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Rottenstreich A, Bussel JB. Treatment of immune thrombocytopenia during pregnancy with thrombopoietin receptor agonists. Br J Haematol 2023; 203:872-885. [PMID: 37830251 DOI: 10.1111/bjh.19161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 09/30/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
The introduction of thrombopoietin receptor agonists (TPO-RAs) led to a paradigm shift in the management of immune thrombocytopenia (ITP). However, TPO-RAs are not approved for use during pregnancy due to the absence of evidence and concerns for possible effects on the fetus due to their expected transplacental transfer. This comprehensive review examines the safety and efficacy of TPO-RA in 45 pregnancies of women with ITP (romiplostim n = 22; eltrombopag n = 21; both in the same pregnancy n = 2). Mothers experienced failure of the median of three treatment lines during pregnancy prior to TPO-RA administration. A platelet response (>30 × 109 /L) was seen in 86.7% of cases (including a complete response >100 × 109 /L in 66.7%) and was similar between eltrombopag and romiplostim (87.0% and 83.3%, p = 0.99). The maternal safety profile was favourable, with no thromboembolic events encountered. Neonatal thrombocytopenia was noted in one third of cases, with one case of ICH grade 3, and neonatal thrombocytosis was observed in three cases. No other neonatal adverse events attributable to TPO-RAs were seen. This review suggests that the use of TPO-RA during pregnancy is associated with a high response rate and appears safe. Nevertheless, TPO-RA should not be routinely used in pregnancy and should be avoided in the first trimester until further evidence is accumulated.
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Affiliation(s)
- Amihai Rottenstreich
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, New York, New York, USA
- Laboratory of Blood and Vascular Biology, Rockefeller University, New York, New York, USA
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
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2
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Yu J, Miao P, Qian S. Application of recombinant human thrombopoietin in pregnant women with immune thrombocytopenia: a single-center experience of four patients and literature review. J Int Med Res 2023; 51:3000605231187950. [PMID: 37548331 PMCID: PMC10408329 DOI: 10.1177/03000605231187950] [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: 03/10/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023] Open
Abstract
The management of pregnant women with immune thrombocytopenia who fail to respond to corticosteroids and intravenous immunoglobulin is an intractable clinical challenge because of the limited availability of evidence-based information. Recombinant human thrombopoietin (rhTPO) is recommended for refractory immune thrombocytopenia (ITP). To date, however, few studies have investigated rhTPO treatment during pregnancy. We retrospectively reviewed four cases who were diagnosed with ITP and treated with rhTPO during pregnancy in our center from January 2015 to June 2020. Of the four cases, two (50%) responded to rhTPO treatment. No adverse events were noted in the newborns. Our findings indicate that rhTPO treatment is safe for patients with refractory gestational ITP, and that subcutaneous injection is a convenient delivery method that does not lead to adverse events. Thus, rhTPO may be a viable alternative treatment option for patients with refractory gestational ITP who do not respond to first-line therapies.
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Affiliation(s)
- Jingdi Yu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Peiwen Miao
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang Chinese Medical University, Hangzhou, China
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3
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Russell MD, Dey M, Flint J, Davie P, Allen A, Crossley A, Frishman M, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Schreiber K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids. Rheumatology (Oxford) 2022; 62:e48-e88. [PMID: 36318966 PMCID: PMC10070073 DOI: 10.1093/rheumatology/keac551] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Shropshire, UK
| | - Philippa Davie
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology, London, UK
| | | | - Margreta Frishman
- Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Mary Gayed
- Rheumatology, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Munther Khamashta
- Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady's Hospice and Care Service, Dublin, Ireland
| | - Sonia Panchal
- Department of Rheumatology, South Warwickshire NHS Foundation Trust, Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital, Bath, UK
| | | | - Katherine Saxby
- Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Schreiber
- Thrombosis and Haemostasis, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Rheumatology, Danish Hospital for Rheumatic Diseases, Sonderborg, Denmark.,Department of Regional Health Research (IRS), University of Southern Denmark, Odense, Denmark
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | | | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust, London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
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4
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Favier R, De Carne C, Elefant E, Rigouzzo A. A promising treatment to optimize delivery management in a pregnant woman with inherited thrombocytopenias: a new report of thrombopoietin receptor agonist administration. Int J Obstet Anesth 2022; 50:103541. [DOI: 10.1016/j.ijoa.2022.103541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 11/26/2022]
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5
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Effect of Thrombopoietin Receptor Agonist on Pregnant Mice. Pharmaceutics 2022; 14:pharmaceutics14030514. [PMID: 35335889 PMCID: PMC8951389 DOI: 10.3390/pharmaceutics14030514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 12/04/2022] Open
Abstract
Thrombopoietin receptor agonists (TPO-RAs) are an effective treatment for refractory immune thrombocytopenia (ITP). However, the use of TPO-RAs is limited for ITP in pregnant women due to concerns about fetal toxicity. In this study, we examined the effects of romiplostim, one of the TPO-RAs, on pregnant mice. The mice were injected subcutaneously with romiplostim (1, 5, 10, 30, and 100 μg/kg) on gestational days (GD) 1, 8, and 15. We evaluated maternal and fetal platelet and megakaryocyte counts (MK), fetal weight at birth, placental morphology, and miscarriage rates. Romiplostim increased platelet and MK counts in pregnant mice at all doses and in fetuses at doses above 10 µg/kg. Fetal weight at birth was slightly reduced at a dose of 100 μg/kg, but there were no significant differences in placental weight, spiral artery wall thickness, placental growth factor signal changes, or the rate of resorption at that dosage. The dose of romiplostim used clinically for ITP patients (1–10 μg/kg) did not show any adverse effects on pregnant mice. Although the results of the present study are encouraging, until there are more conclusive data, the use of romiplostim should be evaluated individually in severe, life-threatening cases, and all relevant ethical aspects should be considered.
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Shibata S, Misugi T, Nakane T, Hino M, Tachibana D. Use of Eltrombopag for the First Trimester Pregnancy Complicated with Refractory Idiopathic Thrombocytopenic Purpura: A Case Report and Literature Review. Cureus 2022; 14:e22505. [PMID: 35371812 PMCID: PMC8958988 DOI: 10.7759/cureus.22505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 11/05/2022] Open
Abstract
Severe idiopathic thrombocytopenic purpura (ITP) is thought to occur in approximately one in 10,000 pregnancies and refractoriness for conventional treatment is life-threatening. We herein describe a pregnant case of refractory ITP successfully treated with eltrombopag, orally medicated thrombopoietin receptor agonist (TPO-RA). The patient was diagnosed with ITP at the age of 22 and corticosteroid, immune globulin treatments, or splenectomy was invalid. Eltrombopag was administered at 25 mg/day and the platelet count was maintained at 50-80 × 109/L. At the age of 32, she discontinued the medication out of fear of the possible adverse events of TPO-RA. She became pregnant and visited our hospital at the gestational age of 9th week with the result of a platelet count at 18 × 109/L. Two weeks later, her platelet counts further decreased to 9 × 109/L, and eltrombopag administration was resumed with 12.5 mg/day after informed written consent. The platelet counts subsequently increased and were maintained between 30 and 90 × 109/L. At 34th gestational week, the dose of eltrombopag was increased to 25 mg/day in preparation for delivery and the count increased to 123 × 109/L by the 38th gestational week. A healthy female infant weighing 2370 g was vaginally delivered by induced labor. Maternal blood loss was 0.4 L at delivery, and the newborn’s platelet count was 173 × 109/L on the second day after birth and 174 × 109/L on the fifth day. The infant is neurologically and developmentally intact at 6 months of age. Regarding TPO-RA treatment for refractory ITP during pregnancy, only six pregnant cases including the present one treated with eltrombopag have been reported so far. This case is rare with reference to the use of eltrombopag for the first trimester and we increased the dose of eltrombopag at the gestational age of 34 in preparation for delivery and vaginal delivery was successful without platelet transfusion. Despite the very limited information on eltrombopag, its use might be a possible optional treatment for refractory ITP during pregnancy.
