not receive any treatment. There were no significant differences between the recurrence rate and treatment modality (p > 0.05). CONCLUSION In our study, in females and in patients without any history of past infection, platelet count >20 × 109/L and initial diagnosis age > 10 years were found to increase the probability of chronic disease, which is compatible with the literature.
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Affiliation(s)
- Tülin Güngör
- University of Health Sciences, Dr Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Pediatrics Ankara, Turkey.
| | - Özlem Arman Bilir
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Department of Hematology, Ankara, Turkey
| | - Vildan Koşan Çulha
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Department of Hematology, Ankara, Turkey
| | - Ali Güngör
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Pediatrics Ankara, Turkey
| | - Abdurrahman Kara
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Department of Hematology, Ankara, Turkey
| | - Fatih Mehmet Azık
- Sıtkı Koçman University Medical School, Department of Hematology, Muğla, Turkey
| | - Hüsniye Neşe Yaralı
- University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Department of Hematology, Ankara, Turkey
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Monteagudo E, Astigarraga I, Cervera Á, Dasí MA, Sastre A, Berrueco R, Dapena JL. Protocolo de estudio y tratamiento de la trombocitopenia inmune primaria: PTI-2018. An Pediatr (Barc) 2019; 91:127.e1-127.e10. [DOI: 10.1016/j.anpedi.2019.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 02/06/2023] Open
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Lioger B, Maillot F, Ternant D, Passot C, Paintaud G, Bejan-Angoulvant T. Efficacy and Safety of Anti-D Immunoglobulins versus Intravenous Immunoglobulins for Immune Thrombocytopenia in Children: Systematic Review and Meta-analysis of Randomized Controlled Trials. J Pediatr 2019; 204:225-233.e8. [PMID: 30314658 DOI: 10.1016/j.jpeds.2018.07.065] [Citation(s) in RCA: 9] [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: 02/09/2018] [Revised: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To compare the efficacy and safety of intravenous immunoglobulins (IVIG) and anti-D immunoglobulin (anti-D) in pediatric immune thrombocytopenia (ITP). STUDY DESIGN We conducted a systematic review and meta-analysis following PRISMA guidelines, including all randomized controlled trials that have assessed the efficacy and safety of anti-D and IVIG in children with ITP. We searched Medline, Embase, and Cochrane databases. Primary outcomes were the proportion of children achieving platelet count responses as defined in each study and bleeding response. Other safety outcomes included infusion reactions and hemolysis. RESULTS Eleven studies with 558 children were included. Anti-D was significantly inferior to IVIG at increasing platelet counts, both for thresholds of >20 × 109/L at 24-72 hours (response rate ratio for anti-D vs IVIG: 0.85, 95% CI 0.78-0.94) and >50 × 109/L at 24-72 hours (response rate ratio for anti-D vs IVIG: 0.75, 95% CI 0.61-0.92). Bleeding response was assessed in 4 studies, but some heterogeneity in reporting leads to unclear conclusion. General symptoms after anti-D infusion were less frequent than after IVIG (Peto OR 0.39, 95% CI 0.25-0.62). Hemolysis was more frequent after anti-D. The overall quality of the studies was low. CONCLUSIONS Compared with anti-D, IVIG led to a better response in terms of platelet count and may be preferred as a first-line treatment of ITP in children with acute hemorrhagic symptoms. However, the clinical significance of IVIG superiority on platelet count remains unclear.
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Affiliation(s)
- Bertrand Lioger
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Service de Médecine Interne, Tours, France.
