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Wang W, Xu X, Xu Y, Zhan Y, Wu C, Xiao X, Cheng C, Gao C. Quercetin, a key active ingredient of Jianpi Zishen Xiehuo Formula, suppresses M1 macrophage polarization and platelet phagocytosis by inhibiting STAT3 activation based on network pharmacology. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:4219-4233. [PMID: 38055068 DOI: 10.1007/s00210-023-02870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune hemorrhagic disease, and abnormal M1 macrophage polarization participates in the pathogenesis of ITP. Jianpi Zishen Xiehuo (JZX) Formula has a good therapeutic effect on ITP. However, its key active ingredients and molecular mechanisms remain unclear. In this study, we explored the key active ingredients and potential targets of JZX in treating ITP using network pharmacology combined with in vitro experimental verification. A total of 157 active ingredients of JZX were identified from public databases, and quercetin was the most important one. One hundred sixty-five intersection targets of active ingredients in JZX, ITP, and macrophage polarization were obtained by Venn diagram. The top three potential targets were signal transducer and activator of transcription 3 (STAT3), protein kinase B (PKB/AKT) 1, and c-JUN through protein-protein interaction analysis. Molecular docking showed that quercetin had strong binding affinities with them all. In vitro experiment, CD16+ monocytes increased in ITP patients compared with healthy controls, which indicated a M1/M2 polarization imbalance in ITP. The expression levels of M1 polarization markers, CD86, CD80, and inducible nitric oxide synthase (iNOS), M1 polarization-associated cytokines, tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6), and antibody-opsonized platelet phagocytosis significantly increased in THP-1 macrophages stimulated with lipopolysaccharide (LPS). Quercetin markedly inhibited the expressions of M1 markers, decreased the levels of TNF-α and IL-6, and down-regulated the phosphorylated STAT3 (p-STAT3) protein, which confirmed the prediction by network pharmacology and molecular docking. Importantly, quercetin significantly reduced the phagocytosis of antibody opsonised platelet. In conclusion, quercetin suppressed platelet phagocytosis in M1 macrophages via its anti-inflammatory effects and may serve as a potential drug for the treatment of ITP. Quercetin could be a key ingredient for JZX against ITP.
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Affiliation(s)
- Wei Wang
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Xuewen Xu
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Yang Xu
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Yueping Zhan
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Chuanyong Wu
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Xiao Xiao
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Cheng Cheng
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China
| | - Chunfang Gao
- Clinical Laboratory Medicine Center, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, 110 Gan He Road, Shanghai, 200437, China.
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2
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Lambert C, Maitland H, Ghanima W. Risk-based and individualised management of bleeding and thrombotic events in adults with primary immune thrombocytopenia (ITP). Eur J Haematol 2024; 112:504-515. [PMID: 38088207 DOI: 10.1111/ejh.14154] [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: 09/27/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 03/19/2024]
Abstract
Although bleeding is one of the main symptoms of primary immune thrombocytopenia (ITP), risk factors for bleeding have yet to be fully established. Low platelet count (PC; <20-30 × 109 /L) is generally indicative of increased risk of bleeding. However, PC and bleeding events cannot be fully correlated; many other patient- and disease-related factors are thought to contribute to increased bleeding risk. Furthermore, even though ITP patients have thrombocytopenia and are at increased risk of bleeding, ITP also carries higher risk of thrombotic events. Factors like older age and certain ITP treatments are associated with increased thrombotic risk. Women's health in ITP requires particular attention concerning haemorrhagic and thrombotic complications. Management of bleeding/thrombotic risk, and eventually antithrombotic therapies in ITP patients, should be based on individual risk profiles, using a tailored, patient-centric approach. Currently, evidence-based recommendations and validated tools are lacking to support decision-making and help clinicians weigh risk of bleeding against thrombosis. Moreover, evidence is lacking about optimal PC for achieving haemostasis in invasive procedures settings. Further research is needed to fully define risk factors for each event, enabling development of comprehensive risk stratification approaches. This review discusses risk-based and individualised management of bleeding and thrombosis risk in adults with primary ITP.
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Affiliation(s)
- Catherine Lambert
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Hillary Maitland
- Division of Hematology and Oncology, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Waleed Ghanima
- Department of Hemato-oncology, Østfold Hospital, Oslo University, Oslo, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
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3
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Moulis G, Rueter M, Duvivier A, Mahévas M, Viallard JF, Comont T, Chèze S, Audia S, Ebbo M, Terriou L, Lega JC, Jeandel PY, Hemim I, Bozzi S, Daak A, Okada H, Bonnotte B, Michel M, Lapeyre-Mestre M, Godeau B. Difficult-to-treat primary immune thrombocytopenia in adults: Prevalence and burden. Results from the CARMEN-France registry. Br J Haematol 2024; 204:1476-1482. [PMID: 38267268 DOI: 10.1111/bjh.19288] [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: 07/15/2023] [Revised: 11/25/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024]
Abstract
The aim of this study was to assess the prevalence and the burden of difficult-to-treat primary ITP (pITP), defined by the need for another ITP treatment after romiplostim and eltrombopag. Adult patients were selected in the prospective, real-world CARMEN-France registry up to December 2021. Out of 821 adult patients with pITP, 29 had difficult-to-treat ITP (3.5%; 95% confidence interval [CI]: 2.3%-4.8% in total; 7.6%; 95% CI: 4.9%-10.2% of patients needing ≥2nd line treatment). The 3-year cumulative incidence of bleeding, infection and thrombosis was 100%, 24.1% and 13.8% respectively. The median cumulative duration of hospital stays was 31 days (median follow-up: 30.3 months).
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Affiliation(s)
- Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center, Toulouse University Hospital, Toulouse, France
| | - Manuela Rueter
- Clinical Investigation Center, Toulouse University Hospital, Toulouse, France
| | | | - Matthieu Mahévas
- Department of Internal Medicine, National Referral Center for Autoimmune Cytopenias, Créteil University Hospital, Créteil, France
| | | | - Thibault Comont
- Department of Internal Medicine, Toulouse Cancer University Hospital, Toulouse, France
| | - Stéphane Chèze
- Department of Hematology, Caen University Hospital, Caen, France
| | - Sylvain Audia
- Department of Internal Medicine, Dijon University Hospital, Dijon, France
| | - Mikaël Ebbo
- Department of Internal Medicine, Marseille University Hospital, Marseille, France
| | - Louis Terriou
- Department of Internal Medicine, Lille University Hospital, Lille, France
| | | | | | | | | | | | | | - Bernard Bonnotte
- Department of Internal Medicine, Dijon University Hospital, Dijon, France
| | - Marc Michel
- Department of Internal Medicine, National Referral Center for Autoimmune Cytopenias, Créteil University Hospital, Créteil, France
| | - Maryse Lapeyre-Mestre
- Clinical Investigation Center, Toulouse University Hospital, Toulouse, France
- Department of Clinical Pharmacology, Toulouse University Hospital, Toulouse, France
| | - Bertrand Godeau
- Department of Internal Medicine, National Referral Center for Autoimmune Cytopenias, Créteil University Hospital, Créteil, France
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4
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Madkhali MA. Recent advances in the management of immune thrombocytopenic purpura (ITP): A comprehensive review. Medicine (Baltimore) 2024; 103:e36936. [PMID: 38241567 PMCID: PMC10798712 DOI: 10.1097/md.0000000000036936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/20/2023] [Indexed: 01/21/2024] Open
Abstract
Autoimmune disorders place a substantial burden on the healthcare system all over the world affecting almost 3% to 8% of the population. Immune thrombocytopenic purpura (ITP), also known as idiopathic thrombocytopenic purpura, is a blood disorder in which the body immune system destroys platelets, leading to low platelet counts in the blood (peripheral blood platelet count < 150 × 109/L). Although the pathophysiology of ITP is not fully understood, it is believed to result from a complex interplay between hereditary and environmental variables. Certain factors, such as a low platelet count, history of bleeding, and certain comorbidities can increase the risk of severe bleeding in patients with ITP. Corticosteroids, intravenous immunoglobulin (IVIG), immunosuppressants, rituximab, and thrombopoietin receptor agonists (TPO-RAs) are some of the advanced treatments for ITP. Although these therapies may be successful, they also carry the risk of negative effects. Recently, significant advancements have been made in the understanding and treatment of ITP. There is still much to learn about the disease, and new, more effective treatments are needed. This comprehensive review offers a comprehensive assessment of recent advancements in ITP management, with a focus on active research projects, novel therapeutic targets, new treatment modalities, and areas of uncertainty and unmet needs. According to research, it is crucial to develop individualized treatment plans for ITP patients based on their age, platelet count, risk of bleeding, and comorbidities. The article also looks at how future developments in gene editing, bispecific antibody therapies, and cellular therapy may completely change the treatment of ITP.
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Affiliation(s)
- Mohammed Ali Madkhali
- Department of Internal Medicine, Division of Hematology and Oncology, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
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Foy P, Friedman KD, Michaelis LC. How I diagnose and treat thrombocytopenia in geriatric patients. Blood 2024; 143:214-223. [PMID: 37956435 DOI: 10.1182/blood.2022017634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 07/31/2023] [Accepted: 08/16/2023] [Indexed: 11/15/2023] Open
Abstract
ABSTRACT Thrombocytopenia in older individuals is a common but diagnostically challenging condition that has variable clinical impact to those who are affected. Diagnostic approach requires evaluation of the preexisting clinical conditions, detailed review of medications, and assessment for disorders that warrant urgent treatment. In this article, we describe a systematic approach to diagnosis of thrombocytopenia and present a schematic review for management strategies. Three clinical scenarios are presented that are relevant for their prevalence and management challenges in an older adult population. The first scenario addresses primary immune thrombocytopenia (ITP) and reviews different treatment options. The second one addresses complications of thrombocytopenia in management of the myelodysplastic syndrome. The last one reviews diagnostic challenges of drug-induced ITP.
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Affiliation(s)
- Patrick Foy
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Laura C Michaelis
- Department of Medicine, Division of Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI
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6
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Sirotich E, Nazaryan H, Chowdhury SR, Guyatt G, Agarwal A, Leong R, Wen A, Xu E, Liu B, Pallapothu S, Rathod P, Kwon HY, Dookie J, Shafiee A, Charness J, DiRaimo J, Paynter D, Pruitt B, Strachan G, Couban R, Ye Z, Arnold DM. Treatment of critical bleeding events in patients with immune thrombocytopenia: a protocol for a systematic review and meta-analysis. Syst Rev 2024; 13:21. [PMID: 38184622 PMCID: PMC10770981 DOI: 10.1186/s13643-023-02436-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 12/13/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Critical bleeding events in adults and children with ITP are medical emergencies; however, evidence-based treatment protocols are lacking. Due to the severe thrombocytopenia, (typically platelet count less than 20 × 109/L), a critical bleed portends a high risk of death or disability. We plan to perform a systematic review and meta-analysis of treatments for critical bleeding in patients with ITP that will inform evidence-based recommendations. METHODS Literature searches will be conducted in four electronic databases: Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed. Eligible studies will be randomized controlled trials or observational studies that enrolled patients with ITP describing one or more interventions for the management of critical bleeding. Title and abstract screening, full-text screening, data extraction, and risk of bias evaluation will be conducted independently and in duplicate using Covidence and Excel. Outcomes will be pooled for meta-analysis where appropriate or summarized descriptively. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology will be used to evaluate the certainty of the evidence. Primary outcomes of interest will include frequency of critical bleeds, mortality and bleeding-related mortality, bleeding resolution, platelet count, and disability. DISCUSSION Evidence-based treatments for critical bleeding in patients with ITP are needed to improve patient outcomes and standardize care in the emergency setting. SYSTEMATIC REVIEW REGISTRATION CRD42020161206.
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Affiliation(s)
- Emily Sirotich
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Hasmik Nazaryan
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Saifur Rahman Chowdhury
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Russell Leong
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Aaron Wen
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Emily Xu
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Bonnie Liu
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Sushmitha Pallapothu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Preksha Rathod
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Henry Y Kwon
- Department of Surgery, Henry Ford Health Systems, Detroit, MI, USA
| | - Jared Dookie
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Amirmohammad Shafiee
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Jay Charness
- Platelet Disorder Support Association (PDSA), Cleveland, OH, USA
| | - Jennifer DiRaimo
- Platelet Disorder Support Association (PDSA), Cleveland, OH, USA
| | - Dale Paynter
- Platelet Disorder Support Association (PDSA), Cleveland, OH, USA
| | - Barbara Pruitt
- Platelet Disorder Support Association (PDSA), Cleveland, OH, USA
| | - Gail Strachan
- Platelet Disorder Support Association (PDSA), Cleveland, OH, USA
| | - Rachel Couban
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Zhikang Ye
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Donald M Arnold
- Michael G. DeGroote Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada.