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Colquhoun M, Thanopoulou V, Quick V, Mouyis M. Rituximab Administration during the 2nd Trimester of Pregnancy for Systemic Lupus Erythematosus: Case Report and Review of the Literature in Rheumatic Disease. Mod Rheumatol Case Rep 2021; 6:173-177. [PMID: 34850082 DOI: 10.1093/mrcr/rxab051] [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: 06/14/2021] [Revised: 10/01/2021] [Accepted: 10/27/2021] [Indexed: 11/12/2022]
Abstract
Rituximab is an anti-CD20 monoclonal antibody that is used in the treatment of many rheumatic diseases, for both licensed and unlicensed indications. Due to concerns regarding foetal B cell depletion and possible infection, there is conflicting advice about whether the drug should be administered during pregnancy, with some organizations advising administration if the potential benefit to the mother outweighs the risk to the foetus and some advising stopping rituximab six months prior to conception. Caution in particular is advised about administering rituximab in later trimesters when maternal IgG is transported across the placenta. There has been little literature thus far examining the safety of administering rituximab from the second trimester onwards in rheumatic diseases. We present a case where rituximab was used during the second trimester for the treatment of refractory systemic lupus erythematosus, without adverse effect on the neonate.
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Affiliation(s)
- Matthew Colquhoun
- Department of Rheumatology, Northwick Park Hospital, Harrow, United Kingdom
| | | | - Vanessa Quick
- Department of Rheumatology, Luton and Dunstable Hospital, Luton, United Kingdom
| | - Maria Mouyis
- Department of Rheumatology, Luton and Dunstable Hospital, Luton, United Kingdom
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8
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Nguyen H, Ahmed K, Luo W, Flint J, Giles I. A Systematic Review of the safety of non-TNF inhibitor biologic and targeted synthetic drugs in rheumatic disease in pregnancy. Semin Arthritis Rheum 2021; 51:1205-1217. [PMID: 34689007 DOI: 10.1016/j.semarthrit.2021.09.004] [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: 07/06/2021] [Revised: 08/07/2021] [Accepted: 09/13/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Despite increasing evidence to support safe use of tumour necrosis factor inhibitors (TNFi) and other biologic disease modifying anti-rheumatic drugs (bDMARDs) during pre-conception/pregnancy, there remains a paucity of evidence regarding the safety and compatibility of other non-TNFi and novel targeted synthetic (ts)DMARDs during pre-conception/pregnancy. Therefore, we conducted a systematic review to determine the compatibility of these drugs in pre-conception, during pregnancy and post-partum period. METHOD Databases including; EMBASE, Pubmed (MEDLINE), and Cochrane were searched up to 23rd October 2020 to find relevant peer-reviewed papers, using keywords including; rheumatic disease, pregnancy, conception/pre-conception, lactation/breastfeeding, childhood and vaccination/infection, and commonly prescribed non-TNFi drugs and tsDMARDs. RESULTS Our search yielded 1483 papers that were screened independently by two authors, and 109 full-text papers were eligible for final analysis. These studies reported 1291 maternal pregnancies exposed to non-TNFi bDMARDs and tsDMARDs with known outcomes, including 721 live births, 219 spontaneous miscarriages and 27 congenital abnormalities. Paternal exposures in 174 pregnancies had reassuring outcomes. A total of 48 breast-fed infants were exposed to non-TNFi bDMARDs and no adverse events reported upon long-term follow-up. Fifteen infants exposed to bDMARDs received normal vaccination regimes, including live vaccines, and had normal developmental outcomes, without any complications or infections. CONCLUSION Overall, the findings are reassuring and do not suggest a cause for any major concerns or an increased risk of adverse pregnancy outcomes for maternal or paternal exposures to non-TNFi bDMARDs or tsDMARDs. There were no major concerns for breastfeeding exposures to non-TNFi bDMARDs.
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Affiliation(s)
- Hanh Nguyen
- Centre for Rheumatology Research, Rayne Institute, University College London (UCL), London, UK
| | | | - Weike Luo
- University College London (UCL), London, UK
| | | | - Ian Giles
- Centre for Rheumatology Research, Rayne Institute, University College London (UCL), London, UK; Department of Rheumatology, University College London Hospital, London, UK.
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9
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Farahani M, Maghoul A, Nirouei M, Alinia T. A pregnant woman with a history of SLE with PPROM and severe thrombocytopenia: A case study. Clin Case Rep 2021; 9:e04792. [PMID: 34504703 PMCID: PMC8418677 DOI: 10.1002/ccr3.4792] [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: 05/25/2021] [Revised: 08/12/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022] Open
Abstract
This study discusses the management of a pregnant woman with PPROM and a history of lupus. She was found to be severely thrombocytopenic which was unresponsive to prednisolone. During cesarean section, placental abruption was found and postpartum hemorrhage ensued.
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Affiliation(s)
- Masoumeh Farahani
- Department of Obstetrics and GynecologistsAlborz University of Medical SciencesKarajIran
| | | | | | - Tina Alinia
- School of MedicineFaculty of MedicineTehran University of Medical SciencesTehranIran
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10
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Use of thrombopoietin receptor agonists for immune thrombocytopenia in pregnancy: results from a multicenter study. Blood 2021; 136:3056-3061. [PMID: 32814348 DOI: 10.1182/blood.2020007594] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/04/2020] [Indexed: 01/14/2023] Open
Abstract
Management of immune thrombocytopenia (ITP) during pregnancy can be challenging because treatment choices are limited. Thrombopoietin receptor agonists (Tpo-RAs), which likely cross the placenta, are not recommended during pregnancy. To better assess the safety and efficacy of off-label use of Tpo-RAs during pregnancy, a multicenter observational and retrospective study was conducted. Results from 15 pregnant women with ITP (pregnancies, n = 17; neonates, n = 18) treated with either eltrombopag (n = 8) or romiplostim (n = 7) during pregnancy, including 2 patients with secondary ITP, were analyzed. Median time of Tpo-RA exposure during pregnancy was 4.4 weeks (range, 1-39 weeks); the indication for starting Tpo-RAs was preparation for delivery in 10 (58%) of 17 pregnancies, whereas 4 had chronic refractory symptomatic ITP and 3 were receiving eltrombopag when pregnancy started. Regarding safety, neither thromboembolic events among mothers nor Tpo-RA-related fetal or neonatal complications were observed, except for 1 case of neonatal thrombocytosis. Response to Tpo-RAs was achieved in 77% of cases, mostly in combination with concomitant ITP therapy (70% of responders). On the basis of these preliminary findings, temporary off-label use of Tpo-RAs for severe and/or refractory ITP during pregnancy seems safe for both mother and neonate and is likely to be helpful, especially before delivery.
