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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] [What about the content of this article? (0)] [Affiliation(s)] [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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2
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Su J, Xu M, Dong Z, Wang Q, Ma L, Xiao P, Chen X. Efficacy and safety of azathioprine plus prednisone versus prednisone alone as first-line treatment for antinuclear antibody-positive immune thrombocytopenia: a retrospective cohort study. Hematology 2023; 28:2196864. [PMID: 37014744 DOI: 10.1080/16078454.2023.2196864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/26/2023] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE Antinuclear antibody (ANA)-positive immune thrombocytopenia (ITP) patients have an unsatisfactory prognosis due to the more severe conditions of these patients and poor response to first-line glucocorticoids (GCs). The current study intended to compare the efficacy and safety of AZA plus prednisone and prednisone alone as first-line treatment in ANA-positive ITP patients. METHODS Fifteen ANA-positive ITP patients receiving AZA plus prednisone (AZA + GC group) and eighteen ANA-positive ITP patients receiving prednisone alone (GC group) as first-line treatment were retrospectively enrolled. RESULTS The complete response (CR) rate (60.0% versus 22.2%) (P = 0.038) was increased in the AZA + GC group versus the GC group, while the overall response rate (86.7% versus 55.6%) (P = 0.070) only showed an increasing trend that did not achieve statistical significance. In addition, multivariate analysis revealed that AZA + GC (versus GC) (odds ratio = 31.331, P = 0.018) was independently associated with a higher possibility of achieving CR. Additionally, accumulating relapse-free duration was prolonged in the AZA + GC group versus the GC group (median: 7.8 months versus 3.4 months) (P = 0.038). Additionally, the multivariate analysis suggested that AZA + GC (versus GC) (hazard ratio = 0.306, P = 0.007) was independently correlated with longer accumulating relapse-free duration. The incidence of adverse events did not differ between the two groups (all P > 0.05), and the common adverse events in the AZA + GC group were pneumonia (13.3%), anemia (13.3%), cough (13.3%), nausea (6.7%), and granulocytopenia (6.7%), which were all tolerable and manageable. CONCLUSION First-line AZA plus prednisone realizes a better hematological response and relapse-free duration with acceptable adverse events compared to prednisone alone in ANA-positive ITP patients.
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Affiliation(s)
- Junnan Su
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Meihong Xu
- Department of Physical Examination, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Zhigao Dong
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Qingqing Wang
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Lili Ma
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Pingping Xiao
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
| | - Xuyan Chen
- Department of Blood Rheumatism Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People's Republic of China
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Fu Y, Zhao L, Ye S. Intention to treat: The management of connective tissue disease-related immune thrombocytopenia. Int J Rheum Dis 2023; 26:1885-1888. [PMID: 37807615 DOI: 10.1111/1756-185x.14811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/15/2023] [Accepted: 06/21/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Yakai Fu
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Liling Zhao
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Shuang Ye
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Yang J, Zhao L, Wang W, Wu Y. All-trans retinoic acid added to treatment of primary immune thrombocytopenia: a systematic review and meta-analysis. Ann Hematol 2023:10.1007/s00277-023-05263-w. [PMID: 37166528 DOI: 10.1007/s00277-023-05263-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
All-trans retinoic acid (ATRA) application is a novel treatment approach for primary immune thrombocytopenia (ITP). This study aimed to evaluate the efficacy and safety of ATRA in the treatment of ITP. The databases of PubMed (MEDLINE), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and China National Knowledge Internet were searched on August 5, 2022, to find randomized controlled trials (RCTs) and observational studies. Five observational studies and four RCTs from China were included, and 760 Chinese patients were analyzed. In the five observational studies, the pooled overall response rate (ORR) and complete response rate (CRR) were 59.5% (95% confidence interval [CI], 52.4-66.4%) and 20.6% (95% CI, 14.3-27.6%), respectively. In the selected four RCTs, the pooled odds ratios for sustained response rate, ORR, and CRR were 3.00 (95% CI, 1.97-4.57; P < 0.01), 3.21 (95% CI, 2.15-4.78; P < 0.01), and 2.12 (95% CI, 1.17-3.86; P = 0.01), respectively. ATRA was associated with a reduction in relapse rate and salvage treatment rate (odds ratio, 0.30; 95% CI, 0.18-0.50; P < 0.01; 0.36; 95% CI, 0.23-0.56; P < 0.01, respectively). The pooled odds ratios for grade 1-2 dry skin, headache (or dizziness), and rash acneiform were 49.99 (95% CI, 16.05-155.67; P < 0.01), 1.75 (95% CI, 0.98-3.12; P = 0.06), and 0.37 (95% CI, 0.10-1.34; P = 0.13), respectively. This study suggests that ATRA may significantly improve the initial and long-term response of patients with ITP.