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Moulinet T, Moussu A, Pierson L, Pagliuca S. The many facets of immune-mediated thrombocytopenia: Principles of immunobiology and immunotherapy. Blood Rev 2024; 63:101141. [PMID: 37980261 DOI: 10.1016/j.blre.2023.101141] [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: 08/30/2023] [Revised: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 11/20/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune condition, due to peripheral platelet destruction through antibody-dependent cellular phagocytosis, complement-dependent cytotoxicity, cytotoxic T lymphocyte-mediated cytotoxicity, and megakaryopoiesis alteration. This condition may be idiopathic or triggered by drugs, vaccines, infections, cancers, autoimmune disorders and systemic diseases. Recent advances in our understanding of ITP immunobiology support the idea that other forms of thrombocytopenia, for instance, occurring after immunotherapy or cellular therapies, may share a common pathophysiology with possible therapeutic implications. If a decent pipeline of old and new agents is currently deployed for classical ITP, in other more complex immune-mediated thrombocytopenic disorders, clinical management is less harmonized and would deserve further prospective investigations. Here, we seek to provide a fresh overview of pathophysiology and current therapeutical algorithms for adult patients affected by this disorder with specific insights into poorly codified scenarios, including refractory ITP and post-immunotherapy/cellular therapy immune-mediated thrombocytopenia.
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Affiliation(s)
- Thomas Moulinet
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France
| | - Anthony Moussu
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Ludovic Pierson
- Department of Internal Medicine and Clinical Immunology, Regional Competence Center for Rare and Systemic Auto-Immunes Diseases and Auto-Immune cytopenias, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Simona Pagliuca
- UMR 7365, IMoPA, Lorraine University, CNRS, Nancy, France; Department of Hematology, Regional Competence Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Nancy University Hospital, Vandœuvre-lès-Nancy, France.
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8
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Elsaid M, Nune A, Brakat AM, Anand A, Alashwah M, Maher A, Lama N, Peñamante CAC. Immune thrombocytopenic purpura after influenza vaccine administration; a systematic review and meta-analysis. Trop Dis Travel Med Vaccines 2023; 9:22. [PMID: 38001495 PMCID: PMC10675976 DOI: 10.1186/s40794-023-00206-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/07/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND The American Society of Haematology defines immune thrombocytopenic purpura (ITP) as a common hematologic disorder characterized by a transient or long-term decrease in platelet counts (< 100 × 109/L.), purpura, and haemorrhagic episodes caused by antiplatelet autoantibodies, with the exclusion of other clinical conditions. We aimed to systematically determine the incidence of ITP in adults and children following influenza vaccination, the duration between vaccination and the occurrence of ITP, and to identify predictors of ITP after the vaccine. METHODS We searched PubMed, Cochrane Library, Google Scholar, Web of Science, Scopus, and Science Direct. We included primary studies that assessed the occurrence of immune thrombocytopenia in individuals who had received any influenza vaccine (primary or booster dose), regardless of the dosage, preparation, time of administration, or age of the participants. We excluded studies that were (a) Narrative, scoping, and umbrella reviews ;(b) studies with no accessible full text, abstract-only studies, or (c) Overlapping or unreliable data. The risk of bias in the included studies was assessed using the Joanna Briggs Institute (JBI) tool. We categorized studies for qualitative analysis based on study design. Descriptive statistics were used to summarize quantitative data, including the incidence of ITP after influenza vaccination. RESULTS Out of 729 articles retrieved from the database search, we included 24 studies. All patients identified and included in this systematic review presented with immune thrombocytopenia, determined by their platelet count. The period between vaccination and the occurrence of ITP ranged from (2:35 days). The mean duration was 13.5 days. The analysis revealed a statistically significant incidence rate ratio (IRR) = 1.85,95% CI [1.03-3.32] of ITP occurrence after 42 days. CONCLUSIONS Influenza-associated ITP is uncommon, self-limiting, non-life-threatening, and curable. None of the patients reported having severe adverse events or death. Further studies are required to confirm the exact incidence of the ITP to better understand the pathophysiology of ITP development post-influenza vaccination.
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Affiliation(s)
- Mohamed Elsaid
- Faculty of Medicine, Misr University for Science and Technology, 6th of October, Giza, Egypt.
- Medical Research Platform, Giza, Egypt.
| | - Arvind Nune
- Department of Rheumatology and General Medicine, Southport and Ormskirk Hospital NHS Trust, Southport, UK
| | - Aml M Brakat
- Faculty of Medicine, Zagazig University, Ash Sharqia Governorate, Egypt
- Medical Research Platform, Giza, Egypt
| | - Ayush Anand
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
- Medical Research Platform, Giza, Egypt
| | - Mahmoud Alashwah
- Faculty of Medicine, Cairo University, Cairo, Egypt
- Medical Research Platform, Giza, Egypt
| | - Ahmed Maher
- Faculty of Medicine, Al-Azhar University, New-Damietta, Egypt
- Medical Research Platform, Giza, Egypt
| | - Nitu Lama
- Dr. M. V. Shetty College of Physiotherapy, Rajiv Gandhi University of Health Sciences, Mangaluru, India
- Medical Research Platform, Giza, Egypt
| | - Criselle Angeline C Peñamante
- Department of Clinical Epidemiology, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines
- Department of Psychology, College of Science, University of Santo Tomas, Manila, Philippines
- Medical Research Platform, Giza, Egypt
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9
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Nguyen QH, Tran HTT, Nguyen TM, Nguyen NH. A fatal eosinophilic granulomatosis with polyangiitis case presenting intracerebral hemorrhage and thrombocytopenia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100148. [PMID: 37781664 PMCID: PMC10510003 DOI: 10.1016/j.jacig.2023.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/07/2023] [Accepted: 05/17/2023] [Indexed: 10/03/2023]
Abstract
We report the case of a patient with eosinophilic granulomatosis with polyangiitis and unexplained thrombocytopenia that culminated in a fatal intracerebral hemorrhage. Because vessel damage associated with thrombocytopenia could be the leading cause of fatal hemorrhage, more urgent treatment of thrombocytopenia should be performed in such cases.
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Affiliation(s)
- Quan Hong Nguyen
- Department of Neurology, 108 Central Military Hospital, Hanoi, Vietnam
| | | | - Tuyen Manh Nguyen
- Neurological Intensive Care Unit, 108 Central Military Hospital, Hanoi, Vietnam
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10
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Kaiser R, Escaig R, Nicolai L. Hemostasis without clot formation: how platelets guard the vasculature in inflammation, infection, and malignancy. Blood 2023; 142:1413-1425. [PMID: 37683182 DOI: 10.1182/blood.2023020535] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/23/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Platelets are key vascular effectors in hemostasis, with activation signals leading to fast recruitment, aggregation, and clot formation. The canonical process of hemostasis is well-characterized and shares many similarities with pathological thrombus formation. However, platelets are also crucially involved in the maintenance of vascular integrity under both steady-state and inflammatory conditions by ensuring blood vessel homeostasis and preventing microbleeds. In these settings, platelets use distinct receptors, signaling pathways, and ensuing effector functions to carry out their deeds. Instead of simply forming clots, they mainly act as individual sentinels that swiftly adapt their behavior to the local microenvironment. In this review, we summarize previously recognized and more recent studies that have elucidated how anucleate, small platelets manage to maintain vascular integrity when faced with challenges of infection, sterile inflammation, and even malignancy. We dissect how platelets are recruited to the vascular wall, how they identify sites of injury, and how they prevent hemorrhage as single cells. Furthermore, we discuss mechanisms and consequences of platelets' interaction with leukocytes and endothelial cells, the relevance of adhesion as well as signaling receptors, in particular immunoreceptor tyrosine-based activation motif receptors, and cross talk with the coagulation system. Finally, we outline how recent insights into inflammatory hemostasis and vascular integrity may aid in the development of novel therapeutic strategies to prevent hemorrhagic events and vascular dysfunction in patients who are critically ill.
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Affiliation(s)
- Rainer Kaiser
- Medizinische Klinik und Poliklinik I, University Hospital Ludwig Maximilian University, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Partner Site Munich Heart Alliance, Munich, Germany
| | - Raphael Escaig
- Medizinische Klinik und Poliklinik I, University Hospital Ludwig Maximilian University, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Partner Site Munich Heart Alliance, Munich, Germany
| | - Leo Nicolai
- Medizinische Klinik und Poliklinik I, University Hospital Ludwig Maximilian University, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Partner Site Munich Heart Alliance, Munich, Germany
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11
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Yilmaz S, Dağ M, Kizilarslanoğlu MC, Baştürk A. Can Pseudothrombocytopenia be recognised at first look? Medicine (Baltimore) 2023; 102:e35395. [PMID: 37832120 PMCID: PMC10578760 DOI: 10.1097/md.0000000000035395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/05/2023] [Indexed: 10/15/2023] Open
Abstract
Our aim was to determine the laboratory parameters that distinguish pseudothrombocytopenia from true thrombocytopenia. A total of 107 patients who were referred to the adult hematology outpatient clinic with thrombocytopenia and subsequently diagnosed with acute myeloid leukaemia, immune thrombocytopenia and pseudothrombocytopenia were included in our study. Hemogram parameters on admission, platelet value in the control hemogram and peripheral smear findings were recorded. Forty three (40.2%) males and 64 (59.8%) females, were included in our study. There were 25 patients in the leukaemia group, 39 in the immune thrombocytopenia group and 43 in the pseudothrombocytopenia group. Control platelet value and red cell distribution width/platelet ratio were found to be statistically significantly different between the 3 groups. Receiver operating characteristic analysis based on platelet values showed that platelet value ≤ 38,000/µL (86% sensitivity, 78.1% specificity, P < .001), difference between 2 consecutively measured platelet levels ≤ 11. 000/µL (79.1% sensitivity, 79.7% specificity, P < .001), red cell distribution width/platelet ratio ≥ 0.413 (90.7% sensitivity, 78.1% specificity, P < .001) were found to be in favor of true thrombocytopenia. In the differentiation of pseudothrombocytopenia and true thrombocytopenia, the difference between the hemogram parameters at the time of admission and the platelet count in the control blood count may be guiding. This result may reduce patient and physician anxiety and prevent patient referral.
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Affiliation(s)
- Seda Yilmaz
- Department of Internal Medicine, Clinic of Hematology, Konya City Hospital, Konya, Turkey
| | - Mikail Dağ
- Department of Internal Medicine, Şanliurfa Training and Research Hospital, Şanliurfa, Turkey
| | - Muhammet Cemal Kizilarslanoğlu
- Department of Internal Medicine, Division of Geriatrics, University of Health Sciences, Konya City Hospital, Konya, Turkey
| | - Abdulkadir Baştürk
- Department of Internal Medicine, Clinic of Hematology, Konya City Hospital, Konya, Turkey
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Ollier N, Piel-Julian ML, Mahévas M, Viallard JF, Comont T, Chèze S, Audia S, Ebbo M, Terriou L, Lega JC, Jeandel PY, Bonnotte B, Michel M, Lapeyre-Mestre M, Godeau B, Moulis G. Platelet count threshold for hemorrhage in patients with immune thrombocytopenia treated with antiplatelet agents. Blood 2023; 142:1099-1101. [PMID: 37478400 DOI: 10.1182/blood.2023020311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023] Open
Abstract
A significant proportion of older patients with immune thrombocytopenia (ITP) also have clinical indications for treatment of cardiovascular disease with antiplatelet agents. Ollier and colleagues sought to determine the frequency of bleeding in patients with ITP on aspirin therapy, finding that the pattern of bleeding, segregated by platelet count, is similar to that observed in other adults with ITP not on aspirin. They show that a platelet count of <20 × 109/L is associated with most bleeding in ITP patients on antiplatelet agents.