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11
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Agarwal N, Mangla A. Thrombopoietin receptor agonist for treatment of immune thrombocytopenia in pregnancy: a narrative review. Ther Adv Hematol 2021; 12:20406207211001139. [PMID: 33796239 PMCID: PMC7983475 DOI: 10.1177/20406207211001139] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/09/2021] [Indexed: 12/26/2022] Open
Abstract
The treatment of immune thrombocytopenia (ITP) in adults has evolved rapidly over the past decade. The second-generation thrombopoietin receptor agonists (TPO-RAs), romiplostim, eltrombopag, and avatrombopag are approved for the treatment of chronic ITP in adults. However, their use in pregnancy is labeled as category C by the United States Food and Drug Administration (FDA) due to the lack of clinical data on human subjects. ITP is a common cause of thrombocytopenia in the first and second trimester of pregnancy, which not only affects the mother but can also lead to thrombocytopenia in the neonatal thrombocytopenia secondary to maternal immune thrombocytopenia (NMITP). Corticosteroids, intravenous immunoglobulins (IVIGs) are commonly used for treating acute ITP in pregnant patients. Drugs such as rituximab, anti-D, and azathioprine that are used to treat ITP in adults, are labeled category C and seldom used in pregnant patients. Cytotoxic chemotherapy (vincristine, cyclophosphamide), danazol, and mycophenolate are contraindicated in pregnant women. In such a scenario, TPO-RAs present an attractive option to treat ITP in pregnant patients. Current evidence on the use of TPO-RAs in pregnant women with ITP is limited. In this narrative review, we will examine the preclinical and the clinical literature regarding the use of TPO-RAs in the management of ITP in pregnancy and their effect on neonates with NMITP.
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Affiliation(s)
- Nikki Agarwal
- Division of Pediatric Hematology and Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ankit Mangla
- Division of Hematology and Oncology, Seidman Cancer Center, University Hospitals, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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12
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Leng Q, Wang W, Wang Y, Wu L. Treatment of severe thrombocytopenia associated with systemic lupus erythematosus in pregnancy with eltrombopag: A case report and literature review. J Clin Pharm Ther 2020; 46:532-538. [PMID: 33277725 DOI: 10.1111/jcpt.13321] [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] [Received: 10/24/2020] [Revised: 11/10/2020] [Accepted: 11/15/2020] [Indexed: 12/20/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Severe thrombocytopenia associated with systemic lupus erythematosus (SLE) in pregnancy is infrequent. Its occurrence can lead to serious adverse pregnancy consequences and perinatal complications. The thrombopoietin (TPO) analogue eltrombopag has been successfully used in the treatment of autoimmune thrombocytopenia, but its safety and efficacy in severe thrombocytopenia during pregnancy remain unclear. CASE SUMMARY We report a 33-year-old woman with SLE at 29 + 3 weeks gestational age who developed severe thrombocytopenia with complaints of epistaxis, gum bleeding and haematuresis. Most conventional treatments including glucocorticoids, intravenous immunoglobulin (IVIG) and cyclosporine did not elevate her platelets, but eltrombopag worked well and her platelet count gradually recovered, allowing her to deliver a healthy baby at 36 + 3 weeks gestational age. WHAT IS NEW AND CONCLUSION This suggests that eltrombopag in combination with glucocorticoids has a good safety and efficacy profile in pregnant patients with SLE complicated by severe thrombocytopenia.
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Affiliation(s)
- Qianru Leng
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Wei Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
| | - Lujin Wu
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Key Laboratory of Genetics and Molecular Mechanism of Cardiologic Disorders, Wuhan, China
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Sammartano V, Santoni A, Defina M, Ciofini S, Cencini E, Bocchia M. Efficacy and safety of eltrombopag during conception and first trimester of pregnancy in a case of refractory severe immune thrombocytopenia. Blood Coagul Fibrinolysis 2020; 31:416-418. [PMID: 32815918 DOI: 10.1097/mbc.0000000000000936] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Immune thrombocytopenia (ITP) is a relatively frequent cause of thrombocytopenia during pregnancy. Thrombopoietin receptor agonists (TPO-RAs) are the most recent drugs approved for second-line treatment of ITP. Limited data are available about their use in pregnancy with only a few published cases; yet no data exist about their effect when administered only during conception and first trimester of gestation. We describe the case of a woman with refractory ITP who took eltrombopag during conception and first trimester of pregnancy. No fetal or maternal complications were reported. Moreover, the patient remained in complete response after delivery despite therapy discontinuation. The analysis of this case and the revision of the available literature suggest that the use of TPO-RAs, thanks to their short time to response, may be effective and feasible during the first trimester of pregnancy, even if not yet recommended by current guidelines.
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Affiliation(s)
- Vincenzo Sammartano
- Hematology Unit, Azienda Ospedaliera Universitaria Senese e Università di Siena, Siena, Italy
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14
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Abstract
BACKGROUND Severe immune thrombocytopenia complicating pregnancy may require treatment beyond first-line medications (intravenous immunoglobulins or corticosteroids), but there is a paucity of literature on the use of such second-line agents in pregnancy. CASE The patient is a 29-year-old woman with early-onset severe immune thrombocytopenia at 13 weeks of gestation. Maternal platelet counts reached a nadir of less than 5×10/L. The thrombocytopenia persisted despite first-line medications. Romiplostim, rituximab, and azathioprine were added to the therapeutic regimen. Platelet counts eventually stabilized at greater than 150×10/L before delivery. After delivery at term, the neonate had transient B-cell suppression, which was presumed to be secondary to rituximab, but was otherwise doing well and meeting all milestones at 7 months of age. CONCLUSION The addition of second-line agents was associated with sustained elevation in maternal platelet counts and may have obviated the need for splenectomy.
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Abstract
PURPOSE OF THE REVIEW To review the available evidence on the management of a variety of non-criteria manifestations in antiphospholipid syndrome (APS), including valvular disease, alveolar hemorrhage, thrombocytopenia, hemolytic anemia, APS nephropathy, skin ulcers, livedo reticularis, cognitive dysfunction, and epilepsy. RECENT FINDINGS Current treatment relies on low-level evidence and mainly on expert consensus due to the rarity and the heterogeneity of non-criteria APS manifestations and the diversity in management approaches. Conventional anticoagulation and/or antiplatelet APS treatment do not adequately control most of non-criteria manifestations. Increasing knowledge about the contribution of inflammatory in addition to, or independently of, thrombotic mechanisms in non-criteria APS manifestations provides insight into the potential effect of novel therapies targeting B-cells, mammalian target of rapamycin, neutrophil, and complement or interferon pathways. Existing evidence is limited by lack of high-quality studies. Better understanding of the pathophysiology and clinical phenotypes of APS and well-designed prospective studies of homogenous populations are needed to provide evidence-based recommendations for the management of non-criteria APS manifestations.