| | - François Maillot
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; Université François-Rabelais de Tours, INSERM 1069, Tours, France
| | - David Ternant
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Laboratoire de Pharmacologie-Toxicologie, Tours, France
| | - Christophe Passot
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Laboratoire de Pharmacologie-Toxicologie, Tours, France
| | - Gilles Paintaud
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Laboratoire de Pharmacologie-Toxicologie, Tours, France
| | - Theodora Bejan-Angoulvant
- Université François-Rabelais de Tours, CNRS, GICC UMR 7292, Tours, France; CHRU de Tours, Service de Pharmacologie Clinique, Tours, France
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18
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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
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Jang JH, Kim JY, Mun YC, Bang SM, Lim YJ, Shin DY, Choi YB, Yhim HY, Lee JW, Kook H. Management of immune thrombocytopenia: Korean experts recommendation in 2017. Blood Res 2017; 52:254-263. [PMID: 29333401 PMCID: PMC5762735 DOI: 10.5045/br.2017.52.4.254] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/03/2017] [Accepted: 12/13/2017] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Yoon Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Yeung-Chul Mun
- Department of Internal Medicine, Ewha Womans' University School of Medicine, Seoul, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeon Jung Lim
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Korea
| | - Young Bae Choi
- Department of Pediatrics, Chung-Ang University Hospital, Seoul, Korea
| | - Ho-Young Yhim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hoon Kook
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Hwasun, Korea
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Qin W, Huang SL, Li TT. [Clinical effect of anti-D immunoglobulin in treatment of childhood immune thrombocytopenia: a Meta analysis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1070-1076. [PMID: 29046203 PMCID: PMC7389273 DOI: 10.7499/j.issn.1008-8830.2017.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 07/21/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the clinical effect and safety of anti-D immunoglobulin (anti-D) in the treatment of children with newly diagnosed acute immune thrombocytopenia (ITP) through a Meta analysis. METHODS PubMed, EMBASE, Cohrane Library, Ovid, CNKI, and Wanfang Data were searched for randomized controlled trials (RCTs) published up to April 2017. Review Manager 5.3 was used for the Meta analysis. RESULTS Seven RCTs were included. The Meta analysis showed that after 72 hours and 7 days of treatment, the intravenous immunoglobulin (IVIG) group had a significantly higher percentage of children who achieved platelet count >20×109/L than the anti-D group (P<0.05). There were no significant differences in platelet count after 24 hours, 72 hours, and 7 days of treatment between the anti-D (50 μg/kg) group and the IVIG group (P>0.05), and there were also no significant differences in platelet count after 24 hours and 7 days of treatment between the 50 μg/kg and 75 μg/kg anti-D groups (P>0.05). The anti-D group had a significantly greater reduction in the hemoglobin level than the IVIG group after treatment, but did not need transfusion. No children in the anti-D group or the IVIG group experienced serious adverse reactions. CONCLUSIONS Intravenous injection of anti-D may have a similar effect as IVIG in improving platelet count in children with acute ITP, but it may be slightly inferior to IVIG in the rate of platelet increase after treatment. The anti-D dose of 50 μg/kg may have a similar effect as 75 μg/kg. The recommended dose of anti-D for treatment of ITP is safe.
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Affiliation(s)
- Wei Qin
- Department of Pediatrics, First People's Hospital of Nanning, Nanning 530022, China.
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21
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Affiliation(s)
- Abdulgabar Salama
- Charité - Universitätsmedizin Berlin, Germany - Institute of Transfusion Medicine, Berlin, Germany
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22
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Consolini R, Costagliola G, Spatafora D. The Centenary of Immune Thrombocytopenia-Part 2: Revising Diagnostic and Therapeutic Approach. Front Pediatr 2017; 5:179. [PMID: 28871277 PMCID: PMC5566994 DOI: 10.3389/fped.2017.00179] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/07/2017] [Indexed: 01/19/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is the most common cause of thrombocytopenia in children and adolescents and can be considered as a paradigmatic model of autoimmune disease. This second part of our review describes the clinical presentation of ITP, the diagnostic approach and overviews the current therapeutic strategies. Interestingly, it suggests an algorithm useful for differential diagnosis, a crucial process to exclude secondary forms of immune thrombocytopenia (IT) and non-immune thrombocytopenia (non-IT), which require a different therapeutic management. Advances in understanding the pathogenesis led to new therapeutic targets, as thrombopoietin receptor agonists, whose role in treatment of ITP will be discussed in this work.
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Affiliation(s)
- Rita Consolini
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Giorgio Costagliola
- Laboratory of Immunology, Department of Clinical and Experimental Medicine, Division of Pediatrics, University of Pisa, Pisa, Italy
| | - Davide Spatafora
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Mayer B, Depré F, Ringel F, Salama A. New aspects on the efficacy of high-dose intravenous immunoglobulins in patients with autoimmune thrombocytopenia. Vox Sang 2016; 112:64-69. [DOI: 10.1111/vox.12467] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/06/2016] [Accepted: 09/15/2016] [Indexed: 12/18/2022]