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Affiliation(s)
- Natasha Ollier
- Department of Internal Medicine, Toulouse University Hospital, France
| | | | - Matthieu Mahévas
- Department of Internal Medicine, National Referral Center for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est Créteil University, France
| | | | - Thibault Comont
- Department of Internal Medicine, Toulouse University Institute for Cancer, France
| | - Stéphane Chèze
- Department of Hematology, Caen University Hospital, France
| | - Sylvain Audia
- Department of Internal Medicine, Dijon University Hospital, France
| | - Mikaël Ebbo
- Department of Internal Medicine, Marseille University Hospital, Assistance Publique-Hôpitaux de Marseille, France
| | - Louis Terriou
- Department of Internal Medicine, Lille University Hospital, France
| | - Jean-Christophe Lega
- Department of Internal Medicine, Lyon University Hospital, Hôpitaux Civils de Lyon, France
| | | | - Bernard Bonnotte
- Department of Internal Medicine, Dijon University Hospital, France
| | - Marc Michel
- Department of Internal Medicine, National Referral Center for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est Créteil University, France
| | - Maryse Lapeyre-Mestre
- Clinical Investigation Center 1436, Team PEPSS (PharmacoEpidemiology, Populations, cohortS, biomarkerS), Toulouse University Hospital, France
- Department of Clinical Pharmacology, Toulouse University Hospital, France
| | - Bertrand Godeau
- Department of Internal Medicine, National Referral Center for Adult's Immune Cytopenias, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Paris-Est Créteil University, France
| | - Guillaume Moulis
- Department of Internal Medicine, Toulouse University Hospital, France
- Clinical Investigation Center 1436, Team PEPSS (PharmacoEpidemiology, Populations, cohortS, biomarkerS), Toulouse University Hospital, France
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13
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Kim Y, Koutsouras GW, Bourdages G, Beutler T. Insidious onset of spontaneous spinal epidural hematoma in immune thrombocytopenic purpura: a case-based review. Childs Nerv Syst 2023; 39:1903-1909. [PMID: 37126139 DOI: 10.1007/s00381-023-05963-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/16/2023] [Indexed: 05/02/2023]
Abstract
INTRODUCTION Spontaneous spinal epidural hematoma (SSEH) can result from various etiologies with a variable degree of neurological deficits. Here, we describe a rare case of SEH secondary to immune thrombocytopenic purpura (ITP) in a child and review the literature of SSEH caused by ITP. CASE REPORT A 9-year-old female who presented with rapid neurological decline, including bowel and bladder incontinence and paraparesis. A SSEH was observed extending from C2 to T6, causing a mass effect on the spinal cord. Her platelet count was only 7000/µL. Multidisciplinary care was established with neurosurgery, pediatric hematology, and pediatric surgery. The patient was managed emergently with splenectomy and surgical evacuation, with multilevel laminectomy and laminoplasty for evacuation of the hematoma. After a short course of rehabilitation, the patient regained all neurological function. CONCLUSION We report the first case of cervicothoracic SSEH secondary to ITP in a child managed with emergent splenectomy and surgical evacuation with multilevel lamoplasty. We also described the methods of timely diagnosis, urgent management, and overall prognosis of patients with this condition.
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Affiliation(s)
- YeonSoo Kim
- Department of Neurosurgery, SUNY Upstate University Hospital, Syracuse, NY, USA
| | - George W Koutsouras
- Department of Neurosurgery, SUNY Upstate University Hospital, Syracuse, NY, USA.
| | - George Bourdages
- Department of Neurosurgery, SUNY Upstate University Hospital, Syracuse, NY, USA
| | - Timothy Beutler
- Department of Neurosurgery, SUNY Upstate University Hospital, Syracuse, NY, USA
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Dong Y, Xia Z, Zhou J, Hu Y, Yue M, Wang Y, Hu M. Risk of thrombotic events in immune thrombocytopenia patients treated with thrombopoietic agents: a systematic review and meta-analysis. Thromb J 2023; 21:69. [PMID: 37353791 DOI: 10.1186/s12959-023-00509-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Immune thrombocytopenia (ITP), which is a well-known hemorrhagic disorder characterized by low platelet counts, has been shown to be associated with the risk of thrombosis. Thrombopoietic agents (TAs) are extensively used as second-line treatments for ITP, effectively reducing the risk of hemorrhage. However, thrombosis, a potential adverse effect of TAs, raises clinical challenges. METHODS The MEDLINE(PubMed), Embase, and the Cochrane Library databases were systematically searched for relevant studies, including both single-arm trials and randomized controlled trials (RCTs), without language restrictions. RESULTS A total of 17 RCTs comprising 2,105 patients and 29 single-arm trials comprising 3,227 patients were included. In the single-arm meta-analysis, the pooled rate of overall thrombotic events in ITP patients receiving TAs was 2.2% (95% CI 1.0% - 3.7%). In RCTs, a higher incidence of thrombosis (33/1425 vs. 4/680) and higher risk ratios (RR) of overall, arterial, and venous thrombotic events (1.73, 95% CI [0.88, 3.39], P = 0.113; RR 1.98, 95% CI [0.80, 4.92], P = 0.141; RR 1.06, 95% CI [0.46, 2.41], P = 0.895, respectively) were observed in the TAs group than in the control group, although the differences were not significant. Subgroup analysis demonstrated that hetrombopag was the only TA with no increased thrombotic risk (rate 0.3% 95% CI [0.0 - 1.5%]; RR 0.76, 95% CI [0.03, 18.41], P = 0.864) compared to eltrombopag, avatrombopag, romiplostim, and rhTPO. Subgroup analyses also revealed that ITP patients with advanced age (3.7% vs. 1.3%, P = 0.132) or with a thrombotic history (3.0% vs. 1.4%, P = 0.257), and patients who received TAs therapy for a long duration (4.7% vs. 0.1%, P < 0.001) had an increased risk of thrombosis. CONCLUSION Our findings suggest ITP patients treated with TAs have a nonsignificantly higher risk of overall, arterial, and venous thrombotic events. Furthermore, hetrombopag is the recommended TA to avoid thrombophilia. Patients receiving long-term TAs, as well as elderly ITP patients or those with a history of thrombosis, face an increased thrombotic risk. In general, clinicians should consider potential thrombotic risks, address underlying risk factors, and ensure ongoing monitoring and follow-up when treating ITP patients with TAs.
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Affiliation(s)
- Yu Dong
- Department of the Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Urology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Zhinan Xia
- Department of Urology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Jie Zhou
- Department of Basic Medicine College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yutao Hu
- Department of the First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ming Yue
- Department of Basic Medicine College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuyong Wang
- Department of Urology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Mengjiao Hu
- Department of Basic Medicine College, Zhejiang Chinese Medical University, Hangzhou, China.
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Fang L, Sun J, Zhao Y, Hou M, Wu D, Chen Y, Yang R, Zhang L. Efficacy and Safety Analysis of Combination Therapy Consisting of Intravenous Immunoglobulin and Corticosteroids versus Respective Monotherapies in the Treatment of Relapsed ITP in Adults. Glob Med Genet 2023; 10:87-96. [PMID: 37228869 PMCID: PMC10205395 DOI: 10.1055/s-0043-1769087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Objective In this study, we aimed to evaluate the efficacy and safety of combination therapy, consisting of intravenous immunoglobulin (IVIg) and corticosteroids, in comparison to respective monotherapies in the treatment of relapsed immune thrombocytopenia (ITP) in adults. Methods A retrospective analysis of clinical data was conducted on 205 adult patients with relapsed ITP who received first-line combination therapy or monotherapy in multiple centers across China from January 2010 to December 2022. The study evaluated the patients' clinical characteristics, efficacy, and safety. Results We found that the proportion of patients with platelet counts in complete response was significantly higher in the combination group (71.83%) compared with the IVIg group (43.48%) and the corticosteroids group (23.08%). The mean PLT max in the combination group (178 × 10 9 /L) was significantly higher than that in the IVIg group (109 × 10 9 /L) and the corticosteroids group (76 × 10 9 /L). Additionally, the average time for platelet counts to reach 30 × 10 9 /L, 50 × 10 9 /L, and 100 × 10 9 /L in the combination group was significantly shorter than in the monotherapy groups. The proportion curves for reaching these platelet counts during treatment were also significantly different from those in the monotherapy groups. However, there were no significant differences in the effective rate, clinical characteristics, and adverse events among the three groups. Conclusion We concluded that combining IVIg and corticosteroids was a more effective and faster treatment for relapsed ITP in adults than using either therapy alone. The findings of this study provided clinical evidence and reference for the use of first-line combination therapy in the treatment of relapsed ITP in adults.
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Affiliation(s)
- Lijun Fang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Jing Sun
- Nanfang Hospital, Southern Medical University, Guangzhou, People's Republic of China
| | - Yongqiang Zhao
- Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Ming Hou
- Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | - Yunfei Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
- Tianjin Institutes of Health Science, Tianjin, People's Republic of China
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Dumic I, Charokopos A, Parmar A, Grant CR, Cosiquien RJS, Dagnon da Silva M, Petcu E. Drug-Induced Thrombocytopenia Due to Nintedanib during Treatment of Idiopathic Pulmonary Fibrosis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050999. [PMID: 37241231 DOI: 10.3390/medicina59050999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/28/2023]
Abstract
Nintedanib is a tyrosine kinase inhibitor that was approved for the treatment of patients with idiopathic pulmonary fibrosis in 2014. The most common side effect of Nintedanib is diarrhea, and thrombocytopenia is a rare side effect of Nintedanib. The exact mechanism is unknown, and the literature lacks case reports of this phenomenon. Here, we report the case of a patient who developed thrombocytopenia 12 weeks after starting treatment with Nintedanib. The patient underwent an extensive work up for infectious, hematological, autoimmune, and neoplastic diseases. The patient's thrombocytopenia resolved following cessation of Nintedanib. This case is significant as it reports a rare side effect that might have detrimental consequences if not recognized and treated timely. Additionally, the onset of thrombocytopenia was delayed, 3 months after the initiation of Nintedanib. We also highlight the various literature regarding drug-induced thrombocytopenia and explore the necessary work-up needed to exclude other potential diagnoses. We hope to advocate for multidisciplinary teams to be aware of patients with pulmonary fibrosis on Nintedanib so that this adverse effect can be recognized promptly.
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Affiliation(s)
- Igor Dumic
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Antonios Charokopos
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Pulmonary Medicine and Critical Care, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Angadabir Parmar
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Christopher R Grant
- Department of Internal Medicine, University of California, Irvine, CA 92697, USA
| | | | | | - Emilia Petcu
- Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
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Zhong H, Xue Y, Zhang L, Yang Y, Zhou J, Zhang S, Jiang N, Qiao L, Peng L, Wang L, Zhang W, Xu D, Li M, Zhao Y, Zeng X. Predictive value of bone marrow megakaryocyte count for immunotherapeutic response in primary Sjögren's syndrome patients with severe immune thrombocytopenia: A single-center case-control study in China. Int J Rheum Dis 2023. [PMID: 37183556 DOI: 10.1111/1756-185x.14707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 03/25/2023] [Accepted: 04/08/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVES To investigate potential predictors of treatment response in primary Sjögren's syndrome (pSS) patients with severe immune thrombocytopenia (ITP), with a focus on bone marrow megakaryocyte (MK) count. METHODS This case-control study included patients with pSS and severe ITP who were admitted to Peking Union Medical College Hospital and met the 2002 AECG or 2016 American College of Rheumatology / European League Against Rheumatism criteria for SS. Patients who had overlap other connective tissue diseases and with thrombocytopenia that could be explained by other causes were excluded. Severe ITP was defined as platelet count <20 × 109 /L. Response was evaluated at 3 months after treatment. RESULTS Sixty-eight eligible patients were included: 34 (50%) achieved complete remission (CR), 18 (26%) partial remission (PR) and 16 (24%) were non-responders (NRs). Fewer infections were found in the CR group (24%) than in the PR (50%) and NR (56%) groups (P = 0.04). The MK count (CR 32 vs PR 36 vs NR 4 per slide, P < 0.001) in the NR group was significantly lower than in the other groups. MK count >6.5 per slide predicted good treatment response, with 85.7% sensitivity, 88.1% specificity and 0.866 area under the curve. Logistic regression indicated that patients with more MKs were more likely to respond to immunotherapy (crude odds ratio [OR] 1.45, 95% CI 1.2-2.0, adjusted OR 1.68, 95% CI 1.2-2.7). CONCLUSIONS MK count predicted response to immunosuppressive treatment in pSS patients with severe ITP. These patients are recommended to have bone marrow aspiration before treatment initiation. Clinicians should be aware of screening for infections during clinical practice.