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16
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Talotta R, Atzeni F, Laska MJ. Therapeutic peptides for the treatment of systemic lupus erythematosus: a place in therapy. Expert Opin Investig Drugs 2020; 29:845-867. [PMID: 32500750 DOI: 10.1080/13543784.2020.1777983] [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: 12/12/2022]
Abstract
INTRODUCTION Studies in vitro and in vivo have identified several peptides that are potentially useful in treating systemic lupus erythematosus (SLE). The rationale for their use lies in the cost-effective production, high potency, target selectivity, low toxicity, and a peculiar mechanism of action that is mainly based on the induction of immune tolerance. Three therapeutic peptides have entered clinical development, but they have yielded disappointing results. However, some subsets of patients, such as those with the positivity of anti-dsDNA antibodies, appear more likely to respond to these medications. AREAS COVERED This review evaluates the potential use of therapeutic peptides for SLE and gives an opinion on how they may offer advantages for SLE treatment. EXPERT OPINION Given their acceptable safety profile, therapeutic peptides could be added to agents traditionally used to treat SLE and this may offer a synergistic and drug-sparing effect, especially in selected patient populations. Moreover, they could temporarily be utilized to manage SLE flares, or be administered as a vaccine in subjects at risk. Efforts to ameliorate bioavailability, increase the half-life and prevent immunogenicity are ongoing. The formulation of hybrid compounds, like peptibodies or peptidomimetic small molecules, is expected to yield renewed treatments with a better pharmacologic profile and increased efficacy.
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Affiliation(s)
- Rossella Talotta
- Department of Clinical and Experimental Medicine, Rheumatology Unit, Azienda Ospedaliera "Gaetano Martino", University of Messina , Messina, Italy
| | - Fabiola Atzeni
- Department of Clinical and Experimental Medicine, Rheumatology Unit, Azienda Ospedaliera "Gaetano Martino", University of Messina , Messina, Italy
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17
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Abstract
Purpose of review Although antiphospholipid syndrome (APS) is best known for conveying increased risk of thrombotic events and pregnancy morbidity, thrombocytopenia is also recognized as a common association. In this review, we will explore the relationship between thrombocytopenia and APS, highlighting our evolving understanding – and persistent knowledge gaps – through clinically oriented questions and answers. Recent findings A history of thrombocytopenia likely portends a more severe APS phenotype (including increased risk of thrombosis). Although the pathophysiology underlying thrombocytopenia in APS has yet to be definitively revealed, mechanisms that play a role (at least in subsets of patients) include: immune thrombocytopenic purpura/ITP-like autoantibodies against platelet glycoproteins; antiphospholipid antibody (aPL)-mediated platelet activation and consumption; and potentially life threatening thrombotic microangiopathy. Although thrombocytopenia is often ‘mild’ in APS (and therefore, may not require specific therapy), there are causes of acute-onset thrombocytopenia that mandate emergent work-up and treatment. When APS-related thrombocytopenia does require therapy, the approach must be individualized (requiring an understanding of pathophysiology in the particular APS patient). For patients with ITP-like disease, rituximab is emerging as a popular approach to treatment; in contrast, there are hints that thrombopoietin mimetics may be associated with elevated thrombotic risk. Summary Thrombocytopenia is common in APS, and is likely associated with more severe disease. Improved understanding of thrombocytopenia in APS has the potential to improve risk stratification, reveal novel aspects of APS pathophysiology, and lead to treatments that are more individualized and holistic.
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18
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Chua SJ, Morton MR, Svigos J, Ross DM, Kane S. Use of romiplostim in pregnancy for refractory idiopathic thrombocytopenic purpura: Two case reports with maternal and fetal outcomes and literature review. Obstet Med 2020; 13:45-50. [PMID: 32284733 PMCID: PMC7133099 DOI: 10.1177/1753495x18773960] [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: 11/14/2017] [Accepted: 03/30/2018] [Indexed: 12/30/2022] Open
Abstract
Idiopathic thrombocytopenic purpura is a relatively rare complication occurring in pregnancy, with the potential for serious maternal and fetal outcomes. Rarely, the poor response to established first-line therapies results in consideration of second-line therapies, which may have poorly understood risks to the fetus. We report two women with severe idiopathic thrombocytopenic purpura during pregnancy unresponsive to corticosteroids and intravenous immunoglobulin who were treated with romiplostim, a thrombopoietin receptor agonist. One woman with chronic idiopathic thrombocytopenic purpura had a partial response to romiplostim and suffered a post-partum haemorrhage related to uterine atony. The second woman developed severe idiopathic thrombocytopenic purpura in pregnancy and initially responded well to romiplostim. However, a lower segment Caesarean section was performed at 37 weeks for pre-eclampsia. The newborn suffered from severe idiopathic thrombocytopenic purpura and a grade 1 cerebral haemorrhage requiring intravenous immunoglobulin and platelet transfusions. Romiplostim might be a useful therapy for severe idiopathic thrombocytopenic purpura in pregnancy but requires further study.
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Affiliation(s)
- Su J Chua
- Women’s
& Children’s Hospital, North
Adelaide, Australia
| | - Mark R Morton
- Women’s
& Children’s Hospital, North
Adelaide, Australia
| | - John Svigos
- Women’s
& Children’s Hospital, North
Adelaide, Australia
| | - David M Ross
- Department of Haematology,
Royal
Adelaide Hospital, Adelaide,
Australia
| | - Simon Kane
- Lyell
McEwin Hospital, Elizabeth Vale,
Australia
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19
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Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, Ghanima W, Godeau B, González-López TJ, Grainger J, Hou M, Kruse C, McDonald V, Michel M, Newland AC, Pavord S, Rodeghiero F, Scully M, Tomiyama Y, Wong RS, Zaja F, Kuter DJ. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv 2019; 3:3780-3817. [PMID: 31770441 PMCID: PMC6880896 DOI: 10.1182/bloodadvances.2019000812] [Citation(s) in RCA: 511] [Impact Index Per Article: 102.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/18/2019] [Indexed: 01/19/2023] Open
Abstract
Over the last decade, there have been numerous developments and changes in treatment practices for the management of patients with immune thrombocytopenia (ITP). This article is an update of the International Consensus Report published in 2010. A critical review was performed to identify all relevant articles published between 2009 and 2018. An expert panel screened, reviewed, and graded the studies and formulated the updated consensus recommendations based on the new data. The final document provides consensus recommendations on the diagnosis and management of ITP in adults, during pregnancy, and in children, as well as quality-of-life considerations.
