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Xu M, Shu J, Qian S, Guo J, Gong Y, Huang R, Wang S, Zhou Z, Yuan G, Huang M, Lin LE, Lou S, Song Y, Liu Q, Zhou H, Mei H, Hu Y. Zuberitamab, an innovative anti-CD20 monoclonal antibody, for patients with primary immune thrombocytopenia in China: a randomized, double-blind, placebo-controlled, phase 2 study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 47:101096. [PMID: 38808021 PMCID: PMC11131054 DOI: 10.1016/j.lanwpc.2024.101096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/18/2024] [Accepted: 05/07/2024] [Indexed: 05/30/2024]
Abstract
Background Primary immune thrombocytopenia (ITP) is an autoimmune disease, and rituximab (RTX) induces long-term effect as second-line treatments. Zuberitamab is an innovative anti-CD20 monoclonal antibody, which was first developed in China and launched in diffuse large B lymphoma. This study aimed to investigate the safety, efficacy, and anticipated therapeutic dose of zuberitamab in Chinese ITP patients. Methods This randomised, double-blind, placebo-controlled, phase 2 study was conducted at 26 hospitals in China. Eligible patients were aged 18-70 years, had primary immune thrombocytopenia for more than 6 months, and did not respond or relapsed after previous treatment and had a pre-treatment platelet count of <30 × 109/L. Patients randomly received zuberitamab in a dose escalation (100/300/600 mg) or placebo once-weekly for 4 weeks and followed up to 24 weeks. The primary endpoint is the proportion of patients with a platelet count ≥50 × 109/L at week 8. Secondary endpoints include the proportion of patients with platelet counts ≥50 × 109/L or ≥100 × 109/L at least once within week 12/24, the proportion of patients experiencing platelets increased twice more than baseline as well as ≥30 × 109/L at least once during the treatment. Adverse events, pharmacokinetic, B cell depletion and immunogenicity were also assessed. This study is registered with https://www.chictr.org.cn/as ChiCTR2100050513. Findings From October 2021 to March 2023, 50 patients were screened for eligibility, of whom 32 patients were enrolled and randomly assigned to placebo (n = 4), zuberitamab 100 mg (n = 10), 300 mg (n = 8) and 600 mg (n = 10) groups. The primary endpoint (PLT ≥50 × 109/L at week 8) was achieved by 40% of patients in the 100 mg group, while none in the other groups. Within 12 weeks, the proportions of patients in each treatment group achieving at least one instance of platelet count ≥50 × 109/L or ≥100 × 109/L or an increase twice more than baseline as well as ≥30 × 109/L were (70%, 38%, 50%), (60%, 13%, 30%), and (80%, 50%, 70%) in zuberitamab 100/300/600 mg groups, respectively. By week 24, the proportions of patients achieving these secondary endpoints remained relatively stable or showed a mild increase of around 10%. The anticipated therapeutic dose of zuberitamab was 100 mg. The plasma concentration of zuberitamab showed an increasing trend with dose (100 mg-600 mg) and linear pharmacokinetic behavior. CD19+ B cells and CD20+ B lymphocytes rapidly declined to 0% within one week and consistently maintained reduced levels throughout the entire treatment phase in three groups. Adverse events occurred in all patients with most of them were mild to moderate, no severe infections occurred. A slight decrease in immunoglobulins was observed in the 600 mg group, but gradually recovered at week 20. Three patients (2 in 100 mg and 1 in 600 mg group) were tested positive for anti-zuberitamab antibodies. We also observed that women, disease duration <12 months, and MAIPA + patients may have higher response rates. Interpretation This study preliminarily confirmed that 100 mg zuberitamab was safe and effective in treating ITP and was recommended to support further investigation. Funding National Natural Science Foundation of China and Zhejiang Bioray Biopharmaceutical Co. Ltd.
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Affiliation(s)
- Min Xu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinhui Shu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingming Guo
- Department of Hematology, The First College of Clinical Medical Science, China Three Gorges University, Yichang Central People's Hospital, Yichang, China
| | - Yuping Gong
- Department of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Ruibin Huang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shuye Wang
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zeping Zhou
- Department of Hematology, The Second Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Guolin Yuan
- Department of Hematology, Xiangyang Central Hospital, The Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Meijuan Huang
- Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Li-E Lin
- Department Hematology of Hainan Provincial People's Hospital, Haikou, China
| | - Shifeng Lou
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yanping Song
- Department of Hematology, Xi'an Central Hospital, Xi'an, China
| | - Qingchi Liu
- Department of Hematology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hu Zhou
- Department of Hematology, Henan Cancer Hospital, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Delshad M, Davoodi-Moghaddam Z, Pourbagheri-Sigaroodi A, Faranoush M, Abolghasemi H, Bashash D. Translating mechanisms into therapeutic strategies for immune thrombocytopenia (ITP): Lessons from clinical trials. Thromb Res 2024; 235:125-147. [PMID: 38335568 DOI: 10.1016/j.thromres.2024.02.005] [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: 12/26/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/12/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder that causes a significant reduction in peripheral blood platelet count. Fortunately, due to an increased understanding of ITP, there have been significant improvements in the diagnosis and treatment of these patients. Over the past decade, there have been a variety of proven therapeutic options available for ITP patients, including intravenous immunoglobulins (IVIG), Rituximab, corticosteroids, and thrombopoietin receptor agonists (TPO-RAs). Although the effectiveness of current therapies in treating more than two-thirds of patients, still some patients do not respond well to conventional therapies or fail to achieve long-term remission. Recently, a significant advancement has been made in identifying various mechanisms involved in the pathogenesis of ITP, leading to the development of novel treatments targeting these pathways. It seems that new agents that target plasma cells, Bruton tyrosine kinase, FcRn, platelet desialylation, splenic tyrosine kinase, and classical complement pathways are opening new ways to treat ITP. In this study, we reviewed the pathophysiology of ITP and summarized updates in this population's management and treatment options. We also took a closer look at the 315 ongoing trials to investigate their progress status and compare the effectiveness of interventions. May our comprehensive view of ongoing clinical trials serve as a guiding beacon, illuminating the path towards future trials of different drugs in the treatment of ITP patients.