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Affiliation(s)
- Hui Zhong
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yuan Xue
- Department of Rheumatology, Beijing Children's hospital, Capital Medical University, Beijing, China
| | - Li Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yunjiao Yang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiaxin Zhou
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Nan Jiang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Lin Qiao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Linyi Peng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Dong Xu
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Rivière E, Thiébaut R, Lazaro E, Guy A, James C, Mansier O, Blanco P, Viallard JF. Assessment of circulating blood lymphocytes in adult patients on rituximab to treat immune thrombocytopenia: Circulating number of NK cells is associated with the response at 6 months. Br J Haematol 2023. [PMID: 37081607 DOI: 10.1111/bjh.18818] [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: 11/30/2022] [Revised: 03/19/2023] [Accepted: 04/09/2023] [Indexed: 04/22/2023]
Abstract
Immune thrombocytopenia (ITP) is defined by a low platelet count that can trigger potentially life-threatening haemorrhages. Three-quarters of adult patients exhibit persistent or chronic disease and require second-line treatments. Among these, rituximab, an anti-CD20 antibody, has yielded valuable results, with global responses in 60% of patients at 6 months and complete responses in 30% at 5 years. Factors predictive of response to ITP therapy would help physicians choose optimal treatments. We retrospectively analysed clinical courses, biological markers and blood lymphocyte subset numbers of 72 patients on rituximab to treat persistent/chronic ITP followed-up in our department between 2007 and 2021, divided into three groups according to the platelet count at 6 months: complete, partial or no response. Among all studied parameters, a low number of CD3- CD16+ CD56+ circulating NK cells was associated with the complete response to rituximab. We also found that, after rituximab therapy, complete responders exhibited increased NK and decreased activated CD8+ T cell percentages. These results emphasize that the role played by NK cells in ITP remains incompletely known but that factors predictive of response to rituximab can be easily derived using blood lymphocyte subset data.
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Affiliation(s)
- Etienne Rivière
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- INSERM U1034, Bordeaux University, Pessac Cedex, France
| | - Rodolphe Thiébaut
- Department of Public Health, University of Bordeaux, INSERM U1219 Bordeaux Population Health Research Centre, Inria SISTM, UMR 1219, Bordeaux, France
- Department of Medical Information, University Hospital Centre of Bordeaux, Bordeaux, France
| | - Estibaliz Lazaro
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- UMR CNRS 5164, ImmunoconcEpT & FHU ACRONIM, Bordeaux University, Bordeaux, France
| | - Alexandre Guy
- INSERM U1034, Bordeaux University, Pessac Cedex, France
- Laboratory of Hematology, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
| | - Chloé James
- INSERM U1034, Bordeaux University, Pessac Cedex, France
- Laboratory of Hematology, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
| | - Olivier Mansier
- INSERM U1034, Bordeaux University, Pessac Cedex, France
- Laboratory of Hematology, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
| | - Patrick Blanco
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- UMR CNRS 5164, ImmunoconcEpT & FHU ACRONIM, Bordeaux University, Bordeaux, France
| | - Jean-François Viallard
- Internal Medicine and Infectious Diseases Unit, Haut-Leveque Hospital, University Hospital Centre of Bordeaux, Pessac, France
- INSERM U1034, Bordeaux University, Pessac Cedex, France
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Liu X, Zhou H, Hu Y, Yin J, Li J, Chen W, Huang R, Gong Y, Luo C, Mei H, Ding B, Gu C, Sun H, Leng Y, Ji D, Li Y, Yin H, Shi H, Chen K, Wang J, Fan S, Su W, Yang R. Sovleplenib (HMPL-523), a novel Syk inhibitor, for patients with primary immune thrombocytopenia in China: a randomised, double-blind, placebo-controlled, phase 1b/2 study. Lancet Haematol 2023:S2352-3026(23)00034-0. [PMID: 37028433 DOI: 10.1016/s2352-3026(23)00034-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Spleen tyrosine kinase (Syk) inhibitor is a treatment option for primary immune thrombocytopenia. We aimed to evaluate the safety, tolerability, pharmacokinetics, preliminary activity, and recommended phase 2 dose of sovleplenib in patients with primary immune thrombocytopenia. METHODS This randomised, double-blind, placebo-controlled, phase 1b/2 study was conducted at nine hospitals in China. Eligible patients were aged 18-75 years, had an ECOG performance score of 0-1, had primary immune thrombocytopenia for more than 6 months, and did not respond or relapsed after previous first-line treatment or had poor response or postoperative relapse after a splenectomy. Dose-escalation (100 mg, 200 mg, or 300 mg given orally once a day) and dose-expansion phases (recommended phase 2 dose) each consisted of an 8-week, double-blind, placebo-controlled period in which patients were randomly assigned (3:1) to receive sovleplenib or placebo with an interactive web response system followed by a 16-week, open-label period with sovleplenib. Patients, investigators, and the sponsor were masked to treatment allocation during the first 8 weeks. The main efficacy endpoint was the proportion of patients whose platelet count reached 30 × 109 platelets per L or higher and was double of the baseline at two consecutive visits during 0-8 weeks without rescue therapy. Efficacy was evaluated by intention-to-treat. This study is registered with ClinicalTrials.gov, NCT03951623. FINDINGS Between May 30, 2019, and April 22, 2021, 62 patients were assessed for eligibility and 45 (73%) were randomly assigned. Patients received at least one dose of the study drug during the 8-week double-blind period (placebo [n=11] and sovleplenib 100 mg [n=6], 200 mg [n=6], 300 mg [n=16], and 400 mg [n=6]; this group was added following the observation of no protocol-specified safety events at the previous doses). All participants were Asian; 18 (40%) of 45 were male and 27 (60%) were female. The median age was 40·0 years (IQR 33·0-50·0). Ten (29%) of 34 patients in sovleplenib groups versus five (45%) of 11 in the placebo group received concomitant anti-primary immune thrombocytopenia therapy. The recommended phase 2 dose was determined as 300 mg once a day. The proportion of patients who met the main efficacy endpoint were three (50%; 95% CI 12-88) in the 100 mg group, three (50%; 12-88) in the 200 mg group, ten (63%; 35-85) in the 300 mg group, and two (33%; 4-78) in the 400 mg group compared with one (9%; 0-41) in the placebo group. The overall response rate in the 300 mg group was 80% (16 of 20 who received continuous sovleplenib plus those who crossed over from placebo) and the durable response rate was 31% (11-59; five of 16) in the continuous sovleplenib 300 mg and 75% (19-99; three of four) crossed from placebo to sovleplenib during 0-24 weeks. During the 28-day safety evaluation period, two grade 2 or worse treatment-related treatment-emergent adverse events occurred in the sovleplenib groups (hypertriglyceridaemia and anaemia). During 0-8 weeks, the most frequent treatment-emergent adverse events were an increase in blood lactate dehydrogenase, haematuria, and urinary tract infection (seven [21%] of 34 in sovleplenib groups vs one [9%] of 11 in the placebo group); and occult blood-positive and hyperuricaemia (four [12%] vs three [27%] for each). No fatal treatment-emergent adverse events were recorded. INTERPRETATION Sovleplenib was well tolerated, and the recommended phase 2 dose showed a promising durable response in patients with primary immune thrombocytopenia, which provides evidence for future investigations. A phase 3 trial is ongoing (NCT05029635) to confirm the efficacy and safety of sovleplenib in patients with primary immune thrombocytopenia. FUNDING HUTCHMED.
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Affiliation(s)
- Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China
| | - Hu Zhou
- Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Yu Hu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Yin
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Junmin Li
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenming Chen
- Beijing Chaoyang Hospital of Capital Medical University, Beijing, China
| | - Ruibin Huang
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuping Gong
- West China Hospital of Sichuan University, Chengdu, China
| | - Chengwei Luo
- Guangdong Provincial People's Hospital, Guangzhou, China
| | - Heng Mei
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bingjie Ding
- Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Chengyuan Gu
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Huiping Sun
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yun Leng
- Beijing Chaoyang Hospital of Capital Medical University, Beijing, China
| | - Dexiang Ji
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yan Li
- West China Hospital of Sichuan University, Chengdu, China
| | | | | | | | | | | | | | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
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20
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Mehic D, Machacek J, Schramm T, Buresch L, Kaider A, Eichelberger B, Haslacher H, Fillitz M, Dixer B, Flasch T, Anderle T, Rath A, Assinger A, Ay C, Pabinger I, Gebhart J. Platelet function and soluble P-selectin in patients with primary immune thrombocytopenia. Thromb Res 2023; 223:102-110. [PMID: 36738663 DOI: 10.1016/j.thromres.2023.01.012] [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: 11/10/2022] [Revised: 12/22/2022] [Accepted: 01/12/2023] [Indexed: 01/17/2023]
Abstract
BACKGROUND The bleeding phenotype in immune thrombocytopenia (ITP) is heterogeneous, but usually mild and only partly dependent on the severity of thrombocytopenia. Platelet reactivity has previously been suggested to underly the mild phenotype. METHODS Platelet function was assessed as basal and agonist-induced surface expression of P-selectin and activation of GPIIb/IIIa via flow cytometry, and soluble (s)P-selectin levels were assessed in plasma of 77 patients with primary ITP, 19 hemato-oncologic thrombocytopenic controls (TC) and 20 healthy controls (HC). The association of platelet function with laboratory and clinical parameters such as bleeding manifestations at inclusion and previous thrombosis was analyzed. RESULTS ITP patients showed tendency towards increased surface P-selectin and elevated levels of activated GPIIb/IIIa. Platelet activation after stimulation with all agonists including TRAP-6, ADP, arachidonic acid and CRP was decreased compared to HC. Compared to TC, only GPIIb/IIIa activation but not surface P-selectin was higher in ITP. Levels of soluble (s)P-selectin were significantly higher in ITP patients compared to TC, but similar to HC. Higher sP-selectin levels were associated with blood group O and current therapy, with highest levels in TPO-RA treated patients. Platelet reactivity was not associated with platelet count or size, platelet antibodies, treatment regime, or blood group. No correlation between platelet activation with the bleeding phenotype or previous thrombotic events could be observed. CONCLUSION ITP patients did not have hyper-reactive platelets compared to HC, but partly higher reactivity compared to TC. Further studies are needed to understand the underlying mechanism behind the bleeding and pro-thrombotic phenotype in ITP. 250/250.
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Affiliation(s)
- Dino Mehic
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jennifer Machacek
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Theresa Schramm
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Lisbeth Buresch
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alexandra Kaider
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | | | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Fillitz
- Department of Internal Medicine, Hanusch Hospital, Vienna, Austria
| | - Barbara Dixer
- Department of Internal Medicine, Hanusch Hospital, Vienna, Austria
| | - Tanja Flasch
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Theresa Anderle
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anja Rath
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alice Assinger
- Institute of Vascular Biology and Thrombosis Research, Centre of Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Johanna Gebhart
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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21
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Anat GG. Current approaches for the diagnosis and management of immune thrombocytopenia. Eur J Intern Med 2023; 108:18-24. [PMID: 36424271 DOI: 10.1016/j.ejim.2022.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/05/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
Abstract
Immune thrombocytopenia (ITP), is an acquired autoimmune disorder characterized by the destruction of platelets and megakaryocytes, resulting in thrombocytopenia (platelet count <100 × 10⁹/L). This review focuses on the diagnosis and current management of ITP. The diagnosis of ITP is based principally on the exclusion of other causes of isolated thrombocytopenia using patient history, physical examination, blood count, and evaluation of the peripheral blood film. The clinical treatment goals should be to resolve bleeding events and to prevent severe bleeding episodes. The platelet count should be improved to attain a minimum of > 20-30 × 10⁹/L. Therapy should be given as an inpatient in newly diagnosed ITP with a platelet count of > 20 × 10⁹/L or if there is active bleeding. Corticosteroids are considered the standard initial treatment for newly diagnosed patients. Subsequent medical therapies with robust evidence include thrombopoietin receptor agonists (TPO-RAs), rituximab and fostamatinib. Surgical therapy with splenectomy may be considered for patients failing medical therapy. The choice between therapy options is highly dependent upon patient values and preferences.