Affiliation(s)
- B. Mayer
- Institute of Transfusion Medicine; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - F. Depré
- Institute of Transfusion Medicine; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - F. Ringel
- Institute of Transfusion Medicine; Charité - Universitätsmedizin Berlin; Berlin Germany
| | - A. Salama
- Institute of Transfusion Medicine; Charité - Universitätsmedizin Berlin; Berlin Germany
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Swain TR, Jena RK, Swain KP. High dose Intravenous Anti-D Immune Globulin is More Effective and Safe in Indian Paediatric Patients of Immune Thrombocytopenic Purpura. J Clin Diagn Res 2016; 10:FC12-FC15. [PMID: 28208873 DOI: 10.7860/jcdr/2016/20347.8976] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 08/16/2016] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Immune Thrombocytopenia (ITP) is characterised by an autoimmune antibody-mediated destruction of platelets and impaired platelet production. Few controlled trials exist to guide management of patients with ITP in Indian scenario for which patients require an individualized approach. Anti-D (Rho (D) immune globulin) at a higher dose can prove to be a cost effective and safe alternative for Indian patients with ITP. AIM To compare the safety and efficacy of higher dose (75μg/kg) intravenous Anti-D immune globulin against the standard dose of 50μg/kg for the management of ITP in Indian patients. MATERIALS AND METHODS One hundred and sixty four children with newly diagnosed ITP between 4-14 years were randomly selected for inclusion and were treated with 50μg/kg (standard dose) or 75μg /kg (higher dose) of Anti-D to compare the efficacy and safety of higher dose intravenous anti-D immune globulin. Efficacy of Anti-D was measured in terms of rate of response and median time to response for increase in platelet counts. Any adverse event was noted. A decrease in haemoglobin concentration suggested accompanying haemolysis. RESULTS Seventy one out of 84 patients treated with Anti-D at 75μg/kg produced complete response (85%) with median time of response being 2.5 days. On the contrary, 45 patients (70%) patients treated with 50μg/kg had complete response. However, there was no significant increase in haemolysis with higher dose. A significant correlation was found between dose and peak increase in platelet count measured at 7th day following administration. However, there was no relationship between the decrease in haemoglobin and the dose given, or between the increase in platelet count and fall in haemoglobin. CONCLUSION A 75μg/kg dose of Anti-D is more effective with acceptable side effect in comparison to 50μg dose for treatment of newly diagnosed Indian patients of ITP.
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Affiliation(s)
- Trupti Rekha Swain
- Associate Professor and In charge, Clinical Pharmacology Unit, Department of Pharmacology, SCB Medical College and Hospital , Cuttack, Odisha, India
| | - Rabindra Kumar Jena
- Head, Department of Clinical Haematology, SCB Medical College , Cuttack, Odisha, India
| | - Kali Prasanna Swain
- Assistant Professor, Department of Neurology, SCB Medical College , Cuttack, Odisha, India
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Eghbali A, Azadmanesh P, Bagheri B, Taherahmadi H, Sadeghi Sedeh B. Comparison between IV immune globulin (IVIG) and anti-D globulin for treatment of immune thrombocytopenia: a randomized open-label study. Fundam Clin Pharmacol 2016; 30:385-9. [DOI: 10.1111/fcp.12198] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/09/2016] [Accepted: 03/15/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Aziz Eghbali
- Department of Pediatrics; Arak University of Medical Sciences; Arak Iran
| | - Peyman Azadmanesh
- Department of Pediatrics; Arak University of Medical Sciences; Arak Iran
| | - Bahador Bagheri
- Department of Pharmacology; Semnan University of Medical Sciences; Semnan Iran
| | - Hasan Taherahmadi
- Department of Pediatrics; Arak University of Medical Sciences; Arak Iran
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26
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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]
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27
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Zhou Z, Qiao Z, Li H, Luo N, Zhang X, Xue F, Yang R. Different dosages of intravenous immunoglobulin (IVIg) in treating immune thrombocytopenia with long-term follow-up of three years: Results of a prospective study including 167 cases. Autoimmunity 2015; 49:50-7. [PMID: 26525513 DOI: 10.3109/08916934.2015.1104671] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study compared the effects of different dosages of intravenous immunoglobulin (IVIg) against immune thrombocytopenia (ITP). A total of 167 patients, 91 adults and 76 children, with ITP, followed-up for three years in the case-control study, were divided into three subgroups according to the dosages of IVIg administered: group A (0.2 g/kg/day), group B (0.3 g/kg/day) and group C (0.4 g/kg/day). The therapeutic response in 91 adult patients did not differ significantly among the three groups of IVIg dosages (p = 0.459). The response rate of IVIg treatment in the three adult groups was 97.1% for group A, 97.2% for group B and 100% for group C. The mean time for raising platelets to 30 × 10(9)/L in group A was 2.5 days, group B 3.2 days and group C 2.9 days (p = 0.324). The median IVIg consumption in group A was 0.83 g/kg, group B 1.22 g/kg and group C 1.64 g/kg (p < 0.01). Similar results were shown in the children groups. The follow-up results showed no significant difference of clinical outcome between groups A, B and C. In conclusion, low-dose IVIg treatment is shown to be as effective as high-dose regimen without increasing the risk of developing the patients into chronic ITP conditions, suggesting that ITP patients could be treated more cost-effectively by lower conventional dosage of IVIg regimen.