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Affiliation(s)
- Jinjun Yang
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Lei Zhao
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Wen Wang
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China.
| | - Yu Wu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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Rodeghiero F. Recent progress in ITP treatment. Int J Hematol 2023; 117:316-330. [PMID: 36622549 DOI: 10.1007/s12185-022-03527-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 01/10/2023]
Abstract
In this review, the recently approved drugs avatrombopag and fostamatinib, which were not extensively covered within 2019 international recommendations for ITP, will be discussed in some detail. Avatrombopag appears more convenient than eltrombopag as it does not require dietary restrictions or subcutaneous administration like romiplostim. However, data on quality of life (QoL) are lacking and the rate of thromboembolic events in exposed patients is not negligible. Efficacy of fostamatinib, an inhibitor of macrophagic activity, is supported by placebo-controlled trials in patients refractory to several therapies, including TPO-RA. While hypertension and diarrhea have been reported, only one minor thrombotic event occurred in 146 exposed patients. In addition, several new treatment combinations and new agents entered clinical investigation in recent years. In a UK trial, combining mycophenolate mofetil with corticosteroids as first line therapy was more effective than corticosteroids alone, but at the cost of worse QoL. No combination, including oseltamivir or all-trans retinoic acid or danazol, resulted in convincing evidence of superior efficacy and safety when used in first or later lines of treatment. Agents targeting specific mechanisms are also discussed: sutimlimab (complement inhibitor); rilzabrutinib (BTK inhibitor) and efgartigimod (modified Fc fragment inhibiting FcRn). Only efgartigimod has completed phase 3 investigation.
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Affiliation(s)
- Francesco Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Hematology, "S. Bortolo" Hospital, Contrà San Francesco 41, 36100, Vicenza, Italy.
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Huang L, Xu J, Zhang H, Wang M, Zhang Y, Lin Q. Application and investigation of thrombopoiesis-stimulating agents in the treatment of thrombocytopenia. Ther Adv Hematol 2023; 14:20406207231152746. [PMID: 36865986 PMCID: PMC9972067 DOI: 10.1177/20406207231152746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/06/2023] [Indexed: 03/02/2023] Open
Abstract
Platelets, derived from a certain subpopulation of megakaryocytes, are closely related to hemostasis, coagulation, metastasis, inflammation, and cancer progression. Thrombopoiesis is a dynamic process regulated by various signaling pathways in which thrombopoietin (THPO)-MPL is dominant. Thrombopoiesis-stimulating agents could promote platelet production, showing therapeutic effects in different kinds of thrombocytopenia. Some thrombopoiesis-stimulating agents are currently used in clinical practices to treat thrombocytopenia. The others are not in clinical investigations to deal with thrombocytopenia but have potential in thrombopoiesis. Their potential values in thrombocytopenia treatment should be highly regarded. Novel drug screening models and drug repurposing research have found many new agents and yielded promising outcomes in preclinical or clinical studies. This review will briefly introduce thrombopoiesis-stimulating agents currently or potentially valuable in thrombocytopenia treatment and summarize the possible mechanisms and therapeutic effects, which may enrich the pharmacological armamentarium for the medical treatment of thrombocytopenia.