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Affiliation(s)
- Gafter-Gvili Anat
- Department of Medicine A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
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22
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Crickx E, Mahévas M, Michel M, Godeau B. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging 2023; 18:115-130. [PMID: 36726813 PMCID: PMC9885884 DOI: 10.2147/cia.s369574] [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: 10/26/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
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Affiliation(s)
- Etienne Crickx
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris, Université Paris-Est-Créteil, Paris, France,INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Correspondence: Bertrand Godeau, Service de Médecine Interne, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), 51 avenue du maréchal de Lattre de Tassigny, Créteil, 94000, France, Tel +331 49 81 29 05, Fax +331 49 81 29 02, Email
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23
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Liu XG, Hou Y, Hou M. How we treat primary immune thrombocytopenia in adults. J Hematol Oncol 2023; 16:4. [PMID: 36658588 PMCID: PMC9850343 DOI: 10.1186/s13045-023-01401-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an immune-mediated bleeding disorder characterized by decreased platelet counts and an increased risk of bleeding. Multiple humoral and cellular immune abnormalities result in accelerated platelet destruction and suppressed platelet production in ITP. The diagnosis remains a clinical exclusion of other causes of thrombocytopenia. Treatment is not required except for patients with active bleeding, severe thrombocytopenia, or cases in need of invasive procedures. Corticosteroids, intravenous immunoglobulin, and anti-RhD immunoglobulin are the classical initial treatments for newly diagnosed ITP in adults, but these agents generally cannot induce a long-term response in most patients. Subsequent treatments for patients who fail the initial therapy include thrombopoietic agents, rituximab, fostamatinib, splenectomy, and several older immunosuppressive agents. Other potential therapeutic agents, such as inhibitors of Bruton's tyrosine kinase and neonatal Fc receptor, are currently under clinical evaluation. An optimized treatment strategy should aim at elevating the platelet counts to a safety level with minimal toxicity and improving patient health-related quality of life, and always needs to be tailored to the patients and disease phases. In this review, we address the concepts of adult ITP diagnosis and management and provide a comprehensive overview of current therapeutic strategies under general and specific situations.
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Affiliation(s)
- Xin-Guang Liu
- 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
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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24
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Hamzah R, Yusof N, Tumian NR, Abdul Aziz S, Mohammad Basri NS, Leong TS, Ho KW, Selvaratnam V, Tan SM, Muhamad Jamil SA. Clinical Epidemiology, Treatment Outcome and Mortality Rate of Newly Diagnosed Immune Thrombocytopenia in Adult Multicentre Study in Malaysia. J Blood Med 2022; 13:337-349. [PMID: 35761846 PMCID: PMC9233512 DOI: 10.2147/jbm.s358993] [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: 01/24/2022] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Immune thrombocytopenia (ITP) is well characterized in Western, European and other Asia-Pacific countries. Nevertheless, the clinical epidemiology, treatment pattern and disease outcome of ITP in Malaysia are still limited and not well known. Objective This study aimed to describe the clinical epidemiology, treatment outcome and mortality of ITP patients in haematology tertiary multicentre in Malaysia. Methods Clinical and laboratory data of newly diagnosed adults with ITP by a platelet count <100 × 109/L from January 2010 to December 2020 were identified and analyzed. Results Out of 500 incident ITP, 71.8% were females with a striking age preponderance of both genders among those aged 18–29 years. The median age was 36 years. The median platelet count was 17.5 × 109/L, 23.0% had a secondary ITP, 34.6% had a Charlson’s score ≥1, 53.0% had bleeding symptoms including 2.2% intracranial bleedings (ICB). Helicobacter pylori screening was performed in <5% of cases. Persistency and chronicity rates were 13.6% and 41.8%, respectively. Most (80.6%) were treated at diagnosis onset and 31.2% needed second-line treatment. Throughout the course of ITP, 11.0% of patients died; 3.0% and 8.0% with bleeding and non-bleeding related ITP. Conclusion This study confirms the epidemiology of ITP is comparable with worldwide studies. Our incidence is high in the female, Malay ethnicity, primary ITP and events of cutaneous bleeding at ITP onset with 18–29 years predominance age group for both genders. The frequency of persistent and chronic ITP is inconsistent with published literature. Corticosteroids and immunotherapies are the most prescribed first-line and second-line pharmacological treatments. Thrombopoietin receptor agonist medications (TPO-RAs) usage is restricted and splenectomy is uncommon. Our mortality rate is similar but ITP related bleeding death is fourth-fold lower than previous studies. Mortality risks of our ITP patients include age ≥60 years, male, severe bleeding at presentation, CCI≥1 and secondary ITP.
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Affiliation(s)
- Roszymah Hamzah
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia.,Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Nurasyikin Yusof
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Nor Rafeah Tumian
- Haematology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Suria Abdul Aziz
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Nur Syahida Mohammad Basri
- Department of Pathology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
| | - Tze Shin Leong
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Kim Wah Ho
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Veena Selvaratnam
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Sen Mui Tan
- Department of Haematology, Ampang Hospital, Ampang, Selangor, Malaysia
| | - Siti Afiqah Muhamad Jamil
- Faculty of Computer and Mathematical Sciences, Universiti Teknologi Mara, Shah Alam, Selangor, Malaysia
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25
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Developing and validating a mortality prediction model for ICH in ITP: a nationwide representative multicenter study. Blood Adv 2022; 6:4320-4329. [PMID: 35679462 PMCID: PMC9327537 DOI: 10.1182/bloodadvances.2022007226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/24/2022] [Indexed: 02/05/2023] Open
Abstract
Intraparenchymal hemorrhage, platelet count, serious infections, severe bleeding events, and Glasgow coma scale predict poor prognosis. A prognostic model was developed and validated, and an application was established.
Intracranial hemorrhage (ICH) is a rare and life-threatening hemorrhagic event in patients with immune thrombocytopenia (ITP). However, its mortality and related risk factors remain unclear. Herein, we conducted a nationwide multicenter real-world study of ICH in adult ITP patients. According to data from 27 centers in China from 2005 to 2020, the mortality rate from ICH was 33.80% (48/142) in ITP adults. We identified risk factors by logistic univariate and multivariate logistic regression for 30-day mortality in a training cohort of 107 patients as follows: intraparenchymal hemorrhage (IPH), platelet count ≤10 × 109/L at ICH, a combination of serious infections, grade of preceding bleeding events, and Glasgow coma scale (GCS) level on admission. Accordingly, a prognostic model of 30-day mortality was developed based on the regression equation. Then, we evaluated the performance of the prognostic model through a bootstrap procedure for internal validation. Furthermore, an external validation with data from a test cohort with 35 patients from 11 other centers was conducted. The areas under the receiver operating characteristic (ROC) curves for the internal and external validation were 0.954 (95% confidence interval [CI], 0.910-0.998) and 0.942 (95% CI, 0.871-1.014), respectively. Both calibration plots illustrated a high degree of consistency in the estimated and observed risk. In addition, the decision curve analysis showed a considerable net benefit for patients. Thus, an application (47.94.162.105:8080/ich/) was established for users to predict 30-day mortality when ICH occurred in adult patients with ITP.
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26
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Kim B. Diagnostic workup of inherited platelet disorders. Blood Res 2022; 57:11-19. [PMID: 35483920 PMCID: PMC9057669 DOI: 10.5045/br.2022.2021223] [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: 12/27/2021] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 11/17/2022] Open
Abstract
Inherited platelet disorders (IPDs) can cause mucocutaneous bleeding due to impaired primary hemostatic function of platelets, thrombocytopenia, or both. Recent advances in molecular technology can help identify many genes related to platelet biology, control the overall steps of megakaryopoiesis, and cause IPD. In this article, currently available laboratory tools for diagnosing IPDs with the characteristic laboratory features of each IPD are reviewed, and a general diagnostic approach for the evaluation of IPD patients is presented.
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Affiliation(s)
- Bohyun Kim
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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27
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Tsykunova G, Ghanima W. Avatrombopag for the Treatment of Adult Patients with Chronic Immune Thrombocytopenia (cITP): Focus on Patient Selection and Perspectives. Ther Clin Risk Manag 2022; 18:273-286. [PMID: 35386180 PMCID: PMC8977771 DOI: 10.2147/tcrm.s251672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a reduced number of circulating platelets due to immune-mediated destruction and decreased platelet production in the bone marrow. Thrombopoietin receptor agonists (TPO-RAs) are highly effective and widely used in the treatment of patients with steroid treatment failure or dependency. Avatrombopag represents a new supplement to the TPO-RAs family. It was originally approved for the treatment of thrombocytopenia in patients with chronic liver disease who are scheduled to undergo an invasive procedure. However, labeled indications for avatrombopag have been relatively recently expanded to include treatment of chronic ITP in adults with insufficient response to the previous treatments. In this article, we provide an overview of pharmacodynamics and pharmacokinetics of avatrombopag as well as results of the clinical trials related to safety and efficacy of avatrombopag with a perspective on current clinical use. Available data so far suggests that avatrombopag can be effectively used in ITP patients and has a favorable safety profile. Though further studies are needed to affirm the efficacy and safety, avatrombopag has the potential to become a TPO agonist of choice for many patients with ITP.
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Affiliation(s)
- Galina Tsykunova
- Department of Hematology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Hemato-Oncology, Østfold Hospital, Grålum, Norway
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Hemato-Oncology, Østfold Hospital, Grålum, Norway.,Department of hematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Moulis G, Germain J, Rueter M, Lafaurie M, Aroichane M, Comont T, Mahévas M, Viallard J, Chèze S, Ebbo M, Audia S, Leclerc‐Teffahi S, Sommet A, Beyne‐Rauzy O, Michel M, Godeau B, Lapeyre‐Mestre M, ADOUE D, ALRIC L, ANDRE B, ARISTA S, BALARDY L, BONNET D, BONNOTTE B, BEYNE‐RAUZY O, BOREL C, BRECHEMIER D, BRIANTAIS A, BRUN N, CARREIRO M, CASTEL B, COMONT T, COUGOUL P, COURTAULT C, DANU A, DELAVIGNE K, DELBREL X, DESHAYES S, DINGREMONT C, DION J, DUFFAU P, DURAND J, ESTELLE J, FAUCHER B, GACHES F, GAUDIN C, GIRAUD P, GODEL‐LABOURET A, GRAVELEAU J, HADJ‐KHELIFA S, HARLE J, HEBRAUD B, HENNIQUE H, KHATIBI S, LAPEYREMESTRE M, LARIBI K, LEPLAY L, LEVENEUR Y, LIFERMANN F, LIMAL N, LIOGER B, OLLIER S, MACHELART I, MADAULE S, MAIGNE G, MARTEL C, MARTIN‐BLONDEL G, MICHAUD M, MOEGLIN J, MOIGNET‐AUTREL A, MOURGUET M, MONTANE DE LA ROQUE P, NUCCIO F, ORVAIN C, PRUDHOMME L, PUGNET G, RECHER C, REMY V, RISPAL P, ROY‐PEAUD F, SAILLER L, SAINT‐LEZER A, SAINTE MARIE B, SAUNIER A, SAUVETRE G, SCHLEINITZ N, SEGUIER J, SIRE S, SOUBRIER C, SWIADER L, TAVITIAN S, URBANSKI G, VAILLANT W, VEIT V. Eltrombopag in adult patients with immune thrombocytopenia in the real-world in France, including off-label use before 6 months of disease duration: The multicenter, prospective ELEXTRA study. Am J Hematol 2022; 97:E40-E44. [PMID: 34779031 PMCID: PMC9300059 DOI: 10.1002/ajh.26404] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Guillaume Moulis
- Department of Internal Medicine Toulouse University Hospital Toulouse France
- Clinical Investigation Center Toulouse University Hospital Toulouse France
| | - Johanne Germain
- Clinical Investigation Center Toulouse University Hospital Toulouse France
| | - Manuela Rueter
- Clinical Investigation Center Toulouse University Hospital Toulouse France
| | - Margaux Lafaurie
- Clinical Investigation Center Toulouse University Hospital Toulouse France
- Department of Clinical Pharmacology Toulouse University Hospital Toulouse France
| | | | - Thibault Comont
- Department of Internal Medicine Toulouse Cancer University Hospital Toulouse France
| | - Matthieu Mahévas
- Department of Internal Medicine National Referral Center for Autoimmune Cytopenias, Créteil University Hospital Créteil France
| | | | - Stéphane Chèze
- Department of Haematology Caen University Hospital Caen France
| | - Mikaël Ebbo
- Department of Internal Medicine Marseille University Hospital Marseille France
| | - Sylvain Audia
- Department of Internal Medicine Dijon University Hospital Dijon France
| | | | - Agnès Sommet
- Clinical Investigation Center Toulouse University Hospital Toulouse France
- Department of Clinical Pharmacology Toulouse University Hospital Toulouse France
| | | | - Marc Michel
- Department of Internal Medicine Toulouse Cancer University Hospital Toulouse France
| | - Bertrand Godeau
- Department of Internal Medicine Toulouse Cancer University Hospital Toulouse France
| | - Maryse Lapeyre‐Mestre
- Clinical Investigation Center Toulouse University Hospital Toulouse France
- Department of Clinical Pharmacology Toulouse University Hospital Toulouse France
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Zhao Y, Cui S, Wang Y, Xu R. The Extensive Regulation of MicroRNA in Immune Thrombocytopenia. Clin Appl Thromb Hemost 2022; 28:10760296221093595. [PMID: 35536600 PMCID: PMC9096216 DOI: 10.1177/10760296221093595] [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] [Indexed: 11/23/2022] Open
Abstract
MicroRNA (miRNA) is a small, single-stranded, non-coding RNA molecule that plays
a variety of key roles in different biological processes through
post-transcriptional regulation of gene expression. MiRNA has been proved to be
a variety of cellular processes involved in development, differentiation, signal
transduction, and is an important regulator of immune and autoimmune diseases.