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Affiliation(s)
- Zeping Zhou
- a Department of Hematology , Second Affiliated Hospital of Kunming Medical University , Kunming , China .,b Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Tianjin , China
| | - Zhuoqing Qiao
- b Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Tianjin , China .,c Department of Hematopoietic Stem Cell Transplantation , Affiliated Hospital of Academy of Military Medical Sciences , Beijing , China , and
| | - Huiyuan Li
- b Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Tianjin , China
| | - Na Luo
- d Center for Applied English Studies, The University of Hong Kong , Hong Kong
| | - Xian Zhang
- b Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Tianjin , China
| | - Feng Xue
- b Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Tianjin , China
| | - Renchi Yang
- b Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Tianjin , China
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Stotler BA, Schwartz J. How we use WinRho in patients with idiopathic thrombocytopenic purpura. Transfusion 2015; 55:2547-50. [PMID: 26094894 DOI: 10.1111/trf.13185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/30/2015] [Accepted: 04/30/2015] [Indexed: 01/26/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disease that affects children and adults. WinRho SDF is a D immune globulin product that is Food and Drug Administration approved for the treatment of ITP in D+ pediatric and adult patients. WinRho is a plasma-derived biologic product dispensed from blood banks. Transfusion medicine physicians serve as a resource to health care providers regarding blood component and derivative usage and, as such, should be familiar with the use of WinRho for ITP, including the dosage, administration, and contraindications. This report details the transfusion medicine consultation practice and guidelines at a tertiary care academic medical center for the usage of WinRho SDF in patients with ITP.
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Affiliation(s)
- Brie A Stotler
- Transfusion Medicine and Cellular Therapy, Department of Pathology and Cell Biology, New York Presbyterian Hospital, New York, New York
| | - Joseph Schwartz
- Transfusion Medicine and Cellular Therapy, Department of Pathology and Cell Biology, New York Presbyterian Hospital, New York, New York
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29
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Diagnosis and classification of immune-mediated thrombocytopenia. Autoimmun Rev 2014; 13:577-83. [DOI: 10.1016/j.autrev.2014.01.026] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2013] [Indexed: 01/19/2023]
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Labarque V, Van Geet C. Clinical practice: immune thrombocytopenia in paediatrics. Eur J Pediatr 2014; 173:163-72. [PMID: 24390128 DOI: 10.1007/s00431-013-2254-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 12/17/2013] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a disease affecting both children and adults. It is defined as acquired isolated thrombocytopenia caused by the autoimmune production of anti-platelet antibodies. Childhood ITP most frequently occurs in young children who have been previously well, although a viral respiratory tract infection often precedes thrombocytopenia. A benign and self-limiting course is common, but major bleeding complications such as intracranial haemorrhage may occur. Yet one cannot predict which child will have a prolonged course of thrombocytopenia and who will develop an intracranial haemorrhage. In children without atypical characteristics, only minimal diagnostic investigations are needed, and most paediatric ITP patients do not need platelet-enhancing therapy even though various treatment options are available. A "watch and wait" strategy should be considered in paediatric patients with mild disease. Steroids, intravenous immunoglobulin G or anti-D immunoglobulin are the current first-line therapeutic measures for children at risk for severe bleeding. When life-threatening bleeding occurs, a combination of therapies is needed. In this review, we summarise the current knowledge on primary ITP in children and adolescents.
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Affiliation(s)
- Veerle Labarque
- Department of Paediatric Haemato-Oncology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium,
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31
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Loggetto SR, Braga JAP, Veríssimo MPDA, Bernardo WM, Medeiros L, Hoepers ATDC. Guidelines on the treatment of primary immune thrombocytopenia in children and adolescents: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Guidelines Project: Associação Médica Brasileira - 2012. Rev Bras Hematol Hemoter 2014; 35:417-27. [PMID: 24478609 PMCID: PMC3905825 DOI: 10.5581/1516-8484.20130124] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 10/16/2013] [Indexed: 01/19/2023] Open
Affiliation(s)
| | | | | | - Wanderley Marques Bernardo
- Faculdade de Medicina da Universidade de São Paulo - USP, São Paulo, Brazil ; Associação Médica Brasileira - AMB, São Paulo, Brazil
| | | | - Andrea Thives de Carvalho Hoepers
- Centro de Hematologia e Hemoterapia de Santa Catarina - HEMOSC, Florianópolis, SC, Brazil ; Universidade Federal de Santa Catarina - UFSC, Florianópolis, SC, Brazil
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Deel MD, Kong M, Cross KP, Bertolone SJ. Absolute lymphocyte counts as prognostic indicators for immune thrombocytopenia outcomes in children. Pediatr Blood Cancer 2013; 60:1967-74. [PMID: 24038723 DOI: 10.1002/pbc.24628] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 05/15/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Recent studies reviewing immune mechanisms of immune thrombocytopenia (ITP) have suggested acute and chronic forms may represent distinct immunopathological disorders. This study evaluated absolute lymphocyte counts (ALCs) as predictors for ITP outcomes. PROCEDURE CBCs with differential counts were ascertained at presentation, 3, 6, and 12 months for 204 patients. Receiver operating characteristic (ROC) curves were used to determine cutoff values. Logistic regression models and recursive partitioning were used to evaluate which variables were significantly associated with outcomes. RESULTS ALC values at presentation were not independently predictive of disease duration. However, ALC values at 3 months were significant predictors. Sixty-eight percent (40/59) of patients >8 years of age and 43% (20/46) of patients ≤ 8 years who had an ALC ≤ 3,000/μl at 3 months developed chronic ITP. This compares to chronic rates of only 25% (3/12) and 2% (2/87) of patients >8 and ≤ 8 years, respectively, with an ALC > 3,000/μl at 3 months. Further, 92% (60/65) of patients who developed chronic ITP had a 3-month ALC ≤ 3,000/μl. An ALC > 3,000/μl at 3 months is a strong predictor for platelet recovery as only 5% (5/99) of these patients developed chronic ITP. CONCLUSION This study suggests progression to lower lymphocyte counts over the first few months of disease is a strong predictor for chronic ITP, allowing for risk stratification of patients, particularly when used in conjunction with other known predictors. Further research is needed to confirm these findings and to fully investigate the pathophysiological mechanisms responsible for this association.
