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Ferrer-Marín F, Hernández-Boluda JC, Alvarez-Larrán A. Essential thrombocythaemia: A contemporary approach with new drugs on the horizon. Br J Haematol 2024; 204:1605-1616. [PMID: 38586911 DOI: 10.1111/bjh.19403] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/02/2024] [Accepted: 03/03/2024] [Indexed: 04/09/2024]
Abstract
Essential thrombocythaemia (ET) is a myeloproliferative neoplasm characterized by an increased risk of vascular complications and a tendency to progress to myelofibrosis and acute leukaemia. ET patients have traditionally been stratified into two thrombosis risk categories based on age older than 60 years and a history of thrombosis. More recently, the revised IPSET-thrombosis scoring system, which accounts for the increased risk linked to the JAK2 mutation, has been incorporated into most expert recommendations. However, there is increasing evidence that the term ET encompasses different genomic entities, each with a distinct clinical course and prognosis. Moreover, the effectiveness and toxicity of cytoreductive and anti-platelet treatments differ depending on the molecular genotype. While anti-platelets and conventional cytoreductive agents, mainly hydroxycarbamide (hydroxyurea), anagrelide and pegylated interferon, remain the cornerstone of treatment, recent research has shed light on the effectiveness of novel therapies that may help improve outcomes. This comprehensive review focuses on the evolving landscape of treatment strategies in ET, with an emphasis on the role of molecular profiling in guiding therapeutic decisions. Besides evidence-based management according to revised IPSET-thrombosis stratification, we also provide specific observations for those patients with CALR-, MPL-mutated and triple-negative ET, as well as cases with high-risk mutations.
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Affiliation(s)
- Francisca Ferrer-Marín
- Hematology Service, Hospital Universitario Morales-Meseguer, Centro Regional de Hemodonación, IMIB-Pascual Parrilla, CIBERER-ISC III, Universidad Católica San Antonio (UCAM), Murcia, Spain
| | - Juan Carlos Hernández-Boluda
- Department of Hematology, Hospital Clínico Universitario de Valencia, INCLIVA, University of Valencia, Valencia, Spain
| | - Alberto Alvarez-Larrán
- Department of Hematology, Hospital Clínic, Barcelona, Spain
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona, Barcelona, Spain
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2
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Liu W, Pircher J, Schuermans A, Ul Ain Q, Zhang Z, Honigberg MC, Yalcinkaya M, Nakao T, Pournamadri A, Xiao T, Hajebrahimi MA, Wasner L, Stegner D, Petzold T, Natarajan P, Massberg S, Tall AR, Schulz C, Wang N. Jak2 V617F clonal hematopoiesis promotes arterial thrombosis via platelet activation and cross talk. Blood 2024; 143:1539-1550. [PMID: 38142422 PMCID: PMC11033586 DOI: 10.1182/blood.2023022260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/21/2023] [Accepted: 12/06/2023] [Indexed: 12/26/2023] Open
Abstract
ABSTRACT JAK2 V617F (JAK2VF) clonal hematopoiesis (CH) has been associated with atherothrombotic cardiovascular disease (CVD). We assessed the impact of Jak2VF CH on arterial thrombosis and explored the underlying mechanisms. A meta-analysis of 3 large cohort studies confirmed the association of JAK2VF with CVD and with platelet counts and adjusted mean platelet volume (MPV). In mice, 20% or 1.5% Jak2VF CH accelerated arterial thrombosis and increased platelet activation. Megakaryocytes in Jak2VF CH showed elevated proplatelet formation and release, increasing prothrombogenic reticulated platelet counts. Gp1ba-Cre-mediated expression of Jak2VF in platelets (VFGp1ba) increased platelet counts to a similar level as in 20% Jak2VF CH mice while having no effect on leukocyte counts. Like Jak2VF CH mice, VFGp1ba mice showed enhanced platelet activation and accelerated arterial thrombosis. In Jak2VF CH, both Jak2VF and wild-type (WT) platelets showed increased activation, suggesting cross talk between mutant and WT platelets. Jak2VF platelets showed twofold to threefold upregulation of COX-1 and COX-2, particularly in young platelets, with elevated cPLA2 activation and thromboxane A2 production. Compared with controls, conditioned media from activated Jak2VF platelets induced greater activation of WT platelets that was reversed by a thromboxane receptor antagonist. Low-dose aspirin ameliorated carotid artery thrombosis in VFGp1ba and Jak2VF CH mice but not in WT control mice. This study shows accelerated arterial thrombosis and platelet activation in Jak2VF CH with a major role of increased reticulated Jak2VF platelets, which mediate thromboxane cross talk with WT platelets and suggests a potential beneficial effect of aspirin in JAK2VF CH.