Therefore, it may act as potent modulators of the immune system and play an
important role in the development of several autoimmune diseases. Immune
thrombocytopenia (ITP) is an autoimmune systemic disease characterized by a low
platelet count. Several studies suggest that like other autoimmune disorders,
miRNAs are deeply involved in the pathogenesis of ITP, interacting with the
function of innate and adaptive immune responses. In this review, we discuss
emerging knowledge about the function of miRNAs in ITP and describe miRNAs in
terms of their role in the immune system and autoimmune response. These findings
suggest that miRNA may be a useful therapeutic target for ITP by regulating the
immune system. In the future, we need to have a more comprehensive understanding
of miRNAs and how they regulate the immune system of patients with ITP.
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Affiliation(s)
- Yuerong Zhao
- 74738Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Siyuan Cui
- Department of Hematology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yan Wang
- Department of Hematology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China.,Institute of Hematology, 74738Shandong University of Traditional Chinese Medicine, Jinan, China.,Shandong Provincial Health Commission Key Laboratory of Hematology of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Ruirong Xu
- Department of Hematology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China.,Institute of Hematology, 74738Shandong University of Traditional Chinese Medicine, Jinan, China.,Shandong Provincial Health Commission Key Laboratory of Hematology of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
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30
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Banka AL, Eniola-Adefeso O. Method article: an in vitro blood flow model to advance the study of platelet adhesion utilizing a damaged endothelium. Platelets 2021; 33:692-699. [PMID: 34927530 DOI: 10.1080/09537104.2021.1988550] [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: 10/19/2022]
Abstract
In vitro flow assays utilizing microfluidic devices are often used to study human platelets as an alternative to the costly animal models of hemostasis and thrombosis that may not accurately represent human platelet behavior in vivo. Here, we present a tunable in vitro model to study platelet behavior in human whole blood flow that includes both an inflamed, damaged endothelium and exposed extracellular matrix. We demonstrate that the model is adaptable across various anticoagulants, shear rates, and proteins for endothelial cell culture without the need for a complicated, custom-designed device. Furthermore, we verified the ability of this 'damaged endothelium' model as a screening method for potential anti-platelet or anti-thrombotic compounds using a P2Y12 receptor antagonist (ticagrelor), a pan-selectin inhibitor (Bimosiamose), and a histamine receptor antagonist (Cimetidine). These compounds significantly decreased platelet adhesion to the damaged endothelium, highlighting that this model can successfully screen anti-platelet compounds that target platelets directly or the endothelium indirectly.
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Affiliation(s)
- Alison Leigh Banka
- Department of Chemical Engineering, University of Michigan, Ann Arbor, USA
| | - Omolola Eniola-Adefeso
- Department of Chemical Engineering, University of Michigan, Ann Arbor, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, USA
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31
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Yu J, Xu Z, Zhuo Y, Wei H, Ye Y, Xu Q, Li Y, Yu L, Feng W, Hong P, Zhang K. Development and validation of a nomogram for steroid-resistance prediction in immune thrombocytopenia patients. Hematology 2021; 26:956-963. [PMID: 34871524 DOI: 10.1080/16078454.2021.2003066] [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: 10/19/2022] Open
Abstract
OBJECTIVES Corticosteroid is first-line therapy in immune thrombocytopenia. However, nearly 30% of patients appear in steroid-resistance. Our research analyses the relevant indicators of patients and develops a risk prediction model to predict the poor response to steroid-therapy in ITP patients. METHODS We collected data from 111 ITP patients admitted to Xiamen University Zhongshan Hospital from 2013 to 2019 as the training cohort and 65 ITP patients during 2019-2020 as the external validation cohort. Screening significant factors(P < 0.05) in univariate analysis, and further identified to be independent variables in multivariable logistic regression analysis. Incorporated the significant risk factors in and presented them with a nomogram based on independent risk predictors. The nomogram was assessed by receiver operating characteristics curves and decision curve analysis. RESULTS We constructed a steroid-resistance prediction model based on the potential predictors including age, serum ferritin and expression of HBsAg. As a result, based on the area under the ROC curves, the training cohort (AUC: 0.718, 95% CI: 0.615-0.821) and the external validation cohort (AUC:0.799,95%CI:0.692-0.905), which displayed good discrimination. The decision curve showed that predicting the steroid-refractory risk in ITP patients using this nomogram with a range of the threshold probability between >16% and <70%. The nomogram appears good performance in predicting steroid-refractory ITP patients. CONCLUSION Prediction model shows that elder patients with a high level of ferritin and positive expression of HBsAg may appear a high possibility of steroid-resistance. For these patients, TPO-RAs can be considered to help patients to get better treatment effects and develop a better health-related quality of life.
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Affiliation(s)
- Jieni Yu
- Department of Hematology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine). Shaoxing, People's Republic of China.,Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Medical College, Xiamen University, Xiamen, People's Republic of China
| | - Zhiqiang Xu
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China
| | - Yuanyuan Zhuo
- Department of Laboratory, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China
| | - Huahua Wei
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Medical College, Xiamen University, Xiamen, People's Republic of China
| | - Yinhai Ye
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Third Clinical Medical College, Fujian Medical University, Fuzhou, People's Republic of China
| | - Qinhong Xu
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Medical College, Xiamen University, Xiamen, People's Republic of China
| | - Youli Li
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Third Clinical Medical College, Fujian Medical University, Fuzhou, People's Republic of China
| | - Lihong Yu
- Department of Emergency, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Third Clinical Medical College, Fujian Medical University, Fuzhou, People's Republic of China
| | - Weiying Feng
- Department of Hematology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine). Shaoxing, People's Republic of China
| | - Pan Hong
- Department of Hematology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine). Shaoxing, People's Republic of China
| | - Kejie Zhang
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China
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32
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Sokal A, de Nadaï T, Maquet J, Comont T, Limal N, Michel M, Beyne-Rauzy O, Godeau B, Adoue D, Mahévas M, Moulis G. Primary immune thrombocytopenia in very elderly patients: particularities in presentation and management: results from the prospective CARMEN-France Registry. Br J Haematol 2021; 196:1262-1270. [PMID: 34738634 DOI: 10.1111/bjh.17935] [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: 08/23/2021] [Accepted: 10/19/2021] [Indexed: 02/04/2023]
Abstract
Data about the presentation and the management of primary immune thrombocytopenia (ITP) in very elderly patients (VEPs; aged ≥80 years) are lacking. The aim of the present study was to describe ITP in this subgroup. The data source was the prospective CARMEN-France registry. Patients included between 2013 and 2018 were selected. ITP presentation and management in VEPs was compared to elderly patients (EPs; aged 65-79 years). We assessed factors associated with bleeding at ITP onset in VEPs. Of 541 patients, 184 were included: 87 in the VEP group and 97 in the EP group. The mean age was 85·7 years in the VEP group. Comorbidities were more frequent in the VEP group (67·4% vs. 47·9%). The median platelet count at ITP onset was similar but severe bleeding tended to be more frequent in VEPs (10·3% vs. 4·1%, P = 0·1) as well as mortality. Exposure to ITP drugs, response to first-line treatment, need of second-line treatment, evolution towards persistency, occurrence of bleeding, infection and thrombosis did not differ between groups. In VEPs, factors associated to bleeding were female sex [odds ratio (OR) 4·75, 95% confidence interval (CI) 1·31-17·32] and platelet count of <20 × 109 /l (OR 10·05, 95% CI 4·83-67·39). Exposure to anticoagulants was strongly associated with severe bleeding (OR 7·61, 95% CI 1·77-32·83).
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Affiliation(s)
- Aurélien Sokal
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Thomas de Nadaï
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Julien Maquet
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Thibault Comont
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse - Oncopôle, Toulouse, France
| | - Nicolas Limal
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Odile Beyne-Rauzy
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse - Oncopôle, Toulouse, France
| | - Bertrand Godeau
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Daniel Adoue
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse - Oncopôle, Toulouse, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Hôpital Henri-Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil, Créteil, France
| | - Guillaume Moulis
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,Centre d'Investigation Clinique 1436, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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33
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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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Chen Q, Zhang Y, Li Y, Zhang L, Shi W, Tao H, Chen K, He Z, Wang C, Yu L. Comparative study between two bleeding grading systems of immune thrombocytopenia purpura. Hematology 2021; 26:769-774. [PMID: 34565307 DOI: 10.1080/16078454.2021.1978753] [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] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To explore the relationship between platelet count and bleeding score in immune thrombocytopenia purpura (ITP) and compare the clinical practicability of two bleeding grading systems with adult patients with ITP. METHODS A total of 204 patients were retrospectively analyzed with the ITP bleeding scale (IBLS) and the ITP bleeding assessment tool (version 2016) (ITP-2016). The correlation between the two bleeding score systems and the relations among the platelet counts were respectively analyzed. RESULTS (1) There is a linear relationship between platelet count and bleeding score, no matter which scoring system it is based on (rs = -0.429, p < 0.001; rs = -0.331, p < 0.001, the analysis of the number of sites of Grade 1/2 bleeding were done; and rs = -0.466, p < 0.05, the analysis between platelet count and bleeding score by ITP-2016 respectively). (2) Platelet count and bleeding scores are negatively correlated in those with extremely low platelet counts ( < 10*109/L). The number of sites of Grade 2 bleeding and the ITP-2016 scores are negatively correlated with platelet counts (rs = -0.15 and rs = -0.244, p < 0.05, respectively). Significantly, there is no correlation between the platelet count and bleeding scores when the platelet count is more than 10*109/L. (3) It takes less time to score with ITP-2016 than IBLS (z = -3.825, P < 0.001). CONCLUSIONS There is good responsiveness, strong assessment consistency, close correlation between ITP-2016 and IBLS. ITP-2016 takes less time-consuming in clinical application. It can be used as an effective tool of condition judgement, risk assessment and efficacy evaluation of patients with ITP.