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Affiliation(s)
- Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Donald M Arnold
- McMaster Centre for Transfusion Research, Department of Medicine and Department of Pathology and Molecular Medicine, McMaster University and Canadian Blood Services, Hamilton, ON, Canada
| | - James B Bussel
- Division of Hematology/Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Beng H Chong
- St. George Hospital, NSW Health Pathology, University of New South Wales, Sydney, NSW, Australia
| | - Nichola Cooper
- Department of Haematology, Hammersmith Hospital, London, United Kingdom
| | | | - Waleed Ghanima
- Departments of Research, Medicine and Oncology, Østfold Hospital Trust, Grålum, Norway
- Department of Hematology, Institute of Clinical Medicine, Oslo University, Oslo, Norway
| | - Bertrand Godeau
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | | | - John Grainger
- Department of Haematology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Ming Hou
- Department of Haematology, Qilu Hospital, Shandong University, Jinan, China
| | | | - Vickie McDonald
- Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Marc Michel
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil, Créteil, France
| | - Adrian C Newland
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Sue Pavord
- Haematology Theme Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, United Kingdom
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Osaka, Japan
| | - Raymond S Wong
- Sir YK Pao Centre for Cancer and Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Francesco Zaja
- SC Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy; and
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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20
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Affiliation(s)
- Renee Eslick
- Clinical and Laboratory Haematologist, Haematology Department, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Claire McLintock
- Clinical and Laboratory Haematologist, Obstetric Physician, National Women’s Health, Auckland City Hospital, Auckland, New Zealand
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21
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Rosa María RN, Laura RL, Ángeles PB, Laura LB. Use of Romiplostim during pregnancy as a rescue therapy in primary immune thrombocytopenia: Literature review and case description. Platelets 2019; 31:403-406. [PMID: 31116059 DOI: 10.1080/09537104.2019.1615613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Thrombocytopenia could appear during pregnancy, in up to 8-10% of the cases, where 3-5% is related to an autoimmune process so-called immune thrombocytopenia (ITP). We present a 34-year-old woman debuted at 13 weeks gestation, with a platelet count of 19 × 109/L and petechiae. She did not respond to initial treatment with corticosteroids and intravenous immunoglobulin. At this point, considering the limited treatment options due to toxicity and/or teratogenesis of other drugs proven to be effective against ITP like azathioprine, rituximab, cyclophosphamide, etc. and the risk of bleeding symptoms, either from mother or fetus, we decided to begin treatment with Romiplostim (thrombopoietin receptor agonist). On reviewing the literature at this matter, only eight cases with ITP were treated during pregnancy with Romiplostim and only one of those, the ITP, was refractory to Romiplostim. In a retrospective study, Romiplostim used as a bridge to surgery in 47 patients stated a platelet count increment higher than 100 × 109/L in 79% cases after two doses of Romiplostim. According to bibliography, we decided to start Romiplostim to our patient at 35 weeks of gestation with a spectacular platelet count recovery of 158 × 109/L within 1 week of treatment, at 36th week, and after induced labor, she had on the very next day an eutocic vaginal childbearing without major bleeding complications.
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Affiliation(s)
| | | | - Palomo Bravo Ángeles
- Hematology Service, Hospital Materno Infantil de Málaga (Hospital Regional Universitario), Malaga, Spain
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22
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23
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Kanda M, Atsumi T. Thrombopoietin mimetics for systemic lupus erythematosus with antiphospholipid antibodies should be discussed separately. Lupus 2018; 27:1876-1877. [DOI: 10.1177/0961203318784654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M Kanda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - T Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
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24
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Guitton Z, Terriou L, Lega JC, Nove-Josserand R, Hie M, Amoura Z, Bussel JB, Hamidou M, Rosenthal E, Lioger B, Chauveau D, Chaminade A, Magy-Bertrand N, Michel M, Audia S, Godeau B, Mahevas M. Risk of thrombosis with anti-phospholipid syndrome in systemic lupus erythematosus treated with thrombopoietin-receptor agonists. Rheumatology (Oxford) 2018; 57:1432-1438. [DOI: 10.1093/rheumatology/key119] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Indexed: 12/26/2022] Open
Affiliation(s)
- Zelie Guitton
- Département de Médecine Interne et Immunologie Clinique, CHU Lille, Lille, France
| | - Louis Terriou
- Département de Médecine Interne et Immunologie Clinique, CHU Lille, Lille, France
| | | | | | - Miguel Hie
- Department of Internal Medicine, Pitie-Salpetriere University Hospital, Paris, France
| | - Zahir Amoura
- Department of Internal Medicine, Pitie-Salpetriere University Hospital, Paris, France
| | | | - Mohamed Hamidou
- Department of Internal Medicine, Hôtel Dieu University Hospital, Nantes, France
| | - Eric Rosenthal
- Weill Department of Medicine, Internal Medecine, CHRU Nice, Nice, France
| | - Bertrand Lioger
- Department of Internal Medicine, Bretonneau University Hospital, Tours, France
| | | | | | | | - Marc Michel
- Internal Medicine, French Referral Centre for Adult Immune Cytopenia, Henri Mondor Hospital, AP-HP, UPEC University, Créteil, France
| | - Sylvain Audia
- Department of Internal Medicine, Dijon University Hospital, Dijon, France
| | - Bertrand Godeau
- Internal Medicine, French Referral Centre for Adult Immune Cytopenia, Henri Mondor Hospital, AP-HP, UPEC University, Créteil, France
| | - Matthieu Mahevas
- Internal Medicine, French Referral Centre for Adult Immune Cytopenia, Henri Mondor Hospital, AP-HP, UPEC University, Créteil, France
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25
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Lusa A, Carlson A. Safety and efficacy of thrombopoeitin mimetics for refractory immune thrombocytopenia purpura in patients with systemic lupus erythematosus or antiphospholipid syndrome: a case series. Lupus 2018; 27:1723-1728. [DOI: 10.1177/0961203318770023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background While thrombopoeitin (TPO) agonists that act to simulate platelet production have been approved for use in steroid-refractory chronic immune thrombocytopenia purpura (ITP), there are few data on the safety and efficacy of these medications in patients with concurrent systemic lupus erythematosus (SLE) or antiphospholipid syndrome (APS). Given that these agents can increase all hematopoietic cell lineages, it is unclear if there is an increased risk for exacerbation of the underlying lymphocyte-driven autoimmune disease in this population. Case summaries This case series includes four patients with SLE, one with concurrent APS, who were treated for steroid-refractory ITP with TPO mimetics at the University of Virginia between 2005 and 2015. In three of the four cases the medication was successful in improving platelet counts and preventing bleeding events. In addition, none of the patients experienced thrombosis or worsening of their underlying autoimmune disease. Conclusions This case series suggests that TPO mimetics are safe and moderately effective in patients with ITP in the setting of SLE or APS and do not contribute to increased disease activity.