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Affiliation(s)
- Mahda Delshad
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Laboratory Sciences, School of Allied Medical Sciences, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Zeinab Davoodi-Moghaddam
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atieh Pourbagheri-Sigaroodi
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Faranoush
- Pediatric Growth and Development Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Abolghasemi
- Pediatric Congenital Hematologic Disorders Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Davood Bashash
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Cao J, Lu S, Luo D, Pei R, Lu Y, Chen D, Du X, Li S. Successful treatment pure red cell aplasia after ABO major mismatched allogeneic hematopoietic stem cell transplantation with avatrombopag and low dose rituximab. Transfusion 2024; 64:510-516. [PMID: 38351735 DOI: 10.1111/trf.17743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 03/16/2024]
Abstract
BACKGROUND Pure red cell aplasia (PRCA) following allogeneic hematopoietic stem cell transplantation (allo-HSCT) with ABO major incompatibility is characterized by transfusion dependent anemia. No standard treatment existed for PRCA following allo-HSCT yet. STUDY DESIGN AND METHODS We conducted a retrospective study, and reported our experience with the use of avatrombopag and lower dose rituximab to treat five patients with PRCA subsequent to major ABO-incompatible allo-HSCT. RESULTS Five cases of PRCA were identified from 72 patients who underwent allo-HSCT with major or bidirectional ABO mismatch. Cumulative incidence at Day +60 was 6.9% (5/72) at our center. All donor and recipient blood groups were A+ and O+ , respectively. In the first three cases we reported, patients received erythropoietin, plasma exchange, and donor lymphocyte infusion, but none of them had any effect. After 4 weeks of treatment with low dose rituximab (100 mg/week) combined with avatrombopag (40 mg/day), favorable outcomes were obtained. According to the aforementioned experience, Cases 4 and 5 were administered low-dose rituximab and avatrombopag in 3 months after transplantation, and erythroid response was observed on 3 weeks after treatment. Our patients tolerated low-dose rituximab and avatrombopag well and experienced rapid efficacy, with a median duration of 3 weeks. Furthermore, no severe infection or thrombocytosis necessitated a dose adjustment. CONCLUSION Low-dose rituximab and avatrombopag may be an effective treatment for patients with PRCA after major ABO-incompatible allo-HSCT. The patients should be treated at least 90 days post transplantation if conventional erythropoietin therapy fails.
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Affiliation(s)
- Junjie Cao
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Shaoyan Lu
- Department of blood transfusion, The Affiliated People's Hospital of Ningbo University, Ningbo, China
| | - Danjie Luo
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
| | - Renzhi Pei
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Ying Lu
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Dong Chen
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Xiaohong Du
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
| | - Shuangyue Li
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
- Institute of Hematology, Ningbo University, Ningbo, China
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Mingot-Castellano ME, Canaro Hirnyk M, Sánchez-González B, Álvarez-Román MT, Bárez-García A, Bernardo-Gutiérrez Á, Bernat-Pablo S, Bolaños-Calderón E, Butta-Coll N, Caballero-Navarro G, Caparrós-Miranda IS, Entrena-Ureña L, Fernández-Fuertes LF, García-Frade LJ, Gómez del Castillo MDC, González-López TJ, Grande-García C, Guinea de Castro JM, Jarque-Ramos I, Jiménez-Bárcenas R, López-Ansoar E, Martínez-Carballeira D, Martínez-Robles V, Monteagudo-Montesinos E, Páramo-Fernández JA, Perera-Álvarez MDM, Soto-Ortega I, Valcárcel-Ferreiras D, Pascual-Izquierdo C. Recommendations for the Clinical Approach to Immune Thrombocytopenia: Spanish ITP Working Group (GEPTI). J Clin Med 2023; 12:6422. [PMID: 37892566 PMCID: PMC10607106 DOI: 10.3390/jcm12206422] [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: 09/04/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is a complex autoimmune disease whose hallmark is a deregulation of cellular and humoral immunity leading to increased destruction and reduced production of platelets. The heterogeneity of presentation and clinical course hampers personalized approaches for diagnosis and management. In 2021, the Spanish ITP Group (GEPTI) of the Spanish Society of Hematology and Hemotherapy (SEHH) updated a consensus document that had been launched in 2011. The updated guidelines have been the reference for the diagnosis and management of primary ITP in Spain ever since. Nevertheless, the emergence of new tools and strategies makes it advisable to review them again. For this reason, we have updated the main recommendations appropriately. Our aim is to provide a practical tool to facilitate the integral management of all aspects of primary ITP management.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, 41013 Sevilla, Spain
| | | | | | - María Teresa Álvarez-Román
- Hematology Department, Hospital Universitario La Paz-IdiPAZ, Universidad Autónoma de Madrid, 28046 Madrid, Spain;
| | | | - Ángel Bernardo-Gutiérrez
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - Silvia Bernat-Pablo
- Hematology Department, Hospital Universitario de la Plana, 12540 Villarreal, Spain;
| | | | - Nora Butta-Coll
- Hematology Department, Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), 28046 Madrid, Spain;
| | | | | | - Laura Entrena-Ureña
- Hematology Department, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
| | - Luis Fernando Fernández-Fuertes
- Hematology Department, Complejo Hospitalario Universitario Insular Materno-Infantil, 35016 Las Palmas de Gran Canaria, Spain;
| | - Luis Javier García-Frade
- Hematology Department, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León, 47012 Valladolid, Spain;
| | | | | | | | | | - Isidro Jarque-Ramos
- Hematology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Elsa López-Ansoar
- Hematology Department, Complejo Hospitalario Universitario de Vigo, 36312 Vigo, Spain;
| | | | | | | | | | - María del Mar Perera-Álvarez
- Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, 35010 Las Palmas de Gran Canaria, Spain;
| | - Inmaculada Soto-Ortega
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - David Valcárcel-Ferreiras
- Hematology Department, Vall d’Hebron Instituto de Oncología (VHIO), Universitat Autònoma de Barcelona, 08035 Barcelona, Spain;
| | - Cristina Pascual-Izquierdo
- Hematology Department, Hospital General Universitario Gregorio Marañón (HGUGM) Madrid, Instituto de Investigación Gregorio Marañón, 28007 Madrid, Spain;
- Spanish Immune Thrombocytopenia Group, 28040 Madrid, Spain
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5
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Gómez-Almaguer D, Rojas-Guerrero EA, Gómez-De León A, Colunga-Pedraza PR, Jaime-Pérez JC. Alternatives for managing patients with newly diagnosed immune thrombocytopenia: a narrative review. Expert Rev Hematol 2022; 15:493-501. [PMID: 35615916 DOI: 10.1080/17474086.2022.2082936] [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] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is an acquired bleeding disorder. Conventionally, first-line ITP therapy aims to obtain a rapid response and stop or decrease the risk of bleeding by increasing the platelet count. At this point, the duration of the response, the tolerability, and the long-term safety of pharmacologic interventions are considered less of a priority. Combination treatments that simultaneously address multiple disease mechanisms are an attractive strategy to increase efficacy in acute ITP therapy. In this review, we discuss the treatment of newly diagnosed ITP patients, emphasizing the use of new combinations to benefit from their synergy. AREAS COVERED This article summarizes conventional treatment, recent and novel combinations, and COVID-19 management recommendations of newly diagnosed ITP patients. EXPERT OPINION The key areas for improvement consider the long-term effects of conventional first-line therapy, reducing relapse rates, and extending responses to achieve long-term remission. Although corticosteroids remain first-line therapy, restricting their use to avoid toxicity and the increasing use of rituximab and TPO-RAs in the first three months after diagnosis open the landscape for future interventions in frontline therapy for ITP. First-line therapy intensification or synergistic drug combination offers a potential and realistic shift in future treatment guidelines.