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Affiliation(s)
- Qiuni Chen
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
| | - Yijing Zhang
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
| | - Yunjie Li
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
| | - Lijuan Zhang
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
| | - Wenting Shi
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
| | - Hong Tao
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
| | - Kankan Chen
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
| | - Zhengmei He
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
| | - Chunling Wang
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
| | - Liang Yu
- Department of Hematology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, People's Republic of China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, People's Republic of China
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35
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Perez Botero J, Di Paola J. Diagnostic approach to the patient with a suspected inherited platelet disorder: Who and how to test. J Thromb Haemost 2021; 19:2127-2136. [PMID: 34347927 DOI: 10.1111/jth.15484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
Bleeding and thrombocytopenia are common referrals to the pediatric and adult hematology practice. The differential diagnosis encompasses a wide spectrum of entities that vary in acuity, severity, and etiology. Most will be acquired (especially in adult patients), but many can be inherited, and some may have manifestations affecting other organ systems. The first step: defining whether the symptoms and/or laboratory findings are clinically significant and warrant additional work-up, can be equally as challenging as reaching the diagnosis itself. How much bleeding is too much to be considered normal? How low of a platelet count is too low? Once the decision has been made to pursue additional studies, considering the increasing number of laboratory tests available, the diagnostic process can be complex. In this article, we outline a general approach for the evaluation of patients in whom an inherited platelet disorder is being considered. We present two clinical vignettes as introduction to the diagnostic approach to inherited platelet disorders. We describe the rationale for the different types of tests that are clinically available, their limitations, and finally the challenges that are frequently encountered in the interpretation of results. We also intend to provide some guidance on the expected phenotype in terms of severity of bleeding and/or thrombocytopenia according to the etiology of the inherited disorder. Our goal is to provide the practicing hematologist with a practical framework that is clinically applicable in their daily practice.
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Affiliation(s)
- Juliana Perez Botero
- Versiti and Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jorge Di Paola
- Division of Pediatric Hematology Oncology, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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36
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Sirotich E, Guyatt G, Gabe C, Ye Z, Beck CE, Breakey V, Cooper N, Cuker A, Charness J, de Wit K, DiRaimo J, Fein SG, Grace RF, Hassan Z, Jamula E, Kang M, Manski CF, O'Connor C, Pai M, Paynter D, Porter SC, Pruitt B, Strachan G, Webert KE, Yan JW, Kelton JG, Bakchoul T, Arnold DM. Definition of a critical bleed in patients with immune thrombocytopenia: Communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost 2021; 19:2082-2088. [PMID: 34327824 DOI: 10.1111/jth.15368] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/12/2021] [Accepted: 04/28/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Immune thrombocytopenia (ITP) is an autoimmune disease characterized by low platelet counts and increased risk of bleeding. In preparation for an upcoming guideline, the ITP Emergency Management Guideline Panel, including clinical experts in hematology, emergency medicine, research methodology, and patient representatives, identified the need for a standardized definition of a critical ITP bleed. The goal of the definition was to distinguish critical bleeds from bleeds that may not require urgent treatment, typically in the context of severe thrombocytopenia. METHODS The panel met in person and virtually to achieve consensus on the criteria for critical bleeding events among patients with ITP. Existing ITP bleeding scores and published definitions of major bleeds in patients receiving anticoagulation informed the definition of a critical ITP bleed. The Platelet Immunology Scientific Standardization Committee (SSC) of the International Society on Thrombosis and Haemostasis endorsed the definition. RESULTS A critical ITP bleed was defined as: (a) a bleed in a critical anatomical site including intracranial, intraspinal, intraocular, retroperitoneal, pericardial, or intramuscular with compartment syndrome; or (2) an ongoing bleed that results in hemodynamic instability or respiratory compromise. CONCLUSION The definition of a critical ITP bleed was developed by the ITP Emergency Management Guideline Panel and endorsed by the Platelet Immunology SSC. It incorporates both anatomic and physiologic risk and pertains to patients with confirmed or suspected ITP who typically have severe thrombocytopenia (platelet count below 20 × 109 /L).
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Affiliation(s)
- Emily Sirotich
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Caroline Gabe
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Zhikang Ye
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Carolyn E Beck
- Division of Paediatric Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vicky Breakey
- Division of Pediatric Hemaology/Oncology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Nichola Cooper
- Department of Immunology and Inflammation, Department of Medicine, Imperial college, London, UK
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Rachael F Grace
- Department of Pediatric Hematology/Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - Ziauddin Hassan
- Department of Emergency Medicine, Dr FH Wigmore Regional Hosiptal, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Erin Jamula
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Matthew Kang
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Joseph Brant Hospital, Burlington, ON, Canada
| | - Charles F Manski
- Department of Economics and Institute for Policy Research, Northwestern University, Evanston, IL, USA
| | - Clare O'Connor
- Hamilton Health Sciences and McMaster School of Nursing, Hamilton, ON, Canada
| | - Menaka Pai
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, ON, Canada
| | - Dale Paynter
- Platelet Disorder Support Association (PDSA), Cleveland, OH, USA
| | - Stephen C Porter
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Barbara Pruitt
- Platelet Disorder Support Association, Cincinnati, OH, USA
| | - Gail Strachan
- Platelet Disorder Support Association, Cincinnati, OH, USA
| | - Kathryn E Webert
- Canadian Blood Services, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - John G Kelton
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Donald M Arnold
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
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37
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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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38
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Abstract
PURPOSE OF REVIEW In this review, we discuss recent developments and trends in the perioperative management of thrombocytopenia. RECENT FINDINGS Large contemporary data base studies show that preoperative thrombocytopenia is present in about 8% of asymptomatic patients, and is associated with increased risks for bleeding and 30-day mortality. Traditionally specific threshold platelet counts were recommended for specific procedures. However, the risk of bleeding may not correlate well with platelet counts and varies with platelet function depending on the underlying etiology. Evidence to support prophylactic platelet transfusion is limited and refractoriness to platelet transfusion is common. A number of options exist to optimize platelet counts prior to procedures, which include steroids, intravenous immunoglobulin, thrombopoietin receptor agonists, and monoclonal antibodies. In addition, intraoperative alternatives and adjuncts to transfusion should be considered. It appears reasonable to use prophylactic desmopressin and antifibrinolytic agents, whereas activated recombinant factor VII could be considered in severe bleeding. Other options include enhancing thrombin generation with prothrombin complex concentrate or increasing fibrinogen levels with fibrinogen concentrate or cryoprecipitate. SUMMARY Given the lack of good quality evidence, much research remains to be done. However, with a multidisciplinary multimodal perioperative strategy, the risk of bleeding can be decreased effectively.
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How I treat primary ITP in adult patients who are unresponsive to or dependent on corticosteroid treatment. Blood 2021; 137:2736-2744. [PMID: 33827138 DOI: 10.1182/blood.2021010968] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022] Open
Abstract
Approximately 80% of adult patients with immune thrombocytopenia (ITP) have treatment failure with corticosteroids or become dependent on them and require second-line therapy. Several new and effective therapies have been introduced during the past decade and our understanding of disease burden and its effect on quality of life has expanded. It is now recommended that splenectomy, the standard second-line therapy for decades, be delayed for at least 12 to 24 months, allowing for more patients to achieve remission on medical therapies before considering surgery. It is highly recommended that medical therapies be used that have abundant clinical trial evidence, such as the thrombopoietin receptor agonists (TPO-RAs) rituximab and fostamatinib. Unfortunately, there are no reliable biomarkers that help in treatment selection. These therapeutic medical options have variable efficacy, safety profiles, mechanisms of action, and modes of administration. This enables and mandates an individualized approach to treatment, where patient involvement, preferences and values have become central to the process of choosing the appropriate therapy. Both TPO-RAs and fostamatinib are maintenance therapies, whereas rituximab is given for a limited number of doses. Although the response is usually maintained while receiving a TPO-RA or fostamatinib therapy, half of rituximab responders will no longer respond 1 to 2 years after administration and require retreatment or other therapy.
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40
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Risk factors for skin, mucosal, and organ bleeding in adults with primary ITP: a nationwide study in Japan. Blood Adv 2021; 4:1648-1655. [PMID: 32320469 DOI: 10.1182/bloodadvances.2020001446] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/23/2020] [Indexed: 11/20/2022] Open
Abstract
Bleeding manifestations in primary immune thrombocytopenia (ITP) range from skin petechiae to life-threatening intracranial hemorrhage (ICH). However, the relation between these various bleeding manifestations and the platelet count in ITP remains poorly characterized. Using a nationwide database of patients with ITP during the years 2005 to 2014 (10 years) in Japan, we analyzed 19 415 adult patients newly diagnosed with ITP, including 222 with ICH. The frequency of skin purpura was 64.8%, and this increased linearly with thrombocytopenia without a specific platelet count threshold. In contrast, mucosal bleeding (epistaxis and gingival bleeding) and organ bleeding (melena, hematuria, and ICH) increased exponentially with thrombocytopenia at a platelet count threshold of 10 to 15 × 109/L. Age showed a much weaker correlation than platelet count with skin and mucosal bleeding. However, the incidence of organ bleeding increased exponentially above 60 years of age. Multivariate analysis showed that the presence of mucosal bleeding was a risk factor for occurrence of melena and hematuria but not for ICH. The frequency of ICH was 1.1% and risk factors for ICH were age ≥60 years (odds ratio [OR], 3.09; 95% confidence interval [CI], 2.13-4.47; P < .001), platelet count <10 × 109/L (OR, 2.96; 95% CI, 2.11-4.15; P < .001), and the presence of hematuria (OR, 1.56; 95% CI, 1.04-2.35; P = .033). The relation between ICH and platelet count varied with age. This large-scale analysis of risk factors for bleeding in ITP has revealed distinct characteristics of skin, mucosal, and organ bleeding in adult patients with newly diagnosed ITP, thus indicating those who are at a high risk of severe organ bleeding.
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41
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Identification of occult cerebral microbleeds in adults with immune thrombocytopenia. Blood 2021; 136:2875-2880. [PMID: 32750707 DOI: 10.1182/blood.2020004858] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 07/19/2020] [Indexed: 01/14/2023] Open
Abstract
Management of symptoms and prevention of life-threatening hemorrhage in immune thrombocytopenia (ITP) must be balanced against adverse effects of therapies. Because current treatment guidelines based on platelet count are confounded by variable bleeding phenotypes, there is a need to identify new objective markers of disease severity for treatment stratification. In this cross-sectional prospective study of 49 patients with ITP and nadir platelet counts <30 × 109/L and 18 aged-matched healthy controls, we used susceptibility-weighted magnetic resonance imaging to detect cerebral microbleeds (CMBs) as a marker of occult hemorrhage. CMBs were detected using a semiautomated method and correlated with clinical metadata using multivariate regression analysis. No CMBs were detected in health controls. In contrast, lobar CMBs were identified in 43% (21 of 49) of patients with ITP; prevalence increased with decreasing nadir platelet count (0/4, ≥15 × 109/L; 2/9, 10-14 × 109/L; 4/11, 5-9 × 109/L; 15/25 <5 × 109/L) and was associated with longer disease duration (P = 7 × 10-6), lower nadir platelet count (P = .005), lower platelet count at time of neuroimaging (P = .029), and higher organ bleeding scores (P = .028). Mucosal and skin bleeding scores, number of previous treatments, age, and sex were not associated with CMBs. Occult cerebral microhemorrhage is common in patients with moderate to severe ITP. Strong associations with ITP duration may reflect CMB accrual over time or more refractory disease. Further longitudinal studies in children and adults will allow greater understanding of the natural history and clinical and prognostic significance of CMBs.