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Affiliation(s)
- A Lusa
- Fontaine Research Park, University of Virginia, USA
| | - A Carlson
- Fontaine Research Park, University of Virginia, USA
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26
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Favier R, De Carne C, Elefant E, Lapusneanu R, Gkalea V, Rigouzzo A. Eltrombopag to Treat Thrombocytopenia During Last Month of Pregnancy in a Woman With MYH9-Related Disease. A A Pract 2018; 10:10-12. [DOI: 10.1213/xaa.0000000000000621] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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27
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Harrington P, Nelson-Piercy C, Williamson C, Cooper N, Kesse-Adu R, Robinson S. Refractory severe immune thrombocytopenia in a twin pregnancy. Obstet Med 2017; 11:35-38. [PMID: 29636813 DOI: 10.1177/1753495x17709188] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 03/30/2017] [Indexed: 01/18/2023] Open
Abstract
A 34-year-old woman presented at 29 weeks gestation of a twin pregnancy, with a platelet count of 1 × 109/l. She was extensively investigated and was subsequently diagnosed with severe immune thrombocytopenia. She did not respond to initial treatment with corticosteroids and intravenous immunoglobulin. She also failed to respond to second-line therapies of Anti-D immunoglobulin, Azathioprine and the thrombopoietin agonist Romiplostim. Her case was further complicated by an episode of obstetric cholestasis possibly related to Azathioprine treatment. She went on to require plasma exchange around the time of an elective Caesarean section which provided temporary improvement in the platelet count and enabled safe delivery. This case highlights some of the challenges faced in the management of patients with severe and refractory immune thrombocytopenia during pregnancy.
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Affiliation(s)
| | | | | | | | - Rachel Kesse-Adu
- Guys and St Thomas' NHS Foundation Trust, Guys Hospital, London, UK
| | - Susan Robinson
- Guys and St Thomas' NHS Foundation Trust, Guys Hospital, London, UK
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28
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González-López TJ, Alvarez-Román MT, Pascual C, Sánchez-González B, Fernández-Fuentes F, Pérez-Rus G, Hernández-Rivas JA, Bernat S, Bastida JM, Martínez-Badas MP, Martínez-Robles V, Soto I, Olivera P, Bolaños E, Alonso R, Entrena L, Gómez-Nuñez M, Alonso A, Yera Cobo M, Caparrós I, Tenorio M, Arrieta-Cerdán E, Lopez-Ansoar E, García-Frade J, González-Porras JR. Use of eltrombopag for secondary immune thrombocytopenia in clinical practice. Br J Haematol 2017; 178:959-970. [PMID: 28573819 DOI: 10.1111/bjh.14788] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/04/2017] [Indexed: 01/16/2023]
Abstract
Eltrombopag is a second-line treatment in primary immune thrombocytopenia (ITP). However, its role in secondary ITP is unknown. We evaluated the efficacy and safety of eltrombopag in secondary ITP in daily clinical practice. Eighty-seven secondary ITP patients (46 with ITP secondary to autoimmune syndromes, 23 with ITP secondary to a neoplastic disease subtype: lymphoproliferative disorders [LPDs] and 18 with ITP secondary to viral infections) who had been treated with eltrombopag were retrospectively evaluated. Forty-four patients (38%) had a platelet response, including 40 (35%) with complete responses. Median time to platelet response was 15 days (95% confidence interval, 7-28 days), and was longer in the LPD-ITP group. Platelet response rate was significantly lower in the LPD-ITP than in other groups. However, having achieved response, there were no significant differences between the durable response of the groups. Forty-three patients (49·4%) experienced adverse events (mainly grade 1-2), the commonest being hepatobiliary laboratory abnormalities. There were 10 deaths in this case series, all of which were related to pre-existing medical conditions. In routine clinical practice, eltrombopag is effective and well-tolerated in unselected patients with ITP secondary to both immune and infectious disorders. However, the response rate in LPD-ITP is low.
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Affiliation(s)
| | | | - Cristina Pascual
- Department of Haematology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Fernando Fernández-Fuentes
- Department of Haematology, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Gloria Pérez-Rus
- Department of Haematology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | - Silvia Bernat
- Department of Haematology, Hospital de La Plana, Castellón, Spain
| | - José M Bastida
- Department of Haematology, IBSAL-Hospital Universitario de Salamanca, Salamanca, Spain
| | | | | | - Inmaculada Soto
- Department of Haematology, Hospital Universitario Central de Asturias, Oviedo (Asturias), Spain
| | - Pavel Olivera
- Department of Haematology, Hospital Universitario Valle de Hebron, Barcelona, Spain
| | - Estefanía Bolaños
- Department of Haematology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Rafael Alonso
- Department of Haematology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Laura Entrena
- Department of Haematology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Marta Gómez-Nuñez
- Department of Haematology, Parc Sanitari Taulí, Sabadell (Barcelona), Spain
| | - Arancha Alonso
- Department of Haematology, Hospital Universitario Quirón Madrid, Madrid, Spain
| | - María Yera Cobo
- Department of Haematology, Hospital Puerta del Mar, Cádiz, Spain
| | - Isabel Caparrós
- Department of Haematology, Hospital Clínico de Málaga, Malaga, Spain
| | - María Tenorio
- Department of Haematology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Elsa Lopez-Ansoar
- Department of Haematology, Complejo Hospitalario Universitario de Orense, Orense, Spain
| | - Javier García-Frade
- Department of Haematology, Hospital Universitario Río Hortega, Valladolid, Spain
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29
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Galanopoulos N, Christoforidou A, Bezirgiannidou Z. Lupus thrombocytopenia: pathogenesis and therapeutic implications. Mediterr J Rheumatol 2017; 28:20-26. [PMID: 32185250 PMCID: PMC7045921 DOI: 10.31138/mjr.28.1.20] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/01/2017] [Accepted: 03/14/2017] [Indexed: 12/12/2022] Open
Abstract
Systemic Lupus Erythematosus (SLE) is frequently complicated by cytopenias. Thrombocytopenia is usually non severe and its frequency ranges from 20% to 40%. It is mostly an autoimmune process caused by autoantibodies against platelet surface glycoproteins and it is associated with worse prognosis in SLE. It can also be a result of SLE treatment with azathioprine, methotrexate and rarely hydroxychloroquine or thrombotic microangiopathy or macrophage activation syndrome. If thrombocytopenia is mild (>50×109/L) and there is no other evidence of disease there is no need of therapy. Severe thrombocytopenia is less frequent and needs therapeutic management. Corticosteroids are the cornerstone of therapy. Continuous high dose oral prednisolone or pulse high dose methylprednisolone (MP) with or without intravenous immune globulin are used in the acute phase. Second line agents (hydroxychloroquine, danazol, azathioprine, cyclosporine, mycophenolate mofetil, cyclophosphamide, rituximab) are usually needed. Splenectomy is indicated for recurrent or resistant cases. There are no evidence-based guidelines to facilitate selection of one drug over another but certainly the co-existence of other systemic SLE manifestations must be taken into account. Newer therapies are emerging although there is no consensus on the treatment of refractory lupus thrombocytopenia due to the absence of controlled randomized trials.