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Affiliation(s)
- Michael D Deel
- Department of Pediatrics, School of Medicine, University of Louisville, Louisville, Kentucky; Norton's Kosair Children's Hospital, Louisville, Kentucky
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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.
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Affiliation(s)
- Joel C Thompson
- Pediatric Residency Program, Nationwide Children's Hospital, Columbus, Ohio
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Despotovic JM, McGann PT, Smeltzer M, Aygun B, Ware RE. RHD zygosity predicts degree of platelet response to anti-D immune globulin treatment in children with immune thrombocytopenia. Pediatr Blood Cancer 2013; 60:E106-8. [PMID: 23712954 DOI: 10.1002/pbc.24574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 03/31/2013] [Indexed: 11/11/2022]
Abstract
Anti-D immunoglobulin is a common front-line treatment for childhood immune thrombocytopenia (ITP) that typically results in a rapid and significant increase in platelet count. Unpredictable treatment responses and interpatient variability limit more widespread use. We hypothesized that anti-D response variability is influenced by RHD gene zygosity and erythrocyte D antigen expression. We compared RHD zygosity and quantitative D antigen expression to anti-D treatment results. Hemizygous RHD subjects demonstrated significantly higher platelet increases and peak platelet counts than homozygous RHD subjects. Future studies should investigate the mechanisms by which RHD zygosity and D antigen expression affect platelet responses to anti-D immunoglobulin.
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Acute renal failure in a child with thrombocytopenic purpura caused by acute Epstein-Barr virus infection after treatment with anti-D immunoglobulin. Pediatr Emerg Care 2013; 29:748-50. [PMID: 23736070 DOI: 10.1097/pec.0b013e318294f3a5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) in children is usually a benign, self-limiting disorder. An acute Epstein-Barr virus (EBV) infection usually causes atypical lymphocytosis and mild decrease in platelets. Severe thrombocytopenia is an extremely rare complication. Anti-D immunoglobulin has been used for treatment of ITP in Rh(D)-positive nonsplenectomized patients. Severe hemolysis and acute renal failure are extremely rare complications that may be aggravated by the presence of an acute EBV infection. It is believed that anti-D immunoglobulin triggers an unusual virus-induced immune response causing hemolysis. We present a 4-year-old girl with ITP caused by an acute EBV infection that developed acute kidney injury following treatment with anti-D immunoglobulin. The patient recovered completely from thrombocytopenia and renal dysfunction. Intravascular hemolysis and acute kidney injury are consistent with anti-D immunoglobulin mechanism of action. Pediatric patients treated with anti-D immunoglobulin for ITP should be closely monitored for signs and symptoms of hemolysis that may be aggravated by the presence of EBV infection leading to impaired renal function.
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Despotovic JM, Neunert CE. Is anti-D immunoglobulin still a frontline treatment option for immune thrombocytopenia? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:283-285. [PMID: 24319192 DOI: 10.1182/asheducation-2013.1.283] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A 5-year-old boy presents with platelet count of 2×10(9)/L and clinical and laboratory evidence of immune thrombocytopenia. He has epistaxis and oral mucosal bleeding. Complete blood count reveals isolated thrombocytopenia without any decline in hemoglobin and he is Rh+. You are asked if anti-D immunoglobulin is an appropriate initial therapy for this child given the 2010 Food and Drug Administration "black-box" warning.