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Affiliation(s)
- David Gómez-Almaguer
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Edgar A Rojas-Guerrero
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Andrés Gómez-De León
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Perla R Colunga-Pedraza
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - José C Jaime-Pérez
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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Kim DS. Recent advances in treatments of adult immune thrombocytopenia. Blood Res 2022; 57:112-119. [PMID: 35483935 PMCID: PMC9057657 DOI: 10.5045/br.2022.2022038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is isolated thrombocytopenia characterized by autoimmune-mediated disruption of platelet without other etiologies. Treatments for chronic ITP consist of corticosteroids, intravenous immunoglobulins, anti-D immunoglobulin, rituximab, thrombopoietin receptor agonists, immunosuppressants and splenectomy. Although current therapies are effective in over two-thirds of patients, some patients are refractory to therapies or fail to achieve long-term responses. Recently, great advance has been made in identifying various mechanisms involved in ITP pathogenesis, and new treatments targeting these pathways are being developed. Novel agents such as splenic tyrosine kinase inhibitor, Bruton kinase inhibitor, plasma cell targeting therapies, neonatal Fc receptor inhibitor, platelet desialylation inhibitor, and inhibition of the classical complement pathway are expected to be effective for ITP treatment. This review summarizes current strategies and emerging therapies of ITP.
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Affiliation(s)
- Dae Sik Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
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7
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Ni X, Li D, Yuan C, Yu Y, Wang H, Wang L, Yu T, Qin P, Peng J, Hou M, Shi Y, Hou Y. Single-dose versus low-dose rituximab in corticosteroid-resistant or relapsed ITP: A multicenter, randomized, controlled study. Am J Hematol 2022; 97:440-447. [PMID: 35049070 DOI: 10.1002/ajh.26473] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/18/2021] [Accepted: 01/13/2022] [Indexed: 01/19/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune bleeding disorder, in which rituximab (RTX) induces the best long-term effect among recommended second-line treatments. Nevertheless, the optimal regimen of RTX remains unclear. We herein conducted a prospective, multicenter, open-label, randomized controlled trial to compare the efficacy and safety of RTX at two different dosage regimens in patients with corticosteroid-resistant or relapsed ITP. Recruited patients were randomly assigned (1:1) to receive either RTX at a repeated low dose (100 mg weekly for 4 weeks, LD-RTX) or at a single dose (375 mg/m2 , S-RTX). Overall response was achieved in 64.3% of patients who received LD-RTX versus 67.4% of those receiving S-RTX (p = .759). The complete response (CR) rate was 23.8% after LD-RTX and 28.3% after S-RTX (p = .635). In health-related quality of life, S-RTX improved patients' psychological status, quality of life, social activities, and work compared with LD-RTX. Furthermore, S-RTX significantly reduced physician visits without compromising efficacy. Our findings demonstrate that a S-RTX is comparable to LD-RTX in effectiveness and safety for treatment of corticosteroid-resistant or relapsed ITP. The single-dosage regimen optimizes the use of medical resources, improves the cost-effectiveness of RTX, and represents a promising and more convenient replacement for LD-RTX in ITP. This study has been completed and is registered with ClinicalTrials.gov, number NCT03258866.
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Affiliation(s)
- Xiaofei Ni
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Daqi Li
- Jinan Central Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Chenglu Yuan
- Jinan Central Hospital, Cheeloo College of Medicine Shandong University Jinan China
- Department of Hematology, Qilu Hospital (Qingdao) Shandong University Qingdao China
| | - Yafei Yu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Haoyi Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Lingjun Wang
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Tianshu Yu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Ping Qin
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
- Leading Research Group of Scientific Innovation, Department of Science and Technology of Shandong Province, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Yan Shi
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine Shandong University Jinan China
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8
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Beltrami‐Moreira M, Bussel JB. Low-dose rituximab in immune thrombocytopenia: One and done. Am J Hematol 2022; 97:388-389. [PMID: 35132682 DOI: 10.1002/ajh.26489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/08/2022]
Abstract
Rituximab is a widely-used medication for many years, important in management of immune thrombocytopenia (ITP); however, the optimal rituximab dose remains unknown. Ni and colleagues report a clinical trial comparing 2 doses of rituximab: a single dose of 375 mg/m2 versus 100 mg/m2 weekly for four weeks. The authors report similar efficacy and safety profile with both strategies. However, single-dose rituximab offered substantial benefits in quality-of-life and decrease in treatment costs. The study by Ni and colleagues adds a new option for management of ITP with rituximab. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Marina Beltrami‐Moreira
- Division of Hematology/Oncology New York Presbyterian Hospital – Weill Cornell Medicine New York New York USA
| | - James B. Bussel
- Pediatric Hematology/Oncology New York Presbyterian Hospital – Weill Cornell Medicine New York New York USA
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9
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Santacruz JC, Mantilla MJ, Rueda I, Pulido S, Rodriguez-Salas G, Londono J. A Practical Perspective of the Hematologic Manifestations of Systemic Lupus Erythematosus. Cureus 2022; 14:e22938. [PMID: 35399432 PMCID: PMC8986464 DOI: 10.7759/cureus.22938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 12/15/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with an unknown etiology that can affect any organ or system of the human body. Hematological, renal, or central nervous system manifestations in these patients result in great morbidity because high doses of glucocorticoids, cytotoxic medications, or biological drugs are required to control these manifestations. It is noteworthy that hematological involvement predominates during the first years of the disease and tends to last over time, with the premise that it may be the initial manifestation of the disease. Clear examples of this are the cases of hemolytic anemia and immune thrombocytopenia that can be initially classified as idiopathic or primary to be later classified as secondary when associated with infections, medications, neoplasms, or autoimmune diseases. The spectrum of hematologic manifestations in SLE is very broad, including lymphopenia, anemia, thrombocytopenia, or pancytopenia. In some cases, lymphadenopathy and splenomegaly are also identified. The vast majority of these manifestations denote high disease activity. However, many of these alterations have a multifactorial cause that must be taken into account to adopt a more complete therapeutic approach. The objective of this review is to characterize in detail the hematological manifestations of SLE to offer clinicians a practical vision of its diagnosis and treatment.