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Affiliation(s)
- Nikolaos Galanopoulos
- Outpatient Department of Rheumatology, University General Hospital of Evros (Alexandroupolis), Thrace, Greece
| | - Anna Christoforidou
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Zoe Bezirgiannidou
- Department of Haematology, Democritus University of Thrace, Alexandroupolis, Greece
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30
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Velo-García A, Castro SG, Isenberg DA. The diagnosis and management of the haematologic manifestations of lupus. J Autoimmun 2016; 74:139-160. [DOI: 10.1016/j.jaut.2016.07.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
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31
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Piatek CI, El-Hemaidi I, Feinstein DI, Liebman HA, Akhtari M. Management of immune-mediated cytopenias in pregnancy. Autoimmun Rev 2015; 14:806-11. [DOI: 10.1016/j.autrev.2015.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/07/2015] [Indexed: 10/24/2022]
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32
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Magnano L, Enríquez H, Esteve J, Cervera R, Espinosa G. Effectiveness of thrombopoietin-receptor agonists in the treatment of refractory immune thrombocytopenia associated to systemic lupus erythematosus. J Rheumatol 2015; 41:1895-6. [PMID: 25179983 DOI: 10.3899/jrheum.140080] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
| | | | | | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain.
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33
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Loustau V, Pourrat O, Mandelbrot L, Godeau B. Purpura thrombopénique immunologique et grossesse : état des connaissances actuelles et questions encore sans réponse. Rev Med Interne 2015; 36:167-72. [DOI: 10.1016/j.revmed.2014.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 07/30/2014] [Indexed: 11/28/2022]
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34
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Maroun MC, Ososki R, Andersen JC, Dhar JP. Eltrombopag as steroid sparing therapy for immune thrombocytopenic purpura in systemic lupus erythematosus. Lupus 2014; 24:746-50. [PMID: 25416695 DOI: 10.1177/0961203314559632] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/21/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Eltrombopag activates the thrombopoietin (TPO) surface receptor on the megakaryocyte, which increases the production of platelets, and rapidly improves circulating platelet numbers in patients with immune thrombocytopenic purpura (ITP). This allows for rapid tapering and/or cessation of corticosteroid therapy. Less is known about the platelet response to this drug in ITP associated with systemic lupus erythematosus (SLE). METHODS A retrospective review was performed of the clinical course of three consecutive patients, each with SLE-associated ITP who were initially treated with corticosteroids or other immunomodulatory therapy. These patients were treated with eltrombopag at the DMC Center for Bleeding Disorders and Thrombosis. Eltrombopag was administered according the package insert, with an initial dose of 50 mg daily, with weekly, then monthly monitoring of platelet counts and dose adjustments. Some immunomodulatory agents (e.g. hydroxychloroquine) were continued to control non hematologic SLE manifestations. RESULTS All three patients maintained acceptable platelet counts (>50,000/mm(3) for >3 years) following tapering and cessation of corticosteroids. The drug was well-tolerated and there were no adverse events, and specifically no thrombotic events. CONCLUSION Eltrombopag is effective as a rapidly acting corticosteroid sparing therapy for patients with ITP associated with SLE. This is important in reducing corticosteroid related side effects and morbidities in treating SLE patients with ITP. Larger studies are needed to ascertain safety and efficacy of eltrombopag in SLE patients with ITP, particularly those with coexisting antiphospholipid antibodies.
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Affiliation(s)
- M-C Maroun
- Internal Medicine Department, Rheumatology Division, Wayne State University, Detroit, MI, USA
| | - R Ososki
- Medicine and Oncology Department, Wayne State University School of Medicine, Karmanos Cancer Institute, USA
| | - J C Andersen
- Medicine and Oncology Department, Wayne State University School of Medicine, Karmanos Cancer Institute, USA
| | - J P Dhar
- Internal Medicine Department, Rheumatology Division, Wayne State University, Detroit, MI, USA Internal Medicine Department, Central Michigan University, MI, USA
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35
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Matzdorff A, Eberl W, Giagounidis A, Imbach P, Pabinger I, Wörmann B. [Immune thrombocytopenia -- onkopedic guidelines update: recommendations of a joint working group of the DGHO, ÖGHO, SGH + SSH and GPOH]. Oncol Res Treat 2014; 37 Suppl 2:6-25. [PMID: 24613966 DOI: 10.1159/000356910] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Axel Matzdorff
- Klinik für Hämatologie und Onkologie, Caritasklinikum Saarbrücken St. Theresia, Saarbrücken, Deutschland
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Goh KG, Ong SG. Recurrent spontaneous subdural hematoma secondary to immune thrombocytopenia in a patient with overlap syndrome. Lupus 2014; 24:90-3. [PMID: 25305213 DOI: 10.1177/0961203314554248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Patients with autoimmune connective tissue disease may manifest as overlap syndrome with features of systemic lupus erythematosus (SLE), systemic sclerosis, rheumatoid arthritis and myositis. Those presenting with active SLE can present with immune thrombocytopenia (IT) and may be complicated with subdural hematoma which, though rare, is potentially life-threatening. We report here a patient with overlap syndrome who had recurrent spontaneous subdural hematoma due to severe thrombocytopenia which did not respond to corticosteroids and azathioprine. Her platelet count became normal with three doses of low-dose intravenous cyclophosphamide (IV CYC) given at 3-weekly intervals. She remained in remission with maintenance therapy with azathioprine.
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Affiliation(s)
- K G Goh
- Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - S G Ong
- Department of Medicine, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
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Rescue therapy with romiplostim for refractory primary immune thrombocytopenia during pregnancy. Obstet Gynecol 2014; 124:481-483. [PMID: 25004319 DOI: 10.1097/aog.0000000000000371] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary immune thrombocytopenia is not a rare event during pregnancy, and it must be carefully managed to avoid hemorrhagic complications for the mother. After failure of first-line treatments, the teratogenicity and toxicity of other therapeutic agents limit the available options and treatment. CASES We describe the cases of two pregnant patients with corticosteroid-refractory immune thrombocytopenia who were successfully treated by romiplostim, a thrombopoietin receptor agonist, without any fetal or maternal complications. CONCLUSION Romiplostim may represent an important alternative treatment choice during pregnancy for immune thrombocytopenia cases refractory to first-line therapy, especially because of its speed of action and high efficacy. Nevertheless, further data are required to provide definitive evidence of its safety for newborns.
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Li C, Zheng L. The pharmacology and clinical application of thrombopoietin receptor agonists. Int J Hematol 2014; 100:529-39. [DOI: 10.1007/s12185-014-1660-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 08/14/2014] [Accepted: 08/20/2014] [Indexed: 12/17/2022]
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Bolten K, Salama A, Thomas A, Eucker J, Henrich W. Severe Case of Autoimmune Thrombocytopenia First Diagnosed in Pregnancy. Geburtshilfe Frauenheilkd 2014; 73:1252-1255. [PMID: 24771907 DOI: 10.1055/s-0033-1360149] [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: 07/17/2013] [Revised: 11/02/2013] [Accepted: 11/05/2013] [Indexed: 10/25/2022] Open
Abstract
We report on a 28-year old primigravida who presented in the second trimester with sudden onset of bleeding tendencies and thrombocytopenia of 2/nL during the first manifestation of autoimmune thrombocytopenia (ITP). Therapy with intravenous immunoglobulins (IVIG) and steroids was initiated but could not prevent renewed bleeding incidents and recurrent thrombocytopenia in the long term, thus premature delivery by Caesarean section in the 32 + 3 week of pregnancy could not be avoided. The bleeding complications could only be mastered by multiple thrombocyte transfusions. Because the ITP remained refractory to therapy in the postpartum period a thrombopoietin receptor agonist (TPO-RA) was administered. This led to an increase in the thrombocyte count which was later stabilised by prednisolone alone.