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37
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Psaila B, Bussel JB. Immune Thrombocytopenia (ITP). Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00040-7] [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]
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38
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Arnold DM. Positioning new treatments in the management of immune thrombocytopenia. Pediatr Blood Cancer 2013; 60 Suppl 1:S19-22. [PMID: 23109488 PMCID: PMC4854632 DOI: 10.1002/pbc.24341] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 08/30/2012] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a syndrome characterized by low platelet counts and an increased risk of bleeding. For most children, ITP is a self-limiting disease; however, for some children and most adults, thrombocytopenia can become chronic. Newer therapies for ITP include rituximab and thrombopoietin (TPO) receptor agonists. Rituximab is a useful second-line therapy and may be splenectomy-sparing. Thrombopoeitin receptor agonists have demonstrated large treatment effects with respect to increasing platelet levels; however, they require maintenance dosing. This review summarizes how these new agents might be positioned in the management of patients with chronic ITP.
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Affiliation(s)
- Donald M. Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada,Canadian Blood Services, Hamilton, Ontario, Canada,Correspondence to: Donald M. Arnold, MDCM, MSc, Department of Medicine, McMaster University, 1280 Main Street West HSC 3V50, Hamilton, Ontario, Canada L8N 4K1.
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Rozrolimupab, a mixture of 25 recombinant human monoclonal RhD antibodies, in the treatment of primary immune thrombocytopenia. Blood 2012; 120:3670-6. [PMID: 22915649 DOI: 10.1182/blood-2012-06-438804] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rozrolimupab, a recombinant mixture of 25 fully human RhD-specific monoclonal antibodies, represents a new class of recombinant human antibody mixtures. In a phase 1 or 2 dose escalation study, RhD(+) patients (61 subjects) with primary immune thrombocytopenia received a single intravenous dose of rozrolimupab ranging from 75 to 300 μg/kg. The primary outcome was the occurrence of adverse events. The principal secondary outcome was the effect on platelet levels 7 days after the treatment. The most common adverse events were headache and pyrexia, mostly mild, and reported in 20% and 13% of the patients, respectively, without dose relationship. Rozrolimupab caused an expected transient reduction of hemoglobin concentration in the majority of the patients. At the dose of 300 μg/kg platelet responses, defined as platelet count ≥ 30 × 10(9)/L and an increase in platelet count by > 20 × 10(9)/L from baseline were observed after 72 hours and persisted for at least 7 days in 8 of 13 patients (62%). Platelet responses were observed within 24 hours in 23% of patients and lasted for a median of 14 days. Rozrolimupab was well tolerated and elicited rapid platelet responses in patients with immune thrombocytopenia and may be a useful alternative to plasma-derived products. This trial is registered at www.clinicaltrials.gov as #NCT00718692.
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40
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Kühne T, Imbach P. Management of children and adolescents with primary immune thrombocytopenia: controversies and solutions. Vox Sang 2012; 104:55-66. [PMID: 22804721 DOI: 10.1111/j.1423-0410.2012.01636.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The management including diagnostic procedures, prophylaxis, treatment and follow-up of patients with primary immune thrombocytopenia (ITP) in childhood is controversial due to limited clinical data, difficulties in the estimation of individual bleeding risk and heterogeneity of pathophysiology potentially causing various treatment responses. Advances in the management of children include increased international collaborations, improved quality of diagnosis and treatment, increased clinical data, refinement of consensus statements where clinical evidence is absent, new drugs and last but not least establishment of watch-and-wait strategies. The Intercontinental Cooperative ITP Study Group promotes international collaboration since more than 10 years based on a worldwide network and experience in registries. Future considerations include concentration of available resources, strengthening international collaboration, focusing on most important scientific and clinical questions, such as identification of the subgroup of patients that benefits most from prophylactic platelet-enhancing treatments and investigation of treatment endpoints other than concepts solely based on the platelet count, including bleeding symptoms, health-related quality of life and economical aspects of treatments.
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Affiliation(s)
- T Kühne
- Division of Oncology/Hematology, University Children's Hospital, Basel, Switzerland.