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Affiliation(s)
- Wenli Liu
- Division of Molecular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Joachim Pircher
- Department of Cardiology, Medical Clinic I, University Hospital, Ludwig Maximilian University, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Art Schuermans
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA
- Faculty of Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Qurrat Ul Ain
- Department of Cardiology, Medical Clinic I, University Hospital, Ludwig Maximilian University, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Zhe Zhang
- Department of Cardiology, Medical Clinic I, University Hospital, Ludwig Maximilian University, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael C. Honigberg
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Program in Medical and Population Genetics, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Mustafa Yalcinkaya
- Division of Molecular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Tetsushi Nakao
- Program in Medical and Population Genetics, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Cardiology Division, Brigham and Women’s Hospital, Boston, MA
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ashley Pournamadri
- Biomedical Informatics Graduate Training Program, Stanford University, Stanford, CA
| | - Tong Xiao
- Division of Molecular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Mohammad Ali Hajebrahimi
- Department of Cardiology, Medical Clinic I, University Hospital, Ludwig Maximilian University, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Lisa Wasner
- Department of Cardiology, Medical Clinic I, University Hospital, Ludwig Maximilian University, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - David Stegner
- Rudolf Virchow Center for Integrative and Translational Bioimaging, Julius-Maximilians-Universität Würzburg, Würzburg, Germany
- Institute of Experimental Biomedicine, University Hospital Würzburg, Würzburg, Germany
| | - Tobias Petzold
- Department of Cardiology, Medical Clinic I, University Hospital, Ludwig Maximilian University, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Pradeep Natarajan
- Program in Medical and Population Genetics, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Steffen Massberg
- Department of Cardiology, Medical Clinic I, University Hospital, Ludwig Maximilian University, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Alan R. Tall
- Division of Molecular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Christian Schulz
- Department of Cardiology, Medical Clinic I, University Hospital, Ludwig Maximilian University, Munich, Germany
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Nan Wang
- Division of Molecular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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Castelli R, Berzuini A, Manetti R, Delitala AP, Castro D, Sanna G, Sircana MC, Profili NI, Bartoli A, La Cava L, Lambertenghi Deliliers G, Donadoni M, Gidaro A. ADAMTS13, von Willebrand Factor, Platelet Microparticles, Factor VIII, and Impact of Somatic Mutations in the Pathogenesis of Splanchnic Vein Thrombosis Associated with BCR-ABL-Negative Myeloproliferative Neoplasms. Life (Basel) 2024; 14:486. [PMID: 38672756 PMCID: PMC11051276 DOI: 10.3390/life14040486] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Myeloproliferative neoplasms (MPNs) are often associated with splanchnic vein thrombosis (SVT). Not all the factors involved in the thrombotic tendency are currently known. OBJECTIVES This study aims to evaluate a possible association between ADAMTS13, von Willebrand factor (VWF), platelet microvesicles (MV), and factor VIII activity (FVIII:C) with thrombotic events in MPN patients. MATERIALS AND METHODS In total, 36 consecutive MPN patients with SVT were enrolled. The MPNs were diagnosed based on clinical characteristics and one or more gene mutations among JAK-2, CALR, and MPL. As controls, 50 randomly selected patients with MPN without thrombosis, 50 patients with deep vein thrombosis without MPNs, and 50 healthy blood donors were evaluated. Complete blood count, ADAMTS13, VWF, MV, and FVIII:C in plasma were measured in all the subjects. RESULTS The JAK-2 mutation was found in 94% of the patients with SVT, but none were triple-negative for genetic mutations (JAK2 V617F, CALR, MPL, and exon 12). Compared to the normal subjects, in all the MPN patients (with or without SVT), the levels of ADAMTS13 were found to be significantly lower (p < 0.001) and the MV concentrations were significantly higher (p < 0.001). Among the MPN patients, the VWF and FVIII:C levels were significantly higher in the patients with SVT than those without thrombosis (p = 0.007 and p = 0.04, respectively). Splenomegaly was present in 78% of MPN patients with SVT and in 30% of those without SVT (p < 0.001). The ADAMTS13/VWF ratio was reduced in all the patients, but not in the healthy blood donors (p < 0.001). CONCLUSIONS The significant increase in circulating MV, VWF, and FVIII:C in the MPN patients and in the patients with thrombosis supports the role of endothelium damage in promoting thrombotic events. In particular, a significant increase in VWF and FVIII:C levels was found in the MPN patients with SVT.
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Affiliation(s)
- Roberto Castelli
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | | | - Roberto Manetti
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Alessandro Palmerio Delitala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Dante Castro
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Giuseppe Sanna
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Marta Chiara Sircana
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Nicia Isabella Profili
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Arianna Bartoli
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
| | - Leyla La Cava
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
| | | | - Mattia Donadoni
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
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Tefferi A, Vannucchi AM, Barbui T. Essential thrombocythemia: 2024 update on diagnosis, risk stratification, and management. Am J Hematol 2024; 99:697-718. [PMID: 38269572 DOI: 10.1002/ajh.27216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 01/26/2024]
Abstract
OVERVIEW Essential thrombocythemia is a Janus kinase 2 (JAK2) mutation-prevalent myeloproliferative neoplasm characterized by clonal thrombocytosis; clinical course is often indolent but might be interrupted by thrombotic or hemorrhagic complications, microcirculatory symptoms (e.g., headaches, lightheadedness, and acral paresthesias), and, less frequently, by disease transformation into myelofibrosis (MF) or acute myeloid leukemia. DIAGNOSIS In addition to thrombocytosis (platelets ≥450 × 109 /L), formal diagnosis requires the exclusion of other myeloid neoplasms, including prefibrotic MF, polycythemia vera, chronic myeloid leukemia, and myelodysplastic syndromes with ring sideroblasts and thrombocytosis. Bone marrow morphology typically shows increased number of mature-appearing megakaryocytes distributed in loose clusters. GENETICS Approximately 80% of patients express myeloproliferative neoplasm driver mutations (JAK2, CALR, MPL), in a mutually exclusive manner; in addition, about 50% harbor other mutations, the most frequent being TET2 (9%-11%), ASXL1 (7%-20%), DNMT3A (7%), and SF3B1 (5%). Abnormal karyotype is seen in <10% of patients and includes +9/20q-/13q-. SURVIVAL AND PROGNOSIS Life expectancy is less than that of the control population. Median survival is approximately 18 years but exceeds >35 years in younger patients. The triple A survival risk model, based on Age, Absolute neutrophil count, and Absolute lymphocyte count, effectively delineates high-, intermediate-1-, intermediate-2-, and low-risk disease with corresponding median survivals of 8, 14, 