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Affiliation(s)
- Lejun Huang
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
| | - Jianxuan Xu
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
| | - Huaying Zhang
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
| | - Mengfan Wang
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
| | - Yiyue Zhang
- Division of Cell, Developmental and Integrative
Biology, School of Medicine, South China University of Technology,
Guangzhou, P.R. China
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8
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Ou Y, Zhan Y, Zhuang X, Shao X, Xu P, Li F, Chen H, Ji L, Cheng Y. A bibliometric analysis of primary immune thrombocytopenia from 2011 to 2021. Br J Haematol 2023; 201:954-970. [PMID: 36807900 DOI: 10.1111/bjh.18692] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/22/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia. This bibliometric analysis was applied to identify the characteristics of global scientific output, the hotspots, and frontiers of ITP over the past 10 years. We retrieved publications from 2011 to 2021 from the Web of Science Core Collection (WoSCC). Bibliometrix package, VOSviewer, and Citespace were used to analyse and visualize the trend, distribution, and hotspots of research on ITP. Altogether, there were 2084 papers, written by 9080 authors from 410 organizations in 70 countries/regions, published in 456 journals with 37 160 co-cited references. In the last decades, the most productive journal was British Journal of Haematology, China was the most productive country. and the most cited journal was Blood. Shandong University was the most productive institution in the field of ITP. NEUNERT C, 2011, BLOOD, CHENG G, 2011, LANCET, and PATEL VL, 2012, BLOOD were the top three most cited documents. "Thrombopoietin receptor agonist", "regulatory T cell" and "sialic acid" were three hotspots of the last decade. And "immature platelet fraction", "Th17", and "fostamatinib" would be research frontiers in the feature. The present study provided a novel insight for future research directions and scientific decision-making.
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Affiliation(s)
- Yang Ou
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yanxia Zhan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xibing Zhuang
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xia Shao
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pengcheng Xu
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China
| | - Hao Chen
- Zhongshan Hospital Xuhui Branch, Department of Thoracic Surgery, Fudan University, Shanghai, China
| | - Lili Ji
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yunfeng Cheng
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China.,Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai, China
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Wang Y, Sheng L, Han F, Guo Q, Zhang Z, Hou Y, Feng Q, Zhou H, Ji X, Peng J, Hou M, Xu M. Efficacy and safety of treatments in newly diagnosed adult primary immune thrombocytopenia: A systematic review and network meta-analysis. EClinicalMedicine 2023; 56:101777. [PMID: 36578882 PMCID: PMC9791309 DOI: 10.1016/j.eclinm.2022.101777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Immune thrombocytopenia is an autoimmune disease characterised by decreased platelet count. In recent years, novel therapeutic regimens have been investigated in randomised controlled trials (RCTs). We aimed to compare the efficacy and safety of different treatments in newly diagnosed adult primary immune thrombocytopenia. METHODS We did a systematic review and network meta-analysis of RCTs involving treatments for newly diagnosed primary immune thrombocytopenia. PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched up to April 31, 2022. The primary outcomes were 6-month sustained response and early response. Secondary outcome was grade 3 or higher adverse events. This study is registered with PROSPERO (CRD42022296179). FINDINGS Eighteen RCTs (n = 1944) were included in this study. Pairwise meta-analysis showed that the percentage of patients achieving early response was higher in the dexamethasone-containing doublet group than in the dexamethasone group (79.7% vs 68.7%, odds ratio [OR] 1.82, 95% CI 1.10-3.02). The difference was more profound for sustained response (60.5% vs 37.4%, OR 2.57, 95% CI 1.95-3.40). Network meta-analysis showed that dexamethasone plus recombinant human thrombopoietin ranked first for early response, followed by dexamethasone plus oseltamivir or tacrolimus. Rituximab plus prednisolone achieved highest sustained response, followed by dexamethasone plus all-trans retinoic acid or rituximab. Rituximab plus dexamethasone showed 15.3% of grade 3 or higher adverse events, followed by prednis(ol)one (4.8%) and all-trans retinoic acid plus dexamethasone (4.7%). INTERPRETATION Our findings suggested that compared with monotherapy dexamethasone or prednis(ol)one, the combined regimens had better early and sustained responses. rhTPO plus dexamethasone ranked top in early response, while rituximab plus corticosteroids obtained the best sustained response, but with more adverse events. Adding oseltamivir, all-trans retinoic acid or tacrolimus to dexamethasone reached equally encouraging sustained response, without compromising safety profile. Although this network meta-analysis compared all the therapeutic regimens up to date, more head-to-head RCTs with larger sample size are warranted to make direct comparison among these strategies. FUNDING National Natural Science Foundation of China, Major Research Plan of National Natural Science Foundation of China, Shandong Provincial Natural Science Foundation and Young Taishan Scholar Foundation of Shandong Province.