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41
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McGann PT, Despotovic JM, Howard TA, Ware RE. A novel laboratory technique demonstrating the influences of RHD zygosity and the RhCcEe phenotype on erythrocyte D antigen expression. Am J Hematol 2012; 87:266-71. [PMID: 22121029 DOI: 10.1002/ajh.22254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 09/21/2011] [Accepted: 11/08/2011] [Indexed: 11/11/2022]
Abstract
D antigen is the most immunogenic and clinically relevant antigen within the complex Rh blood group system. Variability of D antigen expression was first described decades ago but has rarely been investigated quantitatively, particularly in the context of RHD zygosity along with RhCcEe serological phenotype. With IRB approval, 107 deidentified blood samples were analyzed. Rh phenotypes were determined serologically by saline technique using monoclonal antibodies against D, C, c, E, and e antigens. RHD zygosity was determined using both PCR-restriction fragment length polymorphisms and quantitative real-time PCR techniques. A novel and robust method was developed for quantitation of erythrocyte D antigen sites using calibrated microspheres and flow cytometry, allowing correlation of D antigen density with RHD zygosity and expression of Rh CcEe antigens. Subjects homozygous for RHD expressed nearly twice the number of D antigen sites compared with RHD hemizygotes (33,560 ± 8,222 for DD versus 17,720 ± 4,471 for Dd, P < 0.0001). Expression of c or E antigens was associated with significantly increased erythrocyte D antigen expression, whereas presence of C or e antigens reduced expression. These data and this novel quantitation method will be important for future studies investigating the clinical relevance of D antigen variability.
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Affiliation(s)
- Patrick T McGann
- Baylor International Hematology Center of Excellence and the Texas Children's Center for Global Health, Houston, Texas, USA.
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42
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Despotovic JM, Lambert MP, Herman JH, Gernsheimer TB, McCrae KR, Tarantino MD, Bussel JB. RhIG for the treatment of immune thrombocytopenia: consensus and controversy (CME). Transfusion 2011; 52:1126-36; quiz 1125. [PMID: 21981825 DOI: 10.1111/j.1537-2995.2011.03384.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Anti-D immune globulin (RhIG) is a front-line option in North America for the treatment of immune thrombocytopenia (ITP) in children and adults. Recently, addition of a Food and Drug Administration-mandated black box warning highlighted the risks of intravascular hemolysis, renal failure, and disseminated intravascular coagulation after anti-D infusion, prompting concern within the medical community regarding its use. A working group convened in response to this warning to prepare a consensus document regarding the safety of RhIG because there has been no increased incidence of adverse events since the initial discovery of these reactions many years ago. The efficacy of anti-D is well documented and only briefly reviewed. The estimated incidence and proposed mechanisms for the rare, major treatment-related complications are discussed, and signal detection data associated with heightened risk of acute hemolytic reactions are presented. The importance of considering host factors, given the rarity of severe reactions, is emphasized. Safety profiles of parallel treatment options are reviewed. The working group consensus is that RhIG has comparable safety and efficacy to other front-line agents for the treatment of children and adults with ITP. Safety may be further improved by careful patient selection.
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Affiliation(s)
- Jenny M Despotovic
- Department of Pediatrics, Hematology/Oncology Section, Baylor College of Medicine, Houston, TX 77030, USA.
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43
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Bredlau AL, Semple JW, Segel GB. Management of immune thrombocytopenic purpura in children: potential role of novel agents. Paediatr Drugs 2011; 13:213-23. [PMID: 21692546 DOI: 10.2165/11591640-000000000-00000] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The treatment of immune thrombocytopenic purpura (ITP) in children is controversial, requiring individualized assessment of the patient and consideration of treatment options. If the platelet count is >10 000/μL and the patient is asymptomatic, a 'watch and wait' strategy is appropriate since most children with ITP will recover completely without pharmacotherapy. If therapy is indicated because of bleeding or a platelet count <10 000/μL, then treatment with glucocorticoids, intravenous immunoglobulin (IVIg), or anti-D are possible initial choices. Glucocorticoid treatment is the least expensive and is our usual first choice of therapy. Its use assumes that the blood counts and blood film have been evaluated to ensure the absence of evidence of alternative diagnoses, such as thrombotic thrombocytopenic purpura or incipient acute leukemia. IVIg is expensive and often causes severe headache, nausea and vomiting, and requires hospitalization at our institution. Anti-D therapy is also expensive and can only be used in patients who are Rhesus D positive. These therapies, even if only transiently effective, can be repeated if necessary. Children usually recover from newly diagnosed ITP, with or without multiple courses of medical therapy. If the disease becomes 'persistent' with severe thrombocytopenia and/or bleeding, and is no longer responsive to the three first-line therapies, the next approach includes the use of thrombopoietin receptor agonists or rituximab. When the disease persists for more than 1 year, it is considered chronic, and, if symptomatic, it may become necessary to consider third-line therapies, including splenectomy, alternative immunosuppressive agents, or combination or investigative chemoimmunotherapy. This review considers the indications, mechanism of action, and effectiveness of the traditional and novel treatment options for patients with ITP.