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Wu YJ, Liu H, Zeng QZ, Liu Y, Wang JW, Wang WS, Jia-Feng, Zhou HB, Huang QS, He Y, Fu HX, Zhu XL, Jiang Q, Jiang H, Chang YJ, Xu LP, Huang XJ, Zhang XH. All- trans retinoic acid plus low-dose rituximab vs low-dose rituximab in corticosteroid-resistant or relapsed ITP. Blood 2022; 139:333-342. [DOI: i:10.1182/blood.2021013393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
Abstract
The study aimed to compare the efficacy and safety of all-trans retinoic acid (ATRA) plus low-dose rituximab (LD-RTX) with LD-RTX monotherapy in corticosteroid-resistant or relapsed immune thrombocytopenia (ITP) patients. Recruited patients were randomized at a ratio of 2:1 into 2 groups: 112 patients received LD-RTX plus ATRA, and 56 patients received LD-RTX monotherapy. Overall response (OR), defined as achieving a platelet count of ≥30 × 109/L confirmed on ≥2 separate occasions (≥7 days apart), at least a doubling of the baseline platelet count without any other ITP-specific treatment, and the absence of bleeding within 1 year after enrollment, was observed in more patients in the LD-RTX plus ATRA group (80%) than in the LD-RTX monotherapy group (59%) (between-group difference, 0.22; 95% CI, 0.07-0.36). Sustained response (SR), defined as maintenance of a platelet count >30 × 109/L, an absence of bleeding, and no requirement for any other ITP-specific treatment for 6 consecutive months after achievement of OR during 1 year following enrollment, was achieved by 68 (61%) patients in the combination group and 23 (41%) patients in the monotherapy group (between-group difference, 0.20; 95% CI, 0.04-0.35). The 2 most common adverse events (AEs) for the combination group were dry skin and headache or dizziness. Our findings demonstrated that ATRA plus LD-RTX significantly increased the overall and sustained response, indicating a promising treatment option for corticosteroid-resistant or relapsed adult ITP. This study is registered at www.clinicaltrials.gov as #NCT03304288.
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Affiliation(s)
- Ye-Jun Wu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hui Liu
- Department of Hematology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Qiao-Zhu Zeng
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yi Liu
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Wen-Sheng Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Jia-Feng
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China; and
| | - He-Bing Zhou
- Department of Hematology, The Affiliated Beijing Luhe Hospital of Capital Medical University, Beijing, China
| | - Qiu-Sha Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yun He
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hai-Xia Fu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Lu Zhu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qian Jiang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Hao Jiang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ying-Jun Chang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lan-Ping Xu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Jun Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
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11
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He C, Li W, Xie Q, Yin G. Rituximab in the Treatment of Interstitial Lung Diseases Related to Anti-Melanoma Differentiation-Associated Gene 5 Dermatomyositis: A Systematic Review. Front Immunol 2022; 12:820163. [PMID: 35116041 PMCID: PMC8803653 DOI: 10.3389/fimmu.2021.820163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/28/2021] [Indexed: 01/10/2023] Open
Abstract
Objective The effectiveness of rituximab in anti-melanoma differentiation-associated gene 5 (MDA5) dermatomyositis (DM) with interstitial lung disease (ILD) has been explored only in isolated case reports and small series. This paper aims to review the current evidence regarding rituximab (RTX) use in the treatment of ILD related to anti-MDA5 DM (anti-MDA5 DM-ILD). Methods We conducted a review by searching PubMed, Web of Science, Embase, and Cochrane for articles with information on patients with anti-MDA5 DM and RTX treatment, published until August 2021, in English language. The selected studies listed variation in chest high-resolution computed tomography (HRCT) and/or pulmonary function test (PFT) as a primary outcome, in patients with anti-MDA5 DM-related ILD after using RTX. Results Of the 145 potentially eligible articles, 17 were selected. The information gathered from a total of 35 patients with anti-MDA5 DM-ILD was reviewed, including 13 men and 22 women. Patient age at onset was 47.60 ± 13.72 years old. A total of 11.43% (4/35) of the patients were found to have chronic ILD (C-ILD) and 88.57% (31/30) exhibited rapidly progressive ILD (RP-ILD). Most patients (29/30) had typical DM rashes. Prior to RTX administration, the majority of patients (27/35) were treated with medium- or high-dose glucocorticoids and at least one additional immunotherapeutic agent. With regard to RTX efficacy for ILD in anti-MDA5 DM, 71.43% (25/35) of the patients responded to treatment. Skin rash also improved in more than half of the patients after RTX treatment. The most common side effects were infections, reported by 37.14% (13/35) of the patients after using RTX. Conclusion As a CD20 targeting drug, RTX is a promising therapeutic tool for anti-MDA5 DM-ILD, although the risk of infections should be considered before treatment. Further prospective controlled studies are required to evaluate the optimal RTX treatment regimen. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289714, identifier CRD42021289714.
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Affiliation(s)
- Chenjia He
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Wenyu Li
- Health Management Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qibing Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Geng Yin, ; Qibing Xie,
| | - Geng Yin
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Geng Yin, ; Qibing Xie,
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12
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Yarahmadi P, Alirezaei M, Forouzannia SM, Naser Moghadasi A. The Outcome of COVID-19 in Patients with a History of Taking Rituximab: A Narrative Review. IRANIAN JOURNAL OF MEDICAL SCIENCES 2021; 46:411-419. [PMID: 34840381 PMCID: PMC8611224 DOI: 10.30476/ijms.2021.88717.1946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/26/2021] [Accepted: 03/13/2021] [Indexed: 01/16/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is a recently emerging disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Notably, the safety of immunosuppressive medications
is a major concern during an infectious disease pandemic. Rituximab (RTX), as a monoclonal antibody against CD20 molecule, is widely used for the treatment of various diseases, mostly autoimmune
diseases and some malignancies. Previous studies indicated that RTX, as an immunosuppressive medication, may be associated with the increased risk of infections.