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Key Words
- AEs, adverse events
- ASH, American Society of Hematology
- All-trans retinoic acid
- Anti-D, Rho(D) immune globulin
- CI, confidence interval
- CrI, credible intervals
- DEX, dexamethasone
- Dexamethasone
- ITP, primary immune thrombocytopenia
- IVIg, intravenous immunoglobulin
- NMA, network meta-analysis
- Network meta-analysis
- OR, odds ratio
- OSE, oseltamivir
- Oseltamivir
- PRD, prednis(ol)one
- Prednis(ol)one
- Primary immune thrombocytopenia
- QoL, quality of life
- RA, all-trans retinoic acid
- RCTs, randomised controlled trials
- RTX, rituximab
- Randomized controlled trials
- Rituximab
- SUCRA, the surface under the cumulative ranking curve
- TAC, tacrolimus
- TPO-RAs, thrombopoietin receptor agonists
- Tacrolimus
- mPRD, methylprednisolone
- rhTPO
- rhTPO, recombinant human thrombopoietin
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Affiliation(s)
- Yun Wang
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Lei Sheng
- Department of General Surgery, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Fengjiao Han
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Qiuyu Guo
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Zihan Zhang
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Qi Feng
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Hai Zhou
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Xuebin Ji
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Jun Peng
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
- Advanced Medical Research Institute, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
- Corresponding author. Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Wenhuaxi Road, Jinan, China.
| | - Miao Xu
- Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Jinan, China
- Corresponding author. Department of Hematology, Cheeloo College of Medicine, Qilu Hospital of Shandong University, Wenhuaxi Road, Jinan, China.
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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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Jiang D, Al-Samkari H, Panch SR. Changing Paradigms in ITP Management: Newer Tools for an Old Disease. Transfus Med Rev 2022; 36:188-194. [PMID: 36273934 PMCID: PMC10044485 DOI: 10.1016/j.tmrv.2022.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disease characterized by isolated thrombocytopenia that may be accompanied clinically by bleeding and reduced health-related quality of life (HRQoL). While corticosteroids, splenectomy, and various immunosuppressants (used off-label) have served as historical mainstays of ITP treatment, their use is associated with adverse effects and morbidity. Over the last 15 years, the advent of the thrombopoietin receptor agonists has revolutionized the management of chronic ITP with high response rates, durable responses, and minimal adverse effects in most patients. With four agents now FDA-approved to manage chronic ITP, there is a renewed emphasis on improving HRQoL and minimizing the toxicities associated with traditional therapies. Promising agents with diverse mechanisms of action, ranging from those targeting Bruton's Tyrosine Kinase to the neonatal Fc receptor, are currently under investigation. This review highlights recent landmark clinical trials which have made significant impacts on ITP management and ongoing drug development. In critically analyzing studies of relevance, we illustrate the changing paradigms of ITP management and how the field is advancing beyond traditional therapies.