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Affiliation(s)
- Amy Lee Bredlau
- Department of Pediatrics, Division of Hematology/Oncology, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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44
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Protocolo de estudio y tratamiento de la trombocitopenia inmune primaria (PTI-2010). An Pediatr (Barc) 2011; 74:414.e1-8. [DOI: 10.1016/j.anpedi.2010.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 11/07/2010] [Indexed: 01/19/2023] Open
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45
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The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood 2011; 117:4190-207. [PMID: 21325604 DOI: 10.1182/blood-2010-08-302984] [Citation(s) in RCA: 1239] [Impact Index Per Article: 95.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is commonly encountered in clinical practice. In 1996 the American Society of Hematology published a landmark guidance paper designed to assist clinicians in the management of this disorder. Since 1996 there have been numerous advances in the management of both adult and pediatric ITP. These changes mandated an update in the guidelines. This guideline uses a rigorous, evidence-based approach to the location, interpretation, and presentation of the available evidence. We have endeavored to identify, abstract, and present all available methodologically rigorous data informing the treatment of ITP. We provide evidence-based treatment recommendations using the GRADE system in those areas in which such evidence exists. We do not provide evidence in those areas in which evidence is lacking, or is of lower quality--interested readers are referred to a number of recent, consensus-based recommendations for expert opinion in these clinical areas. Our review identified the need for additional studies in many key areas of the therapy of ITP such as comparative studies of "front-line" therapy for ITP, the management of serious bleeding in patients with ITP, and studies that will provide guidance about which therapy should be used as salvage therapy for patients after failure of a first-line intervention.
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46
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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.
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Affiliation(s)
- Dinesh Yadav
- Division of Pediatric Hematology, Department of Pediatrics, Kalawati Saran Children's Hospital, New Delhi 110001, India.
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47
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Naithani R, Kumar R, Mahapatra M, Tyagi S, Mishra P. Efficacy and safety of anti-D for immune thrombocytopenic purpura in children. Indian Pediatr 2010; 47:517-9. [PMID: 20019392 DOI: 10.1007/s13312-010-0093-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 06/09/2009] [Indexed: 10/19/2022]
Abstract
This study was conducted in 20 children (16 males) (mean age 9.2 +/- 4.34y) with immune thrombocytopenic purpura (ITP) to assess the response to anti-D immunoglobulin. Six patients had newly diagnosed ITP, 6 had persistent ITP and 8 had chronic ITP. The overall response rate was 70% (14/20). The median time to response was 3 days (1-13 days). Response to anti-D was not related to age, sex, severity of bleeding, platelet counts at presentation, ABO blood group, or prior steroid or IVIG response.
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Affiliation(s)
- Rahul Naithani
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India.
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48
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Kivity S, Katz U, Daniel N, Nussinovitch U, Papageorgiou N, Shoenfeld Y. Evidence for the use of intravenous immunoglobulins--a review of the literature. Clin Rev Allergy Immunol 2010; 38:201-69. [PMID: 19590986 PMCID: PMC7101816 DOI: 10.1007/s12016-009-8155-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Intravenous immunoglobulins (IVIg) were first introduced in the middle of the twentieth century for the treatment of primary immunodeficiencies. In 1981, Paul Imbach noticed an improvement of immune-mediated thrombocytopenia, in patients receiving IVIg for immunodeficiencies. This opened a new era for the treatment of autoimmune conditions with IVIg. Since then, IVIg has become an important treatment option in a wide spectrum of diseases, including autoimmune and acute inflammatory conditions, most of them off-label (not included in the US Food and Drug Administration recommendation). A panel of immunologists and internists with experience in IVIg therapy reviewed the medical literature for published data concerning treatment with IVIg. The quality of evidence was assessed, and a summary of the available relevant literature in each disease was given. To our knowledge, this is the first all-inclusive comprehensive review, developed to assist the clinician when considering the use of IVIg in autoimmune diseases, immune deficiencies, and other conditions.
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Affiliation(s)
- Shaye Kivity
- Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
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49
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Cooper N. Intravenous immunoglobulin and anti-RhD therapy in the management of immune thrombocytopenia. Hematol Oncol Clin North Am 2010; 23:1317-27. [PMID: 19932436 DOI: 10.1016/j.hoc.2009.09.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Intravenous immunoglobulin and intravenous anti-D are common therapies in the management of patients with immune thrombocytopenia (ITP). Both are pooled plasma products and both result in an increase in the platelet count in approximately 60% to 70% of patients with ITP. Despite immediate increases in the platelet count, the duration of response is limited, with platelet increments lasting between 2 and 4 weeks. Infusion reactions are common but adverse events rare. Although responses are similar, human and murine data suggest that the mechanisms of action of these treatments are complex and likely different.
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Affiliation(s)
- Nichola Cooper
- Department of Haematology, Hammersmith Hospital, Imperial Health Care NHS Trust, Du Cane Road, London W12 OHS, UK.
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50
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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]
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