Moreover, given the wide use of RTX, a necessity of determining the different aspects of RTX use in the COVID-19 era is strongly felt. We reviewed current studies on the clinical
courses of patients with SARS-CoV-2 infection. It appears that the use of RTX does not increase morbidity and mortality in most patients. However, underlying diseases and other
concomitant medications may play a role in the disease course, while the concerns of vaccine efficacy in patients receiving RTX still need to be addressed.
Therefore, more controlled studies are needed for a better conclusion.
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Affiliation(s)
- Pourya Yarahmadi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Alirezaei
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Forouzannia
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Abdorreza Naser Moghadasi
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
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13
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All-trans retinoic acid plus low-dose rituximab vs low-dose rituximab in corticosteroid-resistant or relapsed ITP. Blood 2021; 139:333-342. [PMID: 34665865 DOI: 10.1182/blood.2021013393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
The study aimed to compare the efficacy and safety of all-trans retinoic acid (ATRA) plus low-dose rituximab (LD-RTX) with LD-RTX monotherapy in corticosteroid-resistant or relapsed immune thrombocytopenia (ITP) patients. Recruited patients were randomized at a ratio of 2:1 into 2 groups: 112 patients received LD-RTX plus ATRA and 56 patients received LD-RTX monotherapy. Overall response (OR), defined as achieving a platelet count of ≥ 30 × 109/L confirmed on at least two separate occasions (at least 7 days apart), at least a doubling of the baseline platelet count without any other ITP-specific treatment and the absence of bleeding within 1 year after enrollment, was observed in more patients in the LD-RTX plus ATRA group (80%) than in the LD-RTX monotherapy group (59%) (between-group difference, 0.22; 95% CI, 0.07 to 0.36). Sustained response (SR), defined as maintenance of a platelet count > 30 x 109/L, an absence of bleeding, and no requirement for any other ITP-specific treatment for 6 consecutive months after achievement of OR during 1 year following enrollment, was achieved by 68 (61%) patients in the combination group and 23 (41%) patients in the monotherapy group (between-group difference, 0.20; 95% CI, 0.04 to 0.35). The 2 most common AEs for the combination group were dry skin and headache or dizziness. Our findings demonstrated that ATRA plus LD-RTX significantly increased the overall and sustained response, indicating a promising treatment option for corticosteroid-resistant or relapsed adult ITP. This study is registered at www.clinicaltrials.gov as #NCT03304288.
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14
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The Efficacy and Safety of Different Dosages of Rituximab for Adults with Immune Thrombocytopenia: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9992086. [PMID: 34660807 PMCID: PMC8514896 DOI: 10.1155/2021/9992086] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 07/17/2021] [Accepted: 08/25/2021] [Indexed: 01/19/2023]
Abstract
Background Rituximab has been frequently used as a second-line treatment for patients with immune thrombocytopenia (ITP). The optimal dose and course of rituximab are uncertain. Methods A comprehensive search for randomized controlled trials reporting the use of low-dose (100 mg) or standard-dose (375 mg/m2) rituximab in ITP treatment was conducted. Meta-analyses were performed on CRR (complete response rate), ORR (overall response rate), PRR (partial response rate), SRR (sustained response rate), infection rate, SB (significant bleeding) rate, and SAE (serious adverse event) rate. Results A total of 12 studies were included, comprising 869 patients. Compared to the control group, rituximab treatment resulted in an obvious increase in CRR (P < 0.00001), ORR (P < 0.0001), and SRR at month 6 and 12 (P = 0.0007, P = 0.0003), without increasing the infection rate (P = 0.12) and SAE rate (P = 0.11). No significant differences in CRR (RR 1.61 vs. 1.42, P = 0.45), ORR (RR 1.26 vs. 1.49, P = 0.28), PRR (RR 1.25 vs. 1.00, P = 0.11), SRR at month 12 (RR 2.00 vs. RR 1.64, P = 0.54), infection rate (RR 0.85 vs. 1.46, P = 0.36), and SB rate (RR 0.14 vs. 1.19, P = 0.17) were found in subgroups of low dose and standard dose. Conclusion Rituximab was effective and safe for adult patients with ITP. A low-dose rituximab regimen might be an effective alternative to the standard-dose regimen in ITP, as it showed similar CRR, ORR, and SRR at month 12 and was relatively safer with a lower cost.
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15
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Choi PY, Merriman E, Bennett A, Enjeti AK, Tan CW, Goncalves I, Hsu D, Bird R. Consensus guidelines for the management of adult immune thrombocytopenia in Australia and New Zealand. Med J Aust 2021; 216:43-52. [PMID: 34628650 PMCID: PMC9293212 DOI: 10.5694/mja2.51284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 06/22/2021] [Accepted: 06/28/2021] [Indexed: 01/21/2023]
Abstract
Introduction The absence of high quality evidence for basic clinical dilemmas in immune thrombocytopenic purpura (ITP) underlines the need for contemporary guidelines relevant to the local treatment context. ITP is diagnosed by exclusions, with a hallmark laboratory finding of isolated thrombocytopenia. Main recommendations Bleeding, family and medication histories and a review of historical investigations are required to gauge the bleeding risk and possible hereditary syndromes. Beyond the platelet count, the decision to treat is affected by individual bleeding risk, disease stage, side effects of treatment, concomitant medications, and patient preference. Treatment is aimed at achieving a platelet count > 20 × 109/L, and avoidance of severe bleeding. Steroids are the standard first line treatment, with either 6‐week courses of tapering prednisone or repeated courses of high dose dexamethasone providing equivalent efficacy. Intravenous immunoglobulin can be used periprocedurally or as first line therapy in combination with steroids. Changes in management as a result of this statement There is no consensus on choice of second line treatments. Options with the most robust evidence include splenectomy, rituximab and thrombopoietin receptor agonists. Other therapies include azathioprine, mycophenolate mofetil, dapsone and vinca alkaloids. Given that up to one‐third of patients achieve a satisfactory haemostatic response, splenectomy should be delayed for at least 12 months if possible. In life‐threatening bleeding, we recommend platelet transfusions to achieve haemostasis, along with intravenous immunoglobulin and high dose steroids.
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Affiliation(s)
- Philip Yi Choi
- Canberra Hospital, Canberra, ACT.,Australian National University, Canberra, ACT
| | | | - Ashwini Bennett
- Monash Medical Centre, Melbourne, VIC.,Monash University, Melbourne, VIC
| | - Anoop K Enjeti
- Calvary Mater Hospital, Newcastle, NSW.,University of Newcastle, Newcastle, NSW
| | - Chee Wee Tan
- Royal Adelaide Hospital, Adelaide, SA.,SA Pathology, Adelaide, SA
| | - Isaac Goncalves
- Peter MacCallum Cancer Centre, Melbourne, VIC.,Royal Melbourne Hospital, Melbourne, VIC
| | - Danny Hsu
- South Western Sydney Local Health District, Sydney, NSW.,University of New South Wales, Sydney, NSW
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Hunt S, Robertson J, Conn J, Casey J, Royle J, Collins J, Hourigan M, Richmond J, Yang Wang T, Mills A, Mason J. A low-dose rituximab regimen for first-line treatment of acquired haemophilia A. Eur J Haematol 2021; 108:28-33. [PMID: 34528303 DOI: 10.1111/ejh.13708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/02/2021] [Accepted: 09/06/2021] [Indexed: 01/31/2023]
Abstract
A low-dose rituximab regimen for first-line treatment of acquired haemophilia A. INTRODUCTION Acquired haemophilia A (AHA) is a rare disease caused by the development of autoantibodies against FVIII. Diagnosis involves confirmation of FVIII deficiency and the presence of an inhibitor via the Bethesda assay. Severe bleeding is often managed with bypassing agents such as recombinant factor VII. This is then followed by eradication of the inhibitor with immunosuppression which typically includes a corticosteroid backbone. AIM Review the current management and outcomes of AHA in Queensland, Australia. Determine the incidence, demographics and clinical characteristics of AHA patients. METHODS Retrospective case series of AHA diagnosed between May 2014 and August 2018. Data were derived from the Australian Bleeding Disorders Registry and state-wide pathology database. Data collection proforma was completed by the treating haematologist and reviewed/compiled centrally. RESULTS 24 patients were identified (incidence 1 in 1.27 million). The median age was 76.5 years. Median follow-up was 20 months. Index bleed was atraumatic and skin/soft tissue in the majority of patients. Recombinant FVIIa was the most commonly used haemostatic therapy and effective in 85% of patients. Immunosuppression and steroid usage were uniform. Upfront second agent was used in 75% of patients and was most commonly rituximab. 87.5% of patients achieved a complete remission in a median time of 48 days. Low-dose rituximab was frequently used and equally as efficacious as standard dose. CONCLUSION Immunosuppression with combination therapy, notably rituximab, appears to be non-inferior and has a favourable side effect profile.
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Affiliation(s)
- Stewart Hunt
- Queensland Haemophilia Centre, Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Jeremy Robertson
- Department of Haematology and Haemophilia, Queensland Children's Hospital, South Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Herston, QLD, Australia
| | - Jason Conn
- Department of Haematology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - John Casey
- Department of Haematology, The Townsville Hospital, Douglas, QLD, Australia
| | - Jane Royle
- Department of Haematology, The Townsville Hospital, Douglas, QLD, Australia
| | - Joel Collins
- Department of Haematology, Toowoomba Hospital, South Toowoomba, QLD, Australia
| | - Matthew Hourigan
- Department of Haematology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Joshua Richmond
- Department of Haematology, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Tzu Yang Wang
- Department of Haematology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Anthony Mills
- Department of Haematology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Jane Mason
- Queensland Haemophilia Centre, Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.,Faculty of Medicine, University of Queensland, Herston, QLD, Australia
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17
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Sandvad M, Pedersen EA, Frederiksen H, Mannering N. Risk of infection in adult patients with primary immune thrombocytopenia (ITP): a systematic review. Expert Rev Hematol 2021; 14:961-974. [PMID: 34487679 DOI: 10.1080/17474086.2021.1976635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is a bleeding disorder characterized by autoimmune destruction and impaired production of platelets. Immunosuppressive drugs are the main treatment and may increase risk of infection. AREAS COVERED This systematic review included studies incorporating adult patients with primary ITP and infectious outcomes. Studies comparing risk of infection with the general population were included as primary and studies without this comparison were considered secondary. Three primary and 10 secondary studies were included. The main findings: 1-year adjusted relative-risk of infection was 4.5 (95% CI, 3.3-6.1) fold elevated compared to the general population. When comparing splenectomized with non-splenectomized ITP patients, the +1-year adjusted relative-risk of infection was 4.0 (95% CI, 2.8-5.6). The unadjusted 5-year mortality rate-ratio for infection-related deaths was 6.0 (95% CI, 3.0-11.8) in one study, and the hazard ratio was 2.4 (95% CI, 1.0-5.7) for fatal infections in another. EXPERT OPINION This review emphasizes that patients with ITP have increased risk of infection. Since ITP is a benign hematologic disease, it is important to assess the extent and causes of infection in the clinical care and considerations before initiating treatment. More homogeneous studies are needed on this topic.
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Affiliation(s)
- Melanie Sandvad
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Nikolaj Mannering
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Hematology, Odense University Hospital, Odense, Denmark
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Lozano ML, Sanz MA, Vicente V. Guidelines of the Spanish ITP Group for the diagnosis, treatment and follow-up of patients with immune thrombopenia. Med Clin (Barc) 2021; 157:191-198. [PMID: 34088525 DOI: 10.1016/j.medcli.2021.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 11/28/2022]
Affiliation(s)
- María L Lozano
- Grupo de investigación CB15/00055, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Hospital General Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, España.
| | - Miguel A Sanz
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Vicente Vicente
- Grupo de investigación CB15/00055, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII), Hospital General Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, España
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19
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Singh A, Uzun G, Bakchoul T. Primary Immune Thrombocytopenia: Novel Insights into Pathophysiology and Disease Management. J Clin Med 2021; 10:jcm10040789. [PMID: 33669423 PMCID: PMC7920457 DOI: 10.3390/jcm10040789] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/08/2021] [Accepted: 02/10/2021] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder defined by a significantly reduced number of platelets in blood circulation. Due to low levels of platelets, ITP is associated with frequent bruising and bleeding. Current evidence suggests that low platelet counts in ITP are the result of multiple factors, including impaired thrombopoiesis and variations in immune response leading to platelet destruction during pathological conditions. Patient outcomes as well as clinic presentation of the disease have largely been shown to be case-specific, hinting towards ITP rather being a group of clinical conditions sharing common symptoms. The most frequent characteristics include dysfunction in primary haemostasis and loss of immune tolerance towards platelet as well as megakaryocyte antigens. This heterogeneity in patient population and characteristics make it challenging for the clinicians to choose appropriate therapeutic regimen. Therefore, it is vital to understand the pathomechanisms behind the disease and to consider various factors including patient age, platelet count levels, co-morbidities and patient preferences before initiating therapy. This review summarizes recent developments in the pathophysiology of ITP and provides a comprehensive overview of current therapeutic strategies as well as potential future drugs for the management of ITP.
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Affiliation(s)
- Anurag Singh
- Institute for Clinical and Experimental Transfusion Medicine (IKET), University Hospital of Tuebingen, 72076 Tuebingen, Germany;
| | - Günalp Uzun
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, 72076 Tuebingen, Germany;
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine (IKET), University Hospital of Tuebingen, 72076 Tuebingen, Germany;
- Centre for Clinical Transfusion Medicine, University Hospital of Tuebingen, 72076 Tuebingen, Germany;
- Correspondence: ; Tel.: +49-7071-29-81601
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Anti-melanoma differentiation-associated gene 5 (MDA5) antibody-positive dermatomyositis responds to rituximab therapy. Clin Rheumatol 2021; 40:2311-2317. [PMID: 33411136 DOI: 10.1007/s10067-020-05530-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 11/11/2020] [Accepted: 11/29/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the efficacy of rituximab (RTX) in the management of anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody-positive dermatomyositis (DM), with or without rapidly progressive interstitial lung disease (RP-ILD). METHODS Medical records of DM patients with anti-MDA5 antibodies treated with RTX therapy were reviewed retrospectively. Skin rash data, lung function tests, chest high-resolution computed tomography (HRCT), and serum markers were compared before and after RTX. RESULTS Eleven consecutive cases, including 5 males and 6 females, were identified. One hundred percent of patients had a typical DM rash and about 45% presented with skin ulceration. All the patients had ILD, 73% had RP-ILD, and 27% had mild or asymptomatic ILD. Ro-52 antibodies were found in 55% of this group. Lymphopenia was present in 10/11 patients (91%). Around half (55%) had a level of ferritin greater than 1000 ng/ml. Nine patients (82%) were refractory. These patients received intravenous RTX (375 mg/m2) at 0 and 14 days (conventional dose) or 100 mg once a week for 4 weeks (low dose). After RTX treatment, 2 patients (18%) with mild ILD showed complete remission, and 6 (55%) showed improvement in lung HRCT and/or lung function. Skin rash in 4 patients (100%) and ILD in 3 (75%) showed improvement in the low-dose group. Infection episodes occurred in four (57%) and one (25%) of the conventional-dose and low-dose group, respectively. CONCLUSIONS Our study found that RTX is sufficient to improve skin rash and ILD or RP-ILD. Our results also suggest that lower RTX doses may be a useful therapy for anti-MDA5 antibody-positive DM patients. Key Points • To clarify efficacy of RTX in the management of anti-MDA5 antibody-positive DM, we performed a retrospective chart review of DM patients with anti-MDA5 antibodies who were treated with RTX. • This study found that RTX is sufficient to improve skin rash and ILD or RP-ILD. • The results suggest that low-dose RTX in treatment of MDA5-DM results in better responses and fewer adverse events.
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Mishra K, Kumar S, Jandial A, Sahu KK, Sandal R, Ahuja A, Khera S, Uday Y, Kumar R, Kapoor R, Verma T, Sharma S, Singh J, Das S, Chatterjee T, Sharma A, Nair V. Real-world Experience of Rituximab in Immune Thrombocytopenia. Indian J Hematol Blood Transfus 2021; 37:404-413. [PMID: 34267459 DOI: 10.1007/s12288-020-01351-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/04/2020] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is a relapsing-remitting disease often requiring more than one line of therapy. Rituximab is a recommended second-line therapy, but the real-world data on its efficacy and safety from resource constraint settings is limited. We aimed to analyze the safety and efficacy of rituximab in ITP. This is a single-center, retrospective study. This study was conducted at a tertiary care hospital in Northern India from 2005 to 2019. On audit of medical records, all patients of ITP (n-513) who had received rituximab (n-81) were screened for inclusion. Patients whose response assessment was not possible were excluded. Finally, 66 patients were analyzed using statistical packages of Python v3.7. The cumulative incidence of overall response on day 20 was 30.61%, and day 30 was 51.72%. The median time to response was 28 day (range 21-51 day). Cumulative incidence of complete response was 16.67%, and partial response 37.88%. After a median follow-up of 789 day (range 181-5260 day), the cumulative incidence of relapse was 30.32%, 36.12%, and 56.57% at 1, 2, and 5 years respectively. There was no effect of age, sex, duration of disease, lines of therapy received, and platelet count on either cumulative incidence of overall response or relapse. ANA positivity was significantly related to the better cumulative incidence of overall response (p = 0.012), but not with relapse. Infusion-related reactions were the commonest adverse event noted (n-4, grade ≥ 3 CTCAEv4). Rituximab and its generic version are safe and effective second line agent in ITP with a good overall response and sustained response.
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Affiliation(s)
- Kundan Mishra
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India
| | - Suman Kumar
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India
| | - Aditya Jandial
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India
| | - Kamal Kant Sahu
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India.,Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA USA
| | - Rajeev Sandal
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India.,Department of Health and Family Welfare, Shimla, Himachal Pradesh India
| | - Ankur Ahuja
- Department of Lab Sciences and Molecular Medicine, Army Hospital (Research & Referral), New Delhi, India
| | - Sanjeev Khera
- Department of Pediatrics, Army Hospital (Research & Referral), New Delhi, India
| | - Yanamandra Uday
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India
| | - Rajiv Kumar
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India.,Department of Internal Medicine, INHS Asvini, Mumbai, India
| | - Rajan Kapoor
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India.,Department of Internal Medicine, Command Hospital (Eastern Command), Kolkata, India
| | - Tarun Verma
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India
| | - Sanjeevan Sharma
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India.,Department of Internal Medicine, Command Hospital (Central Command), Lucknow, India
| | - Jasjit Singh
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India.,Department of Internal Medicine, Command Hospital (Western Command), Chandimandir, India
| | - Satyaranjan Das
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India.,Department of Internal Medicine, Command Hospital (Southern Command), Pune, India
| | - Tathagat Chatterjee
- Department of Lab Sciences and Molecular Medicine, Army Hospital (Research & Referral), New Delhi, India
| | - Ajay Sharma
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India.,Department of Clinical Hematology and Stem Cell Transplant, Sir Ganga Ram Hospital, New Delhi, India
| | - Velu Nair
- Department of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), New Delhi, 110010 India.,Haemato-Oncology & Bone Marrow Transplant, Medical Services & Comprehensive Blood & Cancer Center (CBCC), Ahmedabad, India
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22
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Wang YM, Yu YF, Liu Y, Liu S, Hou M, Liu XG. The association between antinuclear antibody and response to rituximab treatment in adult patients with primary immune thrombocytopenia. ACTA ACUST UNITED AC 2020; 25:139-144. [PMID: 32167032 DOI: 10.1080/16078454.2020.1740430] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Antinuclear antibodies (ANAs) can be detected in about 30% of patients with primary immune thrombocytopenia (ITP), yet their relationship with treatment response to rituximab remains elusive.Methods: we retrospectively reviewed the clinical records of hospitalized adult ITP patients who were treated with rituximab from three medical centers across China. Rituximab was given intravenously at 100 mg weekly for 4 weeks, or at a single dose of 375 mg/m2. All included patients had their ANAs tested before rituximab treatment.Results: A total of 287 patients fulfilled the inclusion criteria and were eligible for analysis. ANAs were positive in 98 (34.1%) of the included patients. The incidence of overall response and complete response (CR) in ANA-positive patients was significantly higher than that in ANA-negative patients (overall response: 76.5% vs. 55.0%, P < 0.001; CR: 46.9% vs. 29.1%, P = 0.003). However, sustained response (SR) rates in ANA-positive patients at 6, 12 and 24 months were all lower compared with ANA-negative patients (all P < 0.05). The overall duration of response (DOR) estimated by Kaplan-Meier analysis in ANA-negative patients was greater than that in ANA-positive patients (P < 0.001).Conclusion: ITP patients with positive ANA test were likely to achieve a better initial response to rituximab treatment, while their long-term outcome was unfavorable. Therefore, ANA test could be useful for predicting rituximab response in ITP.
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Affiliation(s)
- Yan-Ming Wang
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, People's Republic of China.,Department of Hematology, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, People's Republic of China
| | - Ya-Fei Yu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, People's Republic of China
| | - Yu Liu
- School of Chemistry and Pharmaceutical Engineering, Qilu University of Technology, Jinan, People's Republic of China
| | - Shuang Liu
- Department of Hematology, Taian Central Hospital, Taian, People's Republic of China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, People's Republic of China.,Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Jinan, People's Republic of China
| | - Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, People's Republic of China
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Ma W, Bai W, Wu X, Zhao J, Li M, Zeng X. Successful treatment of refractory thrombotic thrombocytopenic purpura associated with systemic lupus erythematosus with combination of plasma exchange and low-dose rituximab. Lupus 2020; 29:1961-1967. [PMID: 32838618 DOI: 10.1177/0961203320953473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Thrombotic thrombocytopenia purpura (TTP) associated with systemic lupus erythematous (SLE) (i.e., SLE-TTP) is a rare life-threatening disease often requiring intensive immunosuppressive agents, in addition to high-dose corticosteroids and plasma exchange (PEX). The optimal therapy of rituximab is unclear, but 375 mg/m2 weekly for 4 weeks is the usual practice, adopted from regimens for non-Hodgkin's lymphoma. We reported two cases of refractory SLE-TTP that showed good efficacy and prognosis with combination of methylprednisolone (MP) pulse, plasma exchange and low-dose rituximab (100 mg weekly for 4 weeks) treatment. METHODS Clinical data and treatment outcomes were reviewed of two patients diagnosed with refractory SLE-TTP at Peking Union Medical College Hospital between July 2017 and July 2018. RESULTS Both patients had SLE and presented with microangiopathic anemia and thrombocytopenia. Laboratory assays revealed high anti-nuclear antibody titers, reduced complement 3 and 4 levels, proteinuria, significantly elevated lactate dehydrogenase, schistocytes on peripheral blood smear, low ADAMTS13 activity, and the presence of ADAMTS13 inhibitor. In both patients, platelet counts remained below 50 × 109/L after MP pulse and 6 PEXs, confirming the diagnosis of refractory SLE-TTP. Low-dose rituximab (100 mg weekly for 4 weeks) was administered in both cases, resulting in normalization of platelet counts and significant reductions in B-lymphocyte counts. No TTP relapse or SLE flare occurred during 24 months of follow-up. CONCLUSIONS Our cases confirmed the efficacy and good follow-up outcomes of low-dose rituximab treatment (100 mg weekly for 4 weeks) for refractory SLE-TTP.
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Affiliation(s)
- Wanlu Ma
- Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Bai
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Xueyan Wu
- Department of Endocrinology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Sciences, Beijing, China.,National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, China.,Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China.,Chinese Rheumatism Data Center (CRDC), Chinese SLE Treatment and Research Group (CSTAR)
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Pantić N, Suvajdžić-Vuković N. Treating ITP: What are the options in the era of new guidelines and new drugs? MEDICINSKI PODMLADAK 2020. [DOI: 10.5937/mp71-28216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disease characterized by isolated thrombocytopenia. Treating ITP may be challenging since different treatment modalities are available. While choosing the suitable option for every patient, a physician should take into account both patient's medical characteristics and wishes. The first line treatment options include: corticosteroids, intravenous immunoglobulins and intravenous anti-D immunoglobulin. Second line treatment options comprise medical (thrombopoietin receptor agonists, rituximab, fostamatinib, azathioprine, cyclophosphamide, cyclosporin A, hydroxychloroquine, mycophenolate mofetil, danazol, dapsone, vinca-alcaloids) and surgical (splenectomy) approach. However, there are some treatment gaps which remain uncovered with existing treatment modalities. Therefore, development of novel therapeutic strategies is required. The aim of this review is to provide an illustrative overview of novel treatments for adult ITP.
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