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Affiliation(s)
- Debbie Jiang
- Division of Hematology, University of Washington, Seattle, WA, USA
| | - Hanny Al-Samkari
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston, MA, USA; Division of Hematology, Harvard Medical School, Boston, MA, USA
| | - Sandhya R Panch
- Division of Hematology, University of Washington, Seattle, WA, USA; Transfusion Services, Seattle Cancer Care Alliance, Seattle, WA, USA.
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Schutgens REG. First-line Therapy for Immune Thrombocytopenia: Time for Change. Hemasphere 2022; 6:e783. [PMID: 36168521 PMCID: PMC9509069 DOI: 10.1097/hs9.0000000000000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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13
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Jiang Y, Cheng Y, Ma S, Li T, Chen Z, Zuo X, Zhang X. Systemic lupus erythematosus-complicating immune thrombocytopenia: From pathogenesis to treatment. J Autoimmun 2022;:102887. [PMID: 36030136 DOI: 10.1016/j.jaut.2022.102887] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022]
Abstract
Immune thrombocytopenia (ITP) is a common hematological manifestation of systemic lupus erythematosus (SLE). The heterogeneity of its clinical characteristics and therapeutic responses reflects a complex pathogenesis. A better understanding of its pathophysiological mechanisms and employing an optimal treatment regimen is therefore important to improve the response rate and prognosis, and avoid unwanted outcomes. Besides glucocorticoids, traditional immunosuppressants (i.e. cyclosporine, mycophenolate mofetil) and intravenous immunoglobulins, new therapies are emerging and promising for the treatment of intractable SLE-ITP, such as thrombopoietin receptor agonists (TPO-RAs), platelet desialylation inhibitors(i.e. oseltamivir), B-cell targeting therapy(i.e. rituximab, belimumab), neonatal Fc receptor(FcRn) inhibitor, spleen tyrosine kinase(Syk) inhibitor and Bruton tyrosine kinase(BTK) inhibitor et al., although more rigorous randomized controlled trials are needed to substantiate their efficacy. In this review, we update our current knowledge on the pathogenesis and treatment of SLE-ITP.
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Wang XB, Yuan LH, Yan LP, Ye YB, Lu B, Xu X. UNC13B Promote Arsenic Trioxide Resistance in Chronic Lymphoid Leukemia Through Mitochondria Quality Control. Front Oncol 2022; 12:920999. [PMID: 35707364 PMCID: PMC9190243 DOI: 10.3389/fonc.2022.920999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/05/2022] [Indexed: 11/19/2022] Open
Abstract
In clinical practice, arsenic trioxide can be used to treat a subset of R/R CML patients, but resistance tends to reappear quickly. We designed an experiment to study arsenic trioxide resistance in K-562 cells. Previously, we identified the UNC13B gene as potentially responsible for arsenic trioxide resistance in K-562 cells via gene chip screening followed by high-content screening. We aimed to investigate the role and mechanism of the UNC13B gene in K-562 cells, an arsenic trioxide-resistant chronic myeloid leukemia cell line. In vitro lentiviral vector-mediated UNC13B siRNA transfection was performed on K-562 cells. The roles of UNC13B in cell proliferation, apoptosis and cell cycle pathways, and colony formation were analyzed by CCK-8 assay, fluorescence-activated cell sorting, and soft agar culture, respectively. Gene chip screening was used to define the possible downstream pathways of UNC13B. Western blot was performed to further validate the possible genes mediated by UNC13B for arsenic trioxide resistance in patients with chronic myeloid leukemia. UNC13B downregulation significantly inhibited growth, promoted apoptosis, decreased colony formation, reduced the duration of the G1 phase, and increased the duration of the S phase of K-562 cells. Western blot results confirmed that UNC13B may modulate the apoptosis and proliferation of arsenic trioxide-resistant chronic myeloid leukemia cells through the mediation of MAP3K7, CDK4, and PINK1. UNC13B is a potential therapeutic target for patients with arsenic trioxide-resistant chronic myeloid leukemia.