21, and 47 years. RISK FACTORS FOR THROMBOSIS Four risk categories are considered: very low (age ≤60 years, no thrombosis history, JAK2 wild-type), low (same as very low but JAK2 mutation present), intermediate (same as low but age >60 years), and high (thrombosis history or age >60 years with JAK2 mutation). MUTATIONS AND PROGNOSIS MPL and CALR-1 mutations have been associated with increased risk of MF transformation; spliceosome with inferior overall and MF-free survival; TP53 with leukemic transformation, and JAK2V617F with thrombosis. Leukemic transformation rate at 10 years is <1% but might be higher in JAK2-mutated patients with extreme thrombocytosis and those with abnormal karyotype. TREATMENT The main goal of therapy is to prevent thrombosis. In this regard, once-daily low-dose aspirin is advised for all patients and twice daily for low-risk disease. Cytoreductive therapy is advised for high-risk and optional for intermediate-risk disease. First-line cytoreductive drugs of choice are hydroxyurea and pegylated interferon-α and second-line busulfan. ADDITIONAL CONTENT The current review includes specific treatment strategies in the context of extreme thrombocytosis, pregnancy, splanchnic vein thrombosis, perioperative care, and post-essential thrombocythemia MF, as well as new investigational drugs.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessandro Maria Vannucchi
- CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, University of Florence, AOU Careggi, Florence, Italy
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Petrucci G, Hatem D, Langley R, Cleary S, Gentry-Maharaj A, Pitocco D, Rizzi A, Ranalli P, Zaccardi F, Habib A, Rocca B. Effect of very long-term storage and multiple freeze and thaw cycles on 11-dehydro-thromboxane-B 2 and 8-iso-prostaglandin F 2α, levels in human urine samples by validated enzyme immunoassays. Sci Rep 2024; 14:5546. [PMID: 38448541 PMCID: PMC10917770 DOI: 10.1038/s41598-024-55720-3] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
Biological samples are often frozen and stored for years and/or thawed multiple times, thus assessing their stability on long-term storage and repeated freeze-thaw cycles is crucial. The study aims were to assess:-the long-term stability of two major enzymatic and non-enzymatic metabolites of arachidonic acid, i.e. urinary 11-dehydro-thromboxane-(Tx) B2, 8-iso-prostaglandin (PG)F2α, and creatinine in frozen urine samples;-the effect of multiple freeze-thaw cycles. Seven-hundred and three urine samples measured in previously-published studies, stored at -40 °C, and measured for a second time for 11-dehydro-TxB2 (n = 677) and/or 8-iso-PGF2α (n = 114) and/or creatinine (n = 610) were stable over 10 years and the 2 measurements were highly correlated (all rho = 0.99, P < 0.0001). Urine samples underwent 10 sequential freeze-thaw cycles, with and without the antioxidant 4-hydroxy-2,2,6,6-tetramethylpiperidin-1-oxyl (10 mM); urinary 11-dehydro-TxB2 and creatinine were stable across all cycles (11-dehydro-TxB2: 100.4 ± 21%; creatinine: 101 ± 7% of baseline at cycle ten; n = 17), while 8-iso-PGF2α significantly increased by cycle 6 (151 ± 22% of baseline at cycle ten, n = 17, P < 0.05) together with hydrogen peroxide only in the absence of antioxidant. Arachidonic acid metabolites and creatinine appear stable in human urines stored at -40 °C over 10 years. Multiple freeze-thaw cycles increase urinary 8-iso-PGF2α in urine samples without antioxidants. These data are relevant for studies using urine samples stored over long-term and/or undergoing multiple freezing-thawing.
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Affiliation(s)
- Giovanna Petrucci
- Department of Bioethics and Safety, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy.
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Duaa Hatem
- Department of Bioethics and Safety, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Ruth Langley
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | - Siobhan Cleary
- Medical Research Council (MRC) Clinical Trials Units at University College London (UCL), London, UK
| | | | - Dario Pitocco
- Diabetology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Rizzi
- Diabetology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paola Ranalli
- Department of Hematology, S. Spirito Hospital, Pescara, Italy
| | - Francesco Zaccardi
- Leicester Real World Evidence Unit, Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Aida Habib
- Department of Basic Medical Sciences, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Bianca Rocca
- Department of Bioethics and Safety, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Morotti A, Barale C, Sornatale M, Giugliano E, Muccio VE, Frascaroli C, Pautasso M, Fornari A, Russo I. Aberrant Platelet Aggregation as Initial Presentation of Essential Thrombocythemia: Failure of Entero-Coated Aspirin to Reduce Platelet Hyperactivation. Int J Mol Sci 2023; 25:176. [PMID: 38203347 PMCID: PMC10778871 DOI: 10.3390/ijms25010176] [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: 11/30/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
Essential thrombocythemia (ET) is a myeloproliferative neoplasm variant characterized by excessive production of platelets. Since the most common cause of mortality and morbidity in ET patients is thrombosis, the excessive production of platelets may cause thrombotic events. However, little is known about the function of platelets in ET. We report a female patient who presented as asymptomatic, without a remarkable medical history, and ET was diagnosed after an incidental finding of moderate thrombocytosis. Notably, together with thrombocytosis, an abnormal platelet phenotype was found for the presence of a massive, rapid and spontaneous formation of aggregates and platelet hypersensitivity to subthreshold concentrations of aggregating agonists. Bone marrow histopathological examination and genetic analysis with the JAK2 (V617F) gene mutation findings confirmed the initial suspicion of ET. Although the ET patient was placed on aspirin, the persistence of the platelet hyperactivation and hyperaggregability prompted a switch in antiplatelet medication from entero-coated (EC) to plain aspirin. As result, platelet hypersensitivity to agonists and spontaneous aggregation were no longer found. Collectively, our study demonstrates that platelet function analysis could be a reliable predictor of ET and that plain aspirin should be preferred over EC aspirin to attenuate platelet hyperreactivity.
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Affiliation(s)
- Alessandro Morotti
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole, 10, Orbassano, I-10043 Turin, Italy; (A.M.); (C.B.); (M.S.)
| | - Cristina Barale
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole, 10, Orbassano, I-10043 Turin, Italy; (A.M.); (C.B.); (M.S.)
| | - Michele Sornatale
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole, 10, Orbassano, I-10043 Turin, Italy; (A.M.); (C.B.); (M.S.)
| | - Emilia Giugliano
- Laboratory of Clinical and Microbiological Analyses, San Luigi Gonzaga Hospital, Orbassano, I-10043 Turin, Italy; (E.G.); (V.E.M.); (C.F.); (M.P.)
| | - Vittorio Emanuele Muccio
- Laboratory of Clinical and Microbiological Analyses, San Luigi Gonzaga Hospital, Orbassano, I-10043 Turin, Italy; (E.G.); (V.E.M.); (C.F.); (M.P.)
| | - Chiara Frascaroli
- Laboratory of Clinical and Microbiological Analyses, San Luigi Gonzaga Hospital, Orbassano, I-10043 Turin, Italy; (E.G.); (V.E.M.); (C.F.); (M.P.)
| | - Marisa Pautasso
- Laboratory of Clinical and Microbiological Analyses, San Luigi Gonzaga Hospital, Orbassano, I-10043 Turin, Italy; (E.G.); (V.E.M.); (C.F.); (M.P.)
| | - Alessandro Fornari
- Department of Oncology, Division of Pathology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, I-10043 Turin, Italy;
| | - Isabella Russo
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole, 10, Orbassano, I-10043 Turin, Italy; (A.M.); (C.B.); (M.S.)