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Affiliation(s)
- K Bolten
- Klinik für Geburtsmedizin CCM, Charité, Berlin
| | - A Salama
- Institut für Transfusionsmedizin, Charité, Berlin
| | - A Thomas
- Klinik für Geburtsmedizin CCM, Charité, Berlin
| | - J Eucker
- Medizinische Klinik mit Schwerpunkt Onkologie und Hämatologie CCM, Charité, Berlin
| | - W Henrich
- Klinik für Geburtsmedizin CCM, Charité, Berlin
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Successful platelet count recovery in lupus-associated thrombocytopenia with the thrombopoietin agonist eltrombopag. Clin Rheumatol 2014; 33:1347-9. [PMID: 24740463 DOI: 10.1007/s10067-014-2600-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/29/2014] [Indexed: 01/08/2023]
Abstract
Eltrombopag is a new thrombomimetic medication approved for the treatment of immune thrombocytopenia. There are very few reports on the use of eltrombopag in patients with thrombocytopenia associated with sytemic lupus.We present a recent case of a patient with lupus with severe thrombocytopenia refractory to conventional therapy and full recovery with the use of eltrombopag. The present status of the literature with the use of this medication in patients with lupus is reviewed and discussed.
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Abstract
Biologic therapies have revolutionized treatment outcomes for patients with inflammatory arthritis. However, there remains a concern regarding their safety during conception, pregnancy and breastfeeding. Data on the safety of these treatments are largely limited to uncontrolled case reports. Collective evidence from many hundreds of pregnancies in inflammatory arthritis and IBD have suggested that exposure to anti-TNF therapies at the time of conception or during the first trimester does not result in an increased risk of adverse pregnancy and fetal outcomes. Monoclonal antibodies, and to a lesser extent recombinant fusion proteins, do cross the placenta during the second and third trimester and are functional in the fetus, as evidence by lymphopaenia reported at birth in children exposed to rituximab in utero. In addition, live vaccines should be avoided in children with in utero exposure to biologics for at least the first 6 months of life. The longer-term effects of in utero exposure remain unknown. Studies suggest that many of these drugs do enter breast milk in small amounts, but the extent to which they are absorbed by the infant is less clear. Limited reports have not suggested adverse pregnancy outcomes in women whose partners were exposed to anti-TNF therapies or rituximab at the time of conception. Data on other biologic therapies, including anakinra, abatacept and tocilizumab, in both men and women remain extremely limited.
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Affiliation(s)
- Kimme L Hyrich
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester, UK.
| | - Suzanne M M Verstappen
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester, UK
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Use of a thrombopoietin mimetic for chronic immune thrombocytopenic purpura in pregnancy. Obstet Gynecol 2013; 122:483-485. [PMID: 23884268 DOI: 10.1097/aog.0b013e31828d5b56] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Romiplostim, a thrombopoietin mimetic, is a novel therapeutic option for patients with chronic immune thrombocytopenic purpura. We report on the effects of romiplostim use throughout pregnancy. CASE A 28-year-old primigravid woman with chronic immune thrombocytopenic purpura initiated a planned pregnancy on romiplostim. The second and third trimesters were marked by a cyclic pattern of thrombocytopenia requiring supplemental corticosteroids or intravenous immunoglobulin and resultant thrombocytosis. Increased romiplostim doses and daily corticosteroids stabilized the platelet count before induction of labor at 33 weeks of gestation. The newborn manifested intraventricular hemorrhage at birth, although no developmental delay was present on follow-up at 10 months of age. CONCLUSION The decreased efficacy of romiplostim monotherapy is attributed to increased target-mediated drug disposition and the physiologic changes of pregnancy. Safety concerns still exist for the developmental effects of romiplostim on the fetus.
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Bashal F. Hematological disorders in patients with systemic lupus erythematosus. Open Rheumatol J 2013; 7:87-95. [PMID: 24198852 PMCID: PMC3816272 DOI: 10.2174/1874312901307010087] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED This article is a review of different management strategies for the hematological manifestations of systemic lupus erythematosus (SLE), the strategies include immunosuppressive drugs, some noval therapies and B-cell depletion for refractory thrombocytopenia in patients with SLE and in antiphospholipid antibody syndrome associated with SLE. The researcher questions the validity of the current classic treatment modes and the article explores the relationships between SLE hematological manifestations and the level of morbidity and mortality burden and focuses on the pathophysiology, diagnostic approaches and management strategies of these manifestations. The researcher focuses on hematological abnormalities because they are the commonest among most manifestations in SLE seen in Anemia, leucopenias and thrombocytopenia. They commonly result from an immune mediated bone marrow failure, excessive peripheral cells destruction or certain drugs and infections. There is also an association between anti-phospholipid antibody syndrome (APS) and SLE referred to as secondary APS or SLE-APS. Furthermore, it was recently found that mycophenolatemofetil acts as corticosteroids and as cyclophosphamide sparing agent. Although there is no specific therapy for cytopenias in SLE, corticosteroids remain the mainstay in the treatment of these patients along with less used other conventional treatment options such as azathioprine, cyclophosphamide and human normal immunoglobulin. There are other novel therapies such as thrombopoietin receptor agonists in thrombocytopenia and the use of autologous hematopoitic stem cells transplantation in refractory SLE-APS that are under review. Some of these therapies include thrombopoietin receptor agonists in thrombocytopenia and the use of autologous hematopoitic stem cells transplantation in refractory SLE-APS. The study concludes that treatment of hematological abnormalities is challenging because the treatment itself can cause undue complications sometimes such as granulocytosis due to infection or the use of high doses of steroids and may occur during acute exacerbations of SLE. It is important to take these factors into consideration for disease therapy and management. PUBLICATION ABSTRACT This article is a review of different management strategies for the hematological manifestations of systemic lupus erythematosus (SLE). The strategies include immunosuppressive drugs, some novel therapies and B-cell depletion for refractory thrombocytopenia in patients with SLE and in anti-phospholipid antibody syndrome associated with SLE. The researcher questions the validity of the current classic treatment modes and the article explores the relationships between SLE hematological manifestations and the level of morbidity and mortality burden while it focuses on the pathophysiology, diagnostic approaches and management strategies. The study concludes that hematological abnormalities are the commonest among most manifestations in SLE, and that their treatment is challenging because the treatment itself can cause undue complications sometimes such as granulocytosis due to infection or the use of high doses of steroids and may occur during acute exacerbations of SLE. It is important to take these factors into consideration for disease therapy and management.
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Affiliation(s)
- Fozya Bashal
- Faculty of Medicine, Department of Internal Medicine, Umm AlQura University, Saudia Arabia
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