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Affiliation(s)
- Xiao-Bo Wang
- Department of Hematology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Li-Hua Yuan
- Department of Pediatric Surgery, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Le-Ping Yan
- Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Yong-Bin Ye
- Department of Hematology, Zhongshan Hospital Affiliated to Sun Yat-Sen University, Zhongshan, China
| | - Bo Lu
- Department of Hematology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Xiaojun Xu
- Department of Hematology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
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Margraf A, Perretti M. Immune Cell Plasticity in Inflammation: Insights into Description and Regulation of Immune Cell Phenotypes. Cells 2022; 11:cells11111824. [PMID: 35681519 PMCID: PMC9180515 DOI: 10.3390/cells11111824] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 02/01/2023] Open
Abstract
Inflammation is a life-saving immune reaction occurring in response to invading pathogens. Nonetheless, inflammation can also occur in an uncontrolled, unrestricted manner, leading to chronic disease and organ damage. Mechanisms triggering an inflammatory response, hindering such a response, or leading to its resolution are well-studied but so far insufficiently elucidated with regard to precise therapeutic interventions. Notably, as an immune reaction evolves, requirements and environments for immune cells change, and thus cellular phenotypes adapt and shift, leading to the appearance of distinct cellular subpopulations with new functional features. In this article, we aim to highlight properties of, and overarching regulatory factors involved in, the occurrence of immune cell phenotypes with a special focus on neutrophils, macrophages and platelets. Additionally, we point out implications for both diagnostics and therapeutics in inflammation research.
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Gómez-Almaguer D, Rojas-Guerrero EA, Gómez-De León A, Colunga-Pedraza PR, Jaime-Pérez JC. Alternatives for managing patients with newly diagnosed immune thrombocytopenia: a narrative review. Expert Rev Hematol 2022; 15:493-501. [PMID: 35615916 DOI: 10.1080/17474086.2022.2082936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is an acquired bleeding disorder. Conventionally, first-line ITP therapy aims to obtain a rapid response and stop or decrease the risk of bleeding by increasing the platelet count. At this point, the duration of the response, the tolerability, and the long-term safety of pharmacologic interventions are considered less of a priority. Combination treatments that simultaneously address multiple disease mechanisms are an attractive strategy to increase efficacy in acute ITP therapy. In this review, we discuss the treatment of newly diagnosed ITP patients, emphasizing the use of new combinations to benefit from their synergy. AREAS COVERED This article summarizes conventional treatment, recent and novel combinations, and COVID-19 management recommendations of newly diagnosed ITP patients. EXPERT OPINION The key areas for improvement consider the long-term effects of conventional first-line therapy, reducing relapse rates, and extending responses to achieve long-term remission. Although corticosteroids remain first-line therapy, restricting their use to avoid toxicity and the increasing use of rituximab and TPO-RAs in the first three months after diagnosis open the landscape for future interventions in frontline therapy for ITP. First-line therapy intensification or synergistic drug combination offers a potential and realistic shift in future treatment guidelines.
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Affiliation(s)
- David Gómez-Almaguer
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Edgar A Rojas-Guerrero
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Andrés Gómez-De León
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Perla R Colunga-Pedraza
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - José C Jaime-Pérez
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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18
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Gabarin N, Arnold DM. All-trans retinoic acid for treating immune thrombocytopenia: new purpose for an old drug? Lancet Haematol 2021; 8:e672-e673. [PMID: 34560008 DOI: 10.1016/s2352-3026(21)00269-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Nadia Gabarin
- Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; McMaster Center for Transfusion Research, McMaster University, Hamilton, ON L8N 3Z5, Canada.
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