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7
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Leiva O, Alvarez-Cardona J, How J, Brunner A, Hobbs G. In-Hospital and readmission outcomes of patients with myeloproliferative neoplasms and heart failure: Insights from the National Readmissions Database. Int J Cardiol Heart Vasc 2023; 49:101304. [PMID: 38173785 PMCID: PMC10761308 DOI: 10.1016/j.ijcha.2023.101304] [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: 09/05/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024]
Abstract
Background Myeloproliferative neoplasms (MPNs) are chronic leukemias associated with increased risk of cardiovascular (CV) events. Prior studies suggest patients with MPN are at increased risk of HF. Additionally, pre-clinical murine models harboring the JAK2 mutation, the most common driver mutation in MPNs, have shown accelerated adverse cardiac remodeling in myocardial infarction and pressure overload HF models. However, clinical outcomes, including in-hospital and readmission outcomes, of patients with MPN admitted for HF have not been well characterized. Methods Patients hospitalized for HF with and without MPN were identified using the 2017 and 2018 National Readmission Database. Propensity score matching (PSM) was performed to match 1 MPN with 10 non-MPN controls. Outcomes were in-hospital death, 90-day CV-related, HF-related, and all-cause readmissions. Logistic regression and Cox proportional hazards regression models were used to estimate risk of in-hospital death and 90-day readmission outcomes, respectively. Results After PSM, 4,626 patients with MPN were matched with 46,260 without. Patients with MPN were associated with increased risk of in-hospital death (OR 1.17, 95% CI 1.00 - 1.35), 90-day CV-related (HR 1.10, 95% CI 1.02 - 1.18) and all-cause (HR 1.24, 95% CI 1.17 - 1.31) but not HF-related (HR 1.05, 95% CI 0.97 - 1.14) readmissions. Conclusion Among patients hospitalized for HF, MPN was associated with increased risk of in-hospital death, and 90-day CV-related readmissions (driven primarily by thrombotic readmissions). Further investigation is needed in order to improve outcomes in patients with MPN and HF.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Jose Alvarez-Cardona
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Joan How
- Division of Hematology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, United States
| | - Andrew Brunner
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Gabriela Hobbs
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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Krečak I, Zekanović I, Morić Perić M, Holik H, Coha B, Periša V, Lucijanić M. High plateletcrit may be associated with thrombotic risk in polycythemia vera. Int J Lab Hematol 2023; 45:799-801. [PMID: 37050866 DOI: 10.1111/ijlh.14073] [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: 02/08/2023] [Accepted: 04/06/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Ivan Krečak
- Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia
- Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Ivan Zekanović
- Department of Internal Medicine, General Hospital Zadar, Zadar, Croatia
| | | | - Hrvoje Holik
- Department of Internal Medicine, Dr. Josip Benčević General Hospital, Slavonski Brod, Croatia
- School of Medicine, University of Osijek, Osijek, Croatia
| | - Božena Coha
- Department of Internal Medicine, Dr. Josip Benčević General Hospital, Slavonski Brod, Croatia
| | - Vlatka Periša
- School of Medicine, University of Osijek, Osijek, Croatia
- Division of Hematology, University Hospital Osijek, Osijek, Croatia
| | - Marko Lucijanić
- Division of Hematology, University Hospital Dubrava, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
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9
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Tefferi A, Barbui T. Polycythemia vera: 2024 update on diagnosis, risk-stratification, and management. Am J Hematol 2023; 98:1465-1487. [PMID: 37357958 DOI: 10.1002/ajh.27002] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Abstract
DISEASE OVERVIEW Polycythemia vera (PV) is a JAK2-mutated myeloproliferative neoplasm characterized by clonal erythrocytosis; other features include leukocytosis, thrombocytosis, splenomegaly, pruritus, constitutional symptoms, microcirculatory disturbances, and increased risk of thrombosis and progression into myelofibrosis (post-PV MF) or acute myeloid leukemia (AML). DIAGNOSIS A working diagnosis is considered in the presence of a JAK2 mutation associated with hemoglobin/hematocrit levels of >16.5 g/dL/49% in men or 16 g/dL/48% in women; morphologic confirmation by bone marrow examination is advised but not mandated. CYTOGENETICS Abnormal karyotype is seen in 15%-20% of patients with the most frequent sole abnormalities being +9 (5%), loss of chromosome Y (4%), +8 (3%), and 20q- (3%). MUTATIONS Over 50% of patients harbor DNA sequence variants/mutations other than JAK2, with the most frequent being TET2 (18%) and ASXL1 (15%). Prognostically adverse mutations include SRSF2, IDH2, RUNX1, and U2AF1, with a combined incidence of 5%-10%. SURVIVAL AND PROGNOSIS Median survival is ⁓15 years but exceeds 35 years for patients aged ≤40 years. Risk factors for survival include older age, leukocytosis, abnormal karyotype, and the presence of adverse mutations. Twenty-year risk for thrombosis, post-PV MF, or AML are ⁓26%, 16% and 4%, respectively. RISK FACTORS FOR THROMBOSIS Two risk categories are considered: high (age >60 years or thrombosis history) and low (absence of both risk factors). Additional predictors for arterial thrombosis include cardiovascular risk factors and for venous thrombosis higher absolute neutrophil count and JAK2V617F allele burden. TREATMENT Current goal of therapy is to prevent thrombosis. Periodic phlebotomy, with a hematocrit target of <45%, combined with once- or twice-daily aspirin (81 mg) therapy, absent contraindications, is the backbone of treatment in all patients, regardless of risk category. Cytoreductive therapy is reserved for high-risk disease with first-line drugs of choice being hydroxyurea and pegylated interferon-α and second-line busulfan and ruxolitinib. In addition, systemic anticoagulation is advised in patients with venous thrombosis history. ADDITIONAL TREATMENT CONSIDERATIONS At the present time, we do not consider a drug-induced reduction in JAK2V617F allele burden, which is often incomplete and seen not only with peg-IFN but also with ruxolitinib and busulfan, as an indicator of disease-modifying activity, unless accompanied by cytogenetic and independently-verified morphologic remission. Accordingly, we do not use the specific parameter to influence treatment choices. The current review also includes specific treatment strategies in the context of pregnancy, splanchnic vein thrombosis, pruritus, perioperative care, and post-PV MF.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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10
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Krečak I, Pivac L, Lucijanić M, Skelin M. Polypharmacy, Potentially Inappropriate Medications, and Drug-to-Drug Interactions in Patients with Chronic Myeloproliferative Neoplasms. Biomedicines 2023; 11:biomedicines11051301. [PMID: 37238972 DOI: 10.3390/biomedicines11051301] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
Polypharmacy, potentially inappropriate medications (PIMs), and drug-to-drug interactions (DDIs) are highly prevalent in the elderly and may have adverse effects on health-related outcomes. Their occurrence and clinical and prognostic associations in patients with chronic myeloproliferative neoplasms (MPN) are unknown. We retrospectively evaluated polypharmacy, PIMs, and DDIs in a cohort of 124 MPN patients (essential thrombocythemia, ET = 63, polycythemia vera, PV = 44, myelofibrosis = 9, MPN unclassifiable = 8) from a single community hematology practice. There were 761 drug prescriptions with a median of five prescribed medications per patient. Polypharmacy, at least one PIM (calculated for persons >60 years of age, n = 101), and at least one DDI were recorded in 76 (61.3%), 46 (45.5%), and 77 (62.1%) of patients, respectively. Seventy-four (59.6%) and twenty-one (16.9%) patients had at least one C or at least one D interaction, respectively. Among other associations, polypharmacy and DDIs were associated with older age, management of disease-related symptoms, osteoarthritis/osteoporosis, and different CV disorders. In multivariate analyses adjusted for clinically meaningful parameters, both polypharmacy and DDIs were significantly associated with inferior overall survival (OS) and time to thrombosis (TTT), whereas PIMs had no significant associations with neither OS nor TTT. There were no associations with bleeding or transformation risks. Polypharmacy, DDIs, and PIMs are very frequent among MPN patients and may have important clinical associations.
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Affiliation(s)
- Ivan Krečak
- Department of Internal Medicine, General Hospital of Sibenik-Knin County, 22000 Sibenik, Croatia
- Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
| | - Ljerka Pivac
- Pharmacy Department, University Hospital Center Split, 21000 Split, Croatia
| | - Marko Lucijanić
- Divison of Hematology, University Hospital Dubrava, 10000 Zagreb, Croatia
- Faculty of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Marko Skelin
- Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
- Pharmacy Department, General Hospital of Sibenik-Knin County, 22000 Sibenik, Croatia
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11
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Kremers BMM, Daemen JHC, ten Cate H, Spronk HMH, Mees BME, ten Cate-Hoek AJ. Inadequate response to antiplatelet therapy in patients with peripheral artery disease: a prospective cohort study. Thromb J 2023; 21:5. [PMID: 36627677 PMCID: PMC9832392 DOI: 10.1186/s12959-022-00445-4] [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] [Received: 03/07/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) are treated with preventive strategies to improve the cardiovascular risk. The incidence of cardiovascular events and mortality however remains high in PAD populations. We therefore aimed to better characterize PAD patients suffering from cardiovascular events and mortality in order to tailor preventive treatment. METHODS Between 2018 and 2020, 246 PAD outpatients (17 newly diagnosed, 229 with known PAD) were prospectively enrolled in this observational cohort study. Patient data and blood samples were collected after inclusion, and the primary composite endpoint (myocardial infarction, elective coronary revascularization, ischemic stroke, acute limb ischemia, mortality) was evaluated after one year. Secondary outcomes included platelet reactivity, measured using the VerifyNow assay, and medication adherence, assessed using the Morisky Medication Adherence Scale-8 (MMAS-8). Logistic regression models were used to identify associations between characteristics and the occurrence of events. RESULTS The cohort comprised 207 patients with claudication and 39 with chronic limb threatening ischemia. Twenty-six (10.6%) patients suffered from an event during follow-up. Prior myocardial infarction (OR 3.3 [1.4-7.7]), prior ischemic stroke (OR 4.5 [1.8-10.9]), higher levels of creatinine (OR 5.2 [2.2-12.6]), lower levels of high-density lipoprotein (OR 4.2 [1.5-10.6]) and lower haemoglobin levels (OR 3.1 [1.3-7.1]) were associated with events. Patients with events had more often high on-treatment platelet reactivity (HTPR) on aspirin (OR 5.9 [1.4-25.1]) or clopidogrel (OR 4.3 [1-19.3]). High adherence to medication was associated with the occurrence of events (OR 4.1 [1-18]). CONCLUSIONS Patients suffering from cardiovascular events and mortality were characterized by prior cardiovascular events as compared to patients who did not experience any events. Antiplatelet therapy was not optimally protective despite high medication adherence, and HTPR was independently associated with the occurrence of events. More research is needed on alternative treatment strategies such as dual antiplatelet therapy or combinations with anticoagulant drugs. TRIAL REGISTRATION The Medical Ethics Committee (METC) of the MUMC+ approved the study (NL63235.068.17) and the study was registered in the Netherlands Trial Register ( NTR7250 ).
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Affiliation(s)
- B. M. M. Kremers
- grid.5012.60000 0001 0481 6099Department of Biochemistry, Laboratory for Clinical Thrombosis and Hemostasis, Maastricht University, Maastricht, The Netherlands
| | - J. H. C. Daemen
- grid.412966.e0000 0004 0480 1382Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - H. ten Cate
- grid.5012.60000 0001 0481 6099Department of Biochemistry, Laboratory for Clinical Thrombosis and Hemostasis, Maastricht University, Maastricht, The Netherlands ,grid.412966.e0000 0004 0480 1382Thrombosis Expertise Center, Maastricht University Medical Center, Maastricht, The Netherlands ,grid.412966.e0000 0004 0480 1382Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands ,grid.410607.4Center for Thrombosis and Hemostasis, Gutenberg University Medical Center, Mainz, Germany
| | - H. M. H. Spronk
- grid.5012.60000 0001 0481 6099Department of Biochemistry, Laboratory for Clinical Thrombosis and Hemostasis, Maastricht University, Maastricht, The Netherlands
| | - B. M. E. Mees
- grid.412966.e0000 0004 0480 1382Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A. J. ten Cate-Hoek
- grid.5012.60000 0001 0481 6099Department of Biochemistry, Laboratory for Clinical Thrombosis and Hemostasis, Maastricht University, Maastricht, The Netherlands ,grid.412966.e0000 0004 0480 1382Thrombosis Expertise Center, Maastricht University Medical Center, Maastricht, The Netherlands
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12
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Abstract
In 2021, we reached the 50th anniversary of the publication of Sir John Vane's seminal paper in Nature New Biology describing the experiments supporting his mechanistic hypothesis that inhibition of prostaglandin synthesis might explain the main pharmacological effects of aspirin and aspirin-like drugs, that is, reduction in pain, fever and inflammation. Bengt Samuelsson's subsequent discoveries elucidating the cyclooxygenase pathway of platelet arachidonic acid metabolism motivated my research interest towards measuring platelet thromboxane A2 biosynthesis as a tool to investigate the clinical pharmacology of cyclooxygenase inhibition by aspirin in health and disease. What followed was a long, winding road of clinical research leading to the characterization of low-dose aspirin as a life-saving antiplatelet drug that still represents the cornerstone of antithrombotic therapy. Having witnessed and participated in these 50 years of aspirin research, I thought of providing a personal testimony of how things developed and eventually led to a remarkable success story of independent research.
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Affiliation(s)
- Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
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13
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Yang E, Lv Y, Wang Z, Wang D, Li Y, Sun Y, Zhang Y, Niu J, Chen Z, Liu W, Hu X. Coagulation status and determinants of possible aspirin resistance in patients with essential thrombocythemia. Front Med (Lausanne) 2022; 9:1092281. [PMID: 36606056 PMCID: PMC9808044 DOI: 10.3389/fmed.2022.1092281] [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] [Received: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives The currently recommended aspirin regimen appears inadequate for thromboprophylaxis in essential thrombocythemia (ET). This study aimed not only to evaluate the curative effect of aspirin but also to explore the coagulation status and determinants of aspirin resistance (AR) of ET patients. Methods A total of 80 ET patients who underwent coagulation tests, thromboelastography (TEG), and next-generation sequencing (NGS) were involved in the study. Patients were divided into the aspirin sensitivity (AS) group and AR group according to the arachidonic acid inhibition rate. Their clinical features and coagulation function were analyzed. Results The incidence of AR was 53.75% (43/80) in 80 ET patients. Fbg was significantly higher in coagulation tests in AR patients compared with AS patients (P < 0.05), while the differences in other variables (D-D, PT, PTA, INR, APTT, TT, FDP, and AT-III) were not statistically significant (P > 0.05). Compared with AS patients, the K values, α angles, MA values, and CI values of TEG in AR patients were statistically smaller (P < 0.05), but there was no significant difference in R value between them (P > 0.05). Univariate and multivariate logistic regression analysis showed that age, irregular use of aspirin, smoking, dyslipidemia, and hypertension increased the risk of AR (P < 0.05). In the routine NGS, the driver gene and non-driver gene had no effect on AR in ET patients. Conclusion Compared with AS patients, AR patients have enhanced platelet aggregation function, are in a relatively hypercoagulable state, and haveelevated fibrinogen function/levels, all of which cause a worse coagulation status. ET patients with increasing age, irregular use of aspirin, smoking, dyslipidemia, and hypertension are possibly at higher risk of AR. The routine NGS may not be helpful for the prediction of AR, therefore we recommend adding relevant drug-resistance genes to NGS.
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Affiliation(s)
- Erpeng Yang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Lv
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ziqing Wang
- Xiyuan Clinical Medical College, Beijing University of Traditional Medicine, Beijing, China
| | - Dehao Wang
- Xiyuan Clinical Medical College, Beijing University of Traditional Medicine, Beijing, China
| | - Yumeng Li
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan Sun
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanyu Zhang
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jicong Niu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhuo Chen
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Weiyi Liu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China,*Correspondence: Weiyi Liu,
| | - Xiaomei Hu
- Department of Hematology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China,Xiaomei Hu,
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14
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Petrucci G, Giaretta A, Ranalli P, Cavalca V, Dragani A, Porro B, Hatem D, Habib A, Tremoli E, Patrono C, Rocca B. Platelet thromboxane inhibition by low-dose aspirin in polycythemia vera: Ex vivo and in vivo measurements and in silico simulation. Clin Transl Sci 2022; 15:2958-2970. [PMID: 36200184 PMCID: PMC9747129 DOI: 10.1111/cts.13415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 06/16/2022] [Accepted: 08/09/2022] [Indexed: 01/26/2023] Open
Abstract
Low-dose aspirin is currently recommended for patients with polycythemia vera (PV), a myeloproliferative neoplasm with increased risk of arterial and venous thromboses. Based on aspirin pharmacodynamics in essential thrombocythemia, a twice-daily regimen is recommended for patients with PV deemed at particularly high thrombotic risk. We investigated the effects of low-dose aspirin on platelet cyclooxygenase activity and in vivo platelet activation in 49 patients with PV, as assessed by serum thromboxane (TX) B2 and urinary TXA2 /TXB2 metabolite (TXM) measurements, respectively. A previously described pharmacokinetic-pharmacodynamic in silico model was used to simulate the degree of platelet TXA2 inhibition by once-daily (q.d.) and twice-daily (b.i.d.) aspirin, and to predict the effect of missing an aspirin dose during q.d. and b.i.d. regimens. Serum TXB2 averaged 8.2 (1.6-54.7) ng/ml and significantly correlated with the platelet count (γ = 0.39) and urinary TXM (γ = 0.52) in multivariable analysis. One-third of aspirin-treated patients with PV displayed less-than-maximal platelet TXB2 inhibition, and were characterized by significantly higher platelet counts and platelet-count corrected serum TXB2 than those with adequate inhibition. Eight patients with PV were sampled again after 12 ± 4 months, and had reproducible serum TXB2 and urinary TXM values. The in silico model predicted complete inhibition of platelet-derived TXB2 by b.i.d. aspirin, a prediction verified in a patient with PV with the highest TXB2 value while on aspirin q.d. and treated short-term with a b.i.d. regimen. In conclusion, one in three patients with PV on low-dose aspirin display less-than-maximal inhibition of platelet TXA2 production. Serum TXB2 measurement can be a valuable option to guide precision dosing of antiplatelet therapy in patients with PV.
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Affiliation(s)
- Giovanna Petrucci
- Department of Safety and Bioethics, Section of PharmacologyCatholic University School of MedicineRomeItaly
| | | | - Paola Ranalli
- Department of HematologyS. Spirito HospitalPescaraItaly
| | | | | | | | - Duaa Hatem
- Department of Safety and Bioethics, Section of PharmacologyCatholic University School of MedicineRomeItaly
| | - Aida Habib
- Department of Basic Medical Sciences, College of Medicine, QU HealthQatar UniversityDohaQatar
| | | | - Carlo Patrono
- Department of Safety and Bioethics, Section of PharmacologyCatholic University School of MedicineRomeItaly
| | - Bianca Rocca
- Department of Safety and Bioethics, Section of PharmacologyCatholic University School of MedicineRomeItaly
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15
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Jones E, Dillon B, Swan D, Thachil J. Practical management of the haemorrhagic complications of myeloproliferative neoplasms. Br J Haematol 2022; 199:313-321. [PMID: 35724983 PMCID: PMC9796684 DOI: 10.1111/bjh.18322] [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: 04/27/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 01/07/2023]
Abstract
Myeloproliferative neoplasms can be associated with bleeding manifestations which can cause significant morbidities. Although haematologists are aware of the likelihood of this complication in the setting of myeloproliferative neoplasms, it may often be overlooked especially in patients with no extreme elevation of blood counts and those with myelofibrosis. Acquired von Willebrand syndrome and platelet dysfunction are the two common diagnoses to be considered in this regard. In this review article, we discuss the mechanisms for the development of these rare bleeding disorders, their diagnosis and practical management.
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Affiliation(s)
- Edward Jones
- Department of HaematologySt James' HospitalDublinIreland
| | - Bryan Dillon
- Department of HaematologySt James' HospitalDublinIreland
| | - Dawn Swan
- National University IrelandGalwayIreland
| | - Jecko Thachil
- Department of HaematologyManchester University Hospitals NHS Foundation TrustManchesterUK
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16
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Hegde NN, Mathew N, Thachathodiyl R, Menon JC. Personalized allocation of acetylsalicylic acid therapy for secondary prevention of coronary artery disease. Front Cardiovasc Med 2022; 9:1004473. [PMID: 36237906 PMCID: PMC9551163 DOI: 10.3389/fcvm.2022.1004473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background A single-daily dose of 75 mg of acetylsalicylic acid inhibits 100% of thromboxane-B2 synthesis within 30–60 min. Thromboxane-B2 synthesis then recovers slowly as new platelets are released from the bone marrow. Normally, only 10% of the platelets are replaced daily by new platelets entering circulation. Hence, 24 h after a dose of acetylsalicylic acid, thromboxane-B2 synthesis is still suppressed by more than 90%. Hence, there is an adequate anti-platelet effect even after 24 h of acetylsalicylic acid intake. However, some patients treated with once-daily acetylsalicylic acid may have an incomplete 24-h suppression of thromboxane-B2 synthesis due to increased platelet turnover. The response could be improved in such patients by twice-daily acetylsalicylic acid administration. This study aimed to identify such a group of patients who would benefit from a twice-daily dose of acetylsalicylic acid. Materials and methods Serum thromboxane-B2 levels were measured in 79 patients with coronary artery disease receiving 75 mg of acetylsalicylic acid for secondary prophylaxis. Serum levels of thromboxane-B2 were measured after 4 and 24 h of acetylsalicylic acid intake. Patients were then classified into three groups: steady suppression group (serum thromboxane B2 is adequately suppressed at 4 and 24 h), i.e., adequate response to acetylsalicylic acid; fast recovery group (more than 10% rise in serum thromboxane-B2 levels at 24-h when compared to at 4-h) and non-responders (serum thromboxane-B2 levels of >3,100 pg/ml after 4 h of acetylsalicylic acid intake). Patients in the fast recovery group were given twice-daily acetylsalicylic acid and thromboxane-B2 levels were re-measured. Results A total of 20 patients (24.3%) had steady suppression of thromboxane-B2 and 11 patients (13.9%) belonged to the fast recovery group, i.e., thromboxane-B2 levels were adequately suppressed at 4 h but had recovered by more than 10% at 24 h; which was adequately suppressed by twice-daily acetylsalicylic acid (p 0.004). A total of 48 patients (60.8%) were non-responders. Conclusion Twice-daily acetylsalicylic acid may be beneficial if serum thromboxane-B2 levels at 4 h are <3,100 and >3,100 pg/ml at 24 h. If thromboxane-B2 levels at 4 and 24 h is <3100 pg/ml but if there is a >10% rise in serum thromboxane B2 at 24 h as compared to that at 4 h, then twice-daily acetylsalicylic acid should be considered. However, if thromboxane-B2 at 4 and 24 h is >3,100 pg/ml consider switching over to a P2Y12 inhibitor.
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17
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Giaretta A, Petrucci G, Rocca B, Toffolo GM. Physiologically based modelling of the antiplatelet effect of aspirin: A tool to characterize drug responsiveness and inform precision dosing. PLoS One 2022; 17:e0268905. [PMID: 35976924 PMCID: PMC9385056 DOI: 10.1371/journal.pone.0268905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 05/11/2022] [Indexed: 11/18/2022] Open
Abstract
A computational approach involving mathematical modeling and in silico experiments was used to characterize the determinants of extent and duration of platelet cyclooxygenase (COX)-1 inhibition by aspirin and design precision dosing in patients with accelerated platelet turnover or reduced drug bioavailability. To this purpose, a recently developed physiologically-based pharmacokinetics (PK) and pharmacodynamics (PD) model of low-dose aspirin in regenerating platelets and megakaryocytes, was used to predict the main features and determinants of platelet COX-1 inhibition. The response to different aspirin regimens in healthy subjects and in pathological conditions associated with alterations in aspirin PK (i.e., severely obese subjects) or PD (i.e., essential thrombocytemya patients), were simulated. A model sensitivity analysis was performed to identify the main processes influencing COX-1 dynamics. In silico experiments and sensitivity analyses indicated a major role for megakaryocytes and platelet turnover in determining the extent and duration of COX-1 inhibition by once-daily, low-dose aspirin. They also showed the superiority of reducing the dosing interval vs increasing the once-daily dose in conditions of increased platelet turnover, while suggested specific dose adjustments in conditions of possible reduction in drug bioavailability. In conclusion, the consistency of our model-based findings with experimental data from studies in healthy subjects and patients with essential thrombocythemia supports the potential of our approach for describing the determinants of platelet inhibition by aspirin and informing precision dosing which may guide personalized antithrombotic therapy in different patient populations, especially in those under-represented in clinical trials or in those associated with poor feasibility.
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Affiliation(s)
- Alberto Giaretta
- Department of Information Engineering, University of Padova, Padova, Italy
- Department of Pathology, University of Cambridge, Cambridge, United Kingdom
- * E-mail: ,
| | - Giovanna Petrucci
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
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18
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Affiliation(s)
- Carlo Patrono
- Pharmacology Section, Department of Safety and Bioethics, Catholic University School of Medicine, Largo F. Vito 1, 00168 Rome, Italy
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19
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Krecak I, Lucijanic M, Verstovsek S. Advances in Risk Stratification and Treatment of Polycythemia Vera and Essential Thrombocythemia. Curr Hematol Malig Rep 2022; 17:155-169. [PMID: 35932395 DOI: 10.1007/s11899-022-00670-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Estimating and modifying thrombotic risk is currently the mainstay of care for patients with polycythemia vera (PV) and essential thrombocythemia (ET). In recent years, however, increased attention has shifted towards quality of life and disease modification. In this review, we discuss recent advances in risk stratification, present updated results for ruxolitinib and interferon randomized clinical trials, discuss new approaches in antiplatelet and anticoagulant treatment, and summarize early phase trials of novel agents and emerging therapeutic concepts for the treatment of PV and ET. RECENT FINDINGS International collaborations and novel technologies, i.e., next-generation sequencing and machine learning techniques, have demonstrated excellent abilities to improve thrombotic risk stratification in PV and ET. Updated results from ruxolitinib and interferon randomized clinical trials have confirmed excellent efficacy and safety of these agents, both as first- and second-line treatments. Early trials of novel agents (histone deacetylase inhibitors, telomerase inhibitors, lysine-specific demethylase-1 inhibitors, human double-minute 2 inhibitors, and hepcidin mimetics) have shown encouraging efficacy and safety in blood count control, reduction of splenomegaly, and alleviation of disease-related symptoms. Finally, accumulating evidence suggested that direct oral anticoagulants may be a valid therapeutic alternative to warfarin for prolonged thromboprophylaxis. International collaborations ("big data") with the help of new technologies represent an exciting new approach to analyze rare outcomes in rare diseases, especially for identifying novel prognostic biomarkers in PV and ET. Randomized clinical trials are also needed to fully elucidate whether novel agents may establish new standards of care.
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Affiliation(s)
- Ivan Krecak
- Department of Internal Medicine, General Hospital of Sibenik-Knin County, Stjepana Radića 83, 22000, Sibenik, Croatia. .,School of Medicine, University of Rijeka, Rijeka, Croatia.
| | - Marko Lucijanic
- Division of Hematology, University Hospital Dubrava, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Srdan Verstovsek
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
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20
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Ariëns RA, Hunt BJ, Agbani EO, Ahnström J, Ahrends R, Alikhan R, Assinger A, Bagoly Z, Balduini A, Barbon E, Barrett CD, Batty P, Carneiro JDA, Chan W, de Maat M, de Wit K, Denis C, Ellis MH, Eslick R, Fu H, Hayward CPM, Ho‐Tin‐Noé B, Klok F, Kumar R, Leiderman K, Litvinov RI, Mackman N, McQuilten Z, Neal MD, Parker WAE, Preston RJS, Rayes J, Rezaie AR, Roberts LN, Rocca B, Shapiro S, Siegal DM, Sousa LP, Suzuki‐Inoue K, Zafar T, Zhou J. Illustrated State-of-the-Art Capsules of the ISTH 2022 Congress. Res Pract Thromb Haemost 2022; 6:e12747. [PMID: 35814801 PMCID: PMC9257378 DOI: 10.1002/rth2.12747] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
The ISTH London 2022 Congress is the first held (mostly) face-to-face again since the COVID-19 pandemic took the world by surprise in 2020. For 2 years we met virtually, but this year's in-person format will allow the ever-so-important and quintessential creativity and networking to flow again. What a pleasure and joy to be able to see everyone! Importantly, all conference proceedings are also streamed (and available recorded) online for those unable to travel on this occasion. This ensures no one misses out. The 2022 scientific program highlights new developments in hemophilia and its treatment, acquired and other inherited bleeding disorders, thromboinflammation, platelets and coagulation, clot structure and composition, fibrinolysis, vascular biology, venous thromboembolism, women's health, arterial thrombosis, pediatrics, COVID-related thrombosis, vaccine-induced thrombocytopenia with thrombosis, and omics and diagnostics. These areas are elegantly reviewed in this Illustrated Review article. The Illustrated Review is a highlight of the ISTH Congress. The format lends itself very well to explaining the science, and the collection of beautiful graphical summaries of recent developments in the field are stunning and self-explanatory. This clever and effective way to communicate research is revolutionary and different from traditional formats. We hope you enjoy this article and will be inspired by its content to generate new research ideas.
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Affiliation(s)
| | | | - Ejaife O. Agbani
- Department of Physiology and Pharmacology, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | | | - Robert Ahrends
- Institute of Analytical ChemistryUniversity of ViennaViennaAustria
| | - Raza Alikhan
- Haemostasis & ThrombosisUniversity Hospital of WalesCardiffUK
| | | | - Zsuzsa Bagoly
- Faculty of Medicine, Department of Laboratory Medicine, Division of Clinical Laboratory Sciences and ELKH‐DE Neurodegenerative and Cerebrovascular Research GroupUniversity of DebrecenDebrecenHungary
| | | | - Elena Barbon
- San Raffaele Telethon Institute for Gene TherapyIRCCS San Raffaele Scientific InstituteMilanItaly
| | - Christopher D. Barrett
- Division of Acute Care Surgery and Surgical Critical Care, Department of SurgeryUniversity of Nebraska Medical CenterOmahaNebraskaUSA,Koch Institute, Center for Precision Cancer MedicineMassachusetts Institute of TechnologyCambridgeMassachusettsUSA,Division of Surgical Critical Care, Department of Surgery, Boston University Medical CenterBoston University School of MedicineBostonMassachusettsUSA
| | | | | | - Wee Shian Chan
- University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Moniek de Maat
- Department of HematologyErasmus MCRotterdamThe Netherlands
| | - Kerstin de Wit
- Queen’s University and McMaster UniversityKingstonONCanada
| | | | - Martin H. Ellis
- Hematology Institute and Blood Bank, Meir Medical Center and Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - Renee Eslick
- Haematology DepartmentCanberra HospitalGarranAustralian Capital TerritoryAustralia
| | - Hongxia Fu
- Division of Hematology, Department of MedicineUniversity of WashingtