Thrombopoetin receptor agonist therapy in thrombocytopenia: ITP and beyond

Unusual symptoms reveal a rare splenic lymphoma: a case report of PS-DLBCL with neck and shoulder pain as the initial presentation

The rare occurrence of diffuse large B-cell lymphoma (DLBCL) limited to the spleen presents difficulties in diagnosis. A case report details a patient whose initial symptoms were neck and shoulder pain, subsequently diagnosed as spontaneous spleen rupture, a rare complication of primary splenic lymphoma. Following a splenectomy, the patient was confirmed to have primary splenic DLBCL and made a good postoperative recovery. This report highlights the diagnostic dilemmas in atypical presentations, where neck and shoulder pain may be the only early sign of a neglected spleen rupture, lacking typical symptoms of the underlying disease. In cases of patients who are not stable, the recommended first imaging method is a focused assessment using sonography for trauma (FAST), as CT scans have a high level of sensitivity. Treatment is determined by hemodynamic status, with conservative management for stable patients and surgical intervention for unstable patients. The importance of recognizing spontaneous spleen rupture as a critical yet uncommon possibility in acute abdominal cases, especially in instances of primary splenic DLBCL, is emphasized in the report.

Real-world, single-center experience of SARS-CoV-2 vaccination in immune thrombocytopenia

BACKGROUND

Immune thrombocytopenic purpura (ITP) relapse following vaccination remains poorly reported in the adult population.

OBJECTIVES

This report details real world data from the largest single-center cohort of ITP relapse following severe acute respiratory syndrome (SARS-CoV-2) vaccination.

METHODS

The vaccination status of 294 patients under active follow-up was reviewed. A total of 17 patients were identified resulting in an incidence of ITP relapse following SARS-CoV-2 vaccination in this cohort of 6.6% and an incidence of newly diagnosed ITP following SARS-CoV-2 vaccination of 1.4%.

RESULTS

Patients were noted to develop marked deviation of platelet count from baseline following vaccination (P =< .0001). Fourteen patients had a prior diagnosis of ITP and median follow-up following diagnosis was 4 years (range 0-45 years). Days from vaccination to presentation ranged from 2-42 (median 14) and the follow-up period was 34 weeks. Fifteen patients (88%) presented with symptoms and all 17 patients developed symptoms during the follow-up period. Nine patients (53%) received a second dose of vaccine during the follow-up period with seven patients (78%) requiring therapeutic support to facilitate second vaccination. Decision to treat patients was multi-factorial and aimed at decreasing bleeding symptoms and obtaining a platelet count >30 × 109 /L. Sixteen patients (94%) required therapeutic intervention and at the end of the follow-up period, four patients (24%) remained unresponsive to treatment with a platelet count <30 × 109 /L.

CONCLUSION

Vaccination of ITP patients continues to have important clinical benefit; however, recommendations for patients who relapse remain lacking. This report outlines the real-world patient outcomes in the era of widespread SARS-CoV-2 vaccination.

Effect of Cytokine Gene Polymorphisms on Eltrombopag Reactivity in Japanese Patients with Immune Thrombocytopenia

BACKGROUND

Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by low platelet counts resulting from antiplatelet autoantibodies. Analysis of polymorphisms in cytokine-encoding genes is important for understanding the pathophysiology of ITP and selecting appropriate treatments. We investigated associations between polymorphisms in cytokine-encoding genes and responses to therapy in Japanese patients with ITP.

METHODS

The participants in this study comprised 153 patients with ITP and 70 healthy controls. We extracted data on sex, age, platelet counts, bleeding symptoms, and therapeutic responses, including those to prednisolone (PSL) and eltrombopag. Genomic DNA was isolated from peripheral blood and polymorphisms in TNF-α, IL-10, TGF-β1, and IFN-γ genes were analyzed using the PCR-SSP method.

RESULTS

Our results showed that the TGF-β1 +869 C/C genotype might be related to ITP in Japanese patients. The IL-10 -592 C/C and A/A, -819 C/C and T/T, and -1082, -819, -592 ATA/ATA genotypes might be associated with reactivity to PSL. Furthermore, the IL-10 -592 C/A -819 C/T genotypes, IL-10 ACC/ATA genotype, and TGF-β1 +869 T/T and T/C genotypes might be linked to the response to eltrombopag.

CONCLUSION

Our results indicate that analysis of polymorphisms in cytokine-encoding genes could aid in understanding PSL and eltrombopag responsiveness in Japanese patients with ITP.

Immune thrombocytopenia in adults: A single-centre review of demographics, clinical features and treatment outcomes

OBJECTIVES

Primary immune thrombocytopenia (ITP) is a bleeding disorder characterised by an isolated thrombocytopenia in the absence of an alternative diagnosis. The condition is highly heterogeneous with some patients requiring multiple of therapy before achieving response. In this study, we collected data on a large cohort of primary ITP patients with the objective of identifying variables which may predict treatment requirements.

METHODS

We collected data on 379 patients, 275 with a confirmed diagnosis of primary ITP included demographics, baseline laboratory results and treatments. These were compared against treatment responses and lines of therapy.

RESULTS

Patients who presented with a platelet count of <30 × 10⁹ /L or bleeding symptoms were observed to require more subsequent lines of therapy (P-value <0.001). 32% of patients (n = 87) received no treatment, and these patients had a significantly higher median count compared to those with required >2 lines of therapy (P-value <0.001). Superior response rates were demonstrated with thrombopoietin receptor agonists when compared with other agents irrespective of baseline characteristics.

CONCLUSIONS

Platelet counts at diagnosis are a potentially strong predictive indicator of subsequent lines of therapy. Patients with bleeding symptoms at diagnosis were more likely to have lower median platelets counts.

Updated international consensus report on the investigation and management of primary immune thrombocytopenia

Over the last decade, there have been numerous developments and changes in treatment practices for the management of patients with immune thrombocytopenia (ITP). This article is an update of the International Consensus Report published in 2010. A critical review was performed to identify all relevant articles published between 2009 and 2018. An expert panel screened, reviewed, and graded the studies and formulated the updated consensus recommendations based on the new data. The final document provides consensus recommendations on the diagnosis and management of ITP in adults, during pregnancy, and in children, as well as quality-of-life considerations.

Efficacy and Safety of Avatrombopag in Patients With Thrombocytopenia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Avatrombopag is a novel oral, nonpeptide thrombopoietin receptor agonist (TPO-RA). A few studies have shown that avatrombopag is effective against thrombocytopenia. However, no systematic review has been conducted on the efficacy and safety of avatrombopag. Therefore, the aim of this study was to comprehensively assess the efficacy and safety of avatrombopag patients with thrombocytopenia. Methods: Databases including Medline, PubMed, Embase, the Cochrane Library and ClinicalTrials.gov were searched for randomized controlled trials that compared avatrombopag with placebo in patients with thrombocytopenia. The deadline was March 2019. Results: In total, 743 patients were analyzed in five clinical trials. Patients treated with avatrombopag achieved higher platelet response (OR: 17.71, 95% CI [11.01 to 28.48], p < 0.00001) than with placebo. Avatrombopag produced an absolute increment in platelet count (WMD: 31.13%, 95% CI [22.27 to 39.99], p < 0.00001) unlike the placebo. In addition, the incidence of serious adverse events (RR: 1.18, 95% CI [0.72 to 1.93], p = 0.51) and deaths (RR: 0.93, 95% CI [0.19 to 4.45], p = 0.93) in patients treated with avatrombopag was not significantly different from that in patients treated with placebo. The incidence of adverse events in patients treated with avatrombopag was slightly higher than that in patients treated with placebo (RR: 1.25, 95% CI [1.05 to 1.49], p = 0. 01) after one trial with high heterogeneity was removed. Conclusions: This meta-analysis showed that avatrombopag was an effective treatment for thrombocytopenia, but there is sufficient evidence to indicate that adverse events may occur.