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42
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Jaime-Pérez JC, Ramos-Dávila EM, Meléndez-Flores JD, Gómez-De León A, Gómez-Almaguer D. Insights on chronic immune thrombocytopenia pathogenesis: A bench to bedside update. Blood Rev 2021; 49:100827. [PMID: 33771403 DOI: 10.1016/j.blre.2021.100827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 12/17/2022]
Abstract
Immune thrombocytopenia (ITP) is a heterogeneous disease with an unpredictable course. Chronicity can develop in up to two-thirds of adults and 20-25% of children, representing a significant burden on patients' quality of life. Despite acceptable responses to treatment, precise etiology and pathophysiology phenomena driving evolution to chronicity remain undefined. We analyzed reported risk factors for chronic ITP and associated them with proposed underlying mechanisms in its pathogenesis, including bone marrow (BM) microenvironment disturbances, clinical features, and immunological markers. Their understanding has diagnostic implications, such as screening for the presence of specific antibodies or BM examination employing molecular tools, which could help predict prognosis and recognize main pathogenic pathways in each patient. Identifying these underlying mechanisms could guide the use of personalized therapies such as all-trans retinoic acid, mTor inhibitors, FcRn inhibitors, oseltamivir, and others. Further research should lead to tailored treatments and chronic course prevention, improving patients' quality of life.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico.
| | - Eugenia M Ramos-Dávila
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Jesús D Meléndez-Flores
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Andrés Gómez-De León
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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43
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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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44
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Risk factors and predictors of treatment responses and complications in immune thrombocytopenia. Ann Hematol 2021; 100:645-651. [PMID: 33515047 DOI: 10.1007/s00277-021-04424-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 01/11/2021] [Indexed: 01/22/2023]
Abstract
Management of adult patients with immune thrombocytopenia (ITP) is often unsatisfactory, due to variable efficacy of treatment, risk of life-threatening bleeding if disease control is poor, and side effects associated with treatment. Lack of data on the platelet count threshold associated with bleeding and infection risk associated with ITP treatment limits risk/benefit clinical decision making. We reviewed medical records of all ITP patients who were admitted to our hospital between 2012 and 2017 to evaluate the platelet count threshold for bleeding, infection burden associated with treatment, and real-world efficacy of second-line treatment. We demonstrated fair discrimination between platelet count and occurrence of bleeding, with 15 × 109/L being the optimal cut-off for predicting any bleeding while 20 × 109/L had the highest negative predictive value for severe bleeding. In multivariable analyses, patients who were treated with corticosteroids for at least 2 months were 5.3 times as likely to have an infection. In addition, rituximab response was strongly associated with response to frontline corticosteroids and infection was associated with older age ≥ 65 years and corticosteroid dependence. If corticosteroids are initiated, physicians should aim for the shortest duration of treatment before switching to effective second-line agents for hemostatic platelet counts.
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45
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Sheyn D, Darvish R, Nayak L, Myer S, Claridge C, Bretschneider CE. Perioperative outcomes for benign hysterectomy among women with thrombocytopenia. Int J Gynaecol Obstet 2021; 154:233-240. [PMID: 33420719 DOI: 10.1002/ijgo.13582] [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: 06/24/2020] [Revised: 09/28/2020] [Accepted: 01/05/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine whether mild or moderate thrombocytopenia is associated with postoperative complications after benign hysterectomy. METHODS A retrospective study of data from women who underwent benign hysterectomy included in the American College of Surgeons National Surgical Quality Improvement Project Database. The data were stratified by normal platelet count, mild thrombocytopenia (100-149 × 103 platelets/µl), and moderate thrombocytopenia (50-99 × 103 platelets/µl). Multivariable logistic regression was used to determine the relationship between mild or moderate thrombocytopenia and the main outcome measures. RESULTS Moderate thrombocytopenia was associated with an increased risk of perioperative transfusion (adjusted odds ratio [aOR], 2.87; 95% confidence interval [CI], 1.96-4.21) and reoperation (aOR, 4.03; 95% CI, 1.94-17.33), but mild thrombocytopenia was not. There was an increased risk of infection among women with both mild (aOR, 1.38; 95% CI, 1.12-1.69) and moderate (aOR, 2.00; 95% CI,1.23-3.22) thrombocytopenia. There was no association between either mild or moderate thrombocytopenia and readmission, prolonged hospital stay, or longer surgical time. CONCLUSION Thrombocytopenia was found to be associated with increased infectious morbidity after hysterectomy, and moderate thrombocytopenia was associated with an increased risk of perioperative transfusion and reoperation.
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Affiliation(s)
- David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA.,Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA.,Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ryan Darvish
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA.,Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Lalitha Nayak
- Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Division of Hematology & Oncology, Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sara Myer
- Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Caitlin Claridge
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA.,Section of Urogynecology and Reconstructive Pelvic Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - C Emi Bretschneider
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
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46
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EVALUATION OF RDW, MPV, PLATELET LABORATORY PARAMETERS IN PROSTATE CANCER PATIENTS ADMITTING TO EMERGENCY DEPARTMENT WITH HEMATURIA. INTERNATIONAL JOURNAL OF HEALTH SERVICES RESEARCH AND POLICY 2020. [DOI: 10.33457/ijhsrp.795668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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47
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Althaus K, Faul C, Bakchoul T. New Developments in the Pathophysiology and Management of Primary Immune Thrombocytopenia. Hamostaseologie 2020; 41:275-282. [PMID: 33348391 DOI: 10.1055/a-1311-8264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease that is characterized by a significant reduction in the number of circulating platelets and frequently associated with bleeding. Although the pathogenesis of ITP is still not completely elucidated, it is largely recognized that the low platelet count observed in ITP patients is due to multiple alterations of the immune system leading to increased platelet destruction as well as impaired thrombopoiesis. The clinical manifestations and patients' response to different treatments are very heterogeneous suggesting that ITP is a group of disorders sharing common characteristics, namely, loss of immune tolerance toward platelet (and megakaryocyte) antigens and dysfunctional primary hemostasis. Management of ITP is challenging and requires intensive communication between patients and caregivers. The decision to initiate treatment should be based on the platelet count level, age of the patient, bleeding manifestation, and other factors that influence the bleeding risk in individual patients. In this review, we present recent data on the mechanisms that lead to platelet destruction in ITP with a particular focus on current findings concerning alterations of thrombopoiesis. In addition, we give an insight into the efficacy and safety of current therapies and management of ITP bleeding emergencies.
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Affiliation(s)
- Karina Althaus
- Transfusion Medicine, Medical Faculty of Tübingen, University Hospital of Tübingen, Tübingen, Germany.,Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Christoph Faul
- Internal Medicine II, University Hospital of Tübingen, Tübingen, Germany
| | - Tamam Bakchoul
- Transfusion Medicine, Medical Faculty of Tübingen, University Hospital of Tübingen, Tübingen, Germany.,Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
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48
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Moulis G, Comont T, Adoue D. New insights into the epidemiology of immune thrombocytopenia in adult patients: Impact for clinical practice. Rev Med Interne 2020; 42:11-15. [PMID: 32798089 DOI: 10.1016/j.revmed.2020.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/26/2020] [Indexed: 12/28/2022]
Abstract
New insights into immune thrombocytopenia (ITP) epidemiology in adult patients highlight three main outcomes of morbidity and mortality: bleeding, infection and thrombosis. This review depicts current evidence about incidence and risk factors of bleeding, infection and thrombosis as well as predictors of chronicity, and shows how this assessment impacts the choice of ITP second-line treatment at the individual-level basis.
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Affiliation(s)
- G Moulis
- Service de Médecine Interne, CHU de Toulouse, France; UMR 1027 INSERM, Université de Toulouse, France; CIC 1436, CHU de Toulouse, France.
| | - T Comont
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse- Oncopôle, France
| | - D Adoue
- Service de Médecine Interne, Institut Universitaire du Cancer de Toulouse- Oncopôle, France
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49
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Zhao P, Hou M, Liu Y, Liu HX, Huang RB, Yao HX, Niu T, Peng J, Jiang M, Han YQ, Hu JD, Zhou H, Zhou ZP, Qiu L, Zhang LS, Wang X, Wang HQ, Feng R, Yang LH, Ma LM, Wang SQ, Kong PY, Wang WS, Sun HP, Sun J, Zhou HB, Zhu TN, Wang LR, Zhang JY, Huang QS, Liu X, Fu HX, Li YY, Wang QF, Jiang Q, Jiang H, Lu J, Zhang XH. Risk stratification and outcomes of intracranial hemorrhage in patients with immune thrombocytopenia under 60 years of age. Platelets 2020; 32:633-641. [PMID: 32614630 DOI: 10.1080/09537104.2020.1786042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Intracranial hemorrhage (ICH) is a devastating complication of immune thrombocytopenia (ITP). However, information on ICH in ITP patients under the age of 60 years is limited, and no predictive tools are available in clinical practice. A total of 93 adult patients with ITP who developed ICH before 60 years of age were retrospectively identified from 2005 to 2019 by 27 centers in China. For each case, 2 controls matched by the time of ITP diagnosis and the duration of ITP were provided by the same center. Multivariate analysis identified head trauma (OR = 3.216, 95%CI 1.296-7.979, P =.012), a platelet count ≤ 15,000/μL at the time of ITP diagnosis (OR = 1.679, 95%CI 1.044-2.698, P =.032) and severe/life-threatening bleeding (severe bleeding vs. mild bleeding, OR = 1.910, 95%CI 1.088-3.353, P =.024; life-threatening bleeding vs. mild bleeding, OR = 2.620, 95%CI 1.360-5.051, P =.004) as independent risk factors for ICH. Intraparenchymal hemorrhage (OR = 5.191, 95%CI 1.717-15.692, P =.004) and a history of severe bleeding (OR = 4.322, 95%CI 1.532-12.198, P =.006) were associated with the 30-day outcome of ICH. These findings may facilitate ICH risk stratification and outcome prediction in patients with ITP.
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Affiliation(s)
- Peng Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yi Liu
- Department of Geriatric Hematology, Chinese PLA General Hospital, Beijing, China
| | - Hui-Xin Liu
- Department of Clinical Epidemiology, Peking University People's Hospital, Beijing, China
| | - Rui-Bin Huang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hong-Xia Yao
- Department of Hematology, Hainan General Hospital, Haikou, China
| | - Ting Niu
- Department of Hemotology, West China Hospital, Sichuan University, Chengdu, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Ming Jiang
- Department of Hematology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yan-Qiu Han
- Department of Hematology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Jian-Da Hu
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hu Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Ze-Ping Zhou
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Lin Qiu
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Lian-Sheng Zhang
- Department of Hematology, Lanzhou University Second Hospital, Lanzhou, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Hua-Quan Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Ru Feng
- Department of Hematology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Lin-Hua Yang
- Department of Hematology, Second Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Liang-Ming Ma
- Department of Hematology, Affiliated Shanxi Big Hospital of Shanxi Medical University, Taiyuan, China
| | - Shun-Qing Wang
- Department of Hematology, Guangzhou First People's Hospital, Guangzhou, China
| | - Pei-Yan Kong
- Xinqiao Hospital, The Third Military Medical University, Chongqing, China
| | - Wen-Sheng Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Hui-Ping Sun
- Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Sun
- Nanfang Hospital, Nanfang Medical University, Guangzhou, China
| | - He-Bing Zhou
- Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Tie-Nan Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li-Ru Wang
- Fuxing Hospital, Capital Medical University, Beijing, China
| | - Jing-Yu Zhang
- Department of Hematology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qiu-Sha Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Yue-Ying Li
- Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
| | - Qian-Fei Wang
- Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Hao Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
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Mithoowani S, Cervi A, Shah N, Ejaz R, Sirotich E, Barty R, Li N, Nazy I, Arnold DM. Management of major bleeds in patients with immune thrombocytopenia. J Thromb Haemost 2020; 18:1783-1790. [PMID: 32219982 DOI: 10.1111/jth.14809] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND A standard approach to the recognition and management of major bleeding in immune thrombocytopenia (ITP) is lacking. METHODS Retrospective cohort study of ITP patients presenting to the emergency department (ED) with severe thrombocytopenia (platelet count <20 × 109 /L) and bleeding in four academic hospitals from 2008 to 2016. We defined a major ITP bleed as a bleed at a critical site or causing hemodynamic instability. RESULTS We identified 112 ITP patients (n = 141 visits) who presented to the ED with platelets <20 × 109 /L and bleeding. Twenty--nine patients (26%) had 32 ED visits with major bleeds. Risk factors for major bleeds were older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.06), male sex (OR 3.25, 95% CI 1.22-9.32), and more prior ITP therapies (OR 1.42, 95% CI 1.10-1.87). Acute treatment of major bleeds required a median of three treatments (interquartile range [IQR] 2--4), which included intravenous immune globulin (91% of visits), corticosteroids (78% of visits), and platelet transfusions (75% of visits). Three patients (10%) died, nine (31%) developed recurrent bleeds, one (3%) developed arterial thrombosis, and one (3%) had permanent neurological disability. Six patients presented with minor bleeding and subsequently developed a major bleed after a median of 2 days (IQR 1-3). All six patients had oral purpura and four of six had gross hematuria preceding the major bleed. CONCLUSIONS Major ITP bleeds are associated with significant morbidity and mortality. Oral purpura and hematuria often preceded major bleeds. Further research is needed to refine the definition of a major ITP bleed and develop evidence-based treatment strategies.
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Affiliation(s)
- Siraj Mithoowani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andrea Cervi
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Nishwa Shah
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Resham Ejaz
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Emily Sirotich
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Rebecca Barty
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Na Li
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Ishac Nazy
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
- Canadian Blood Services, Hamilton, ON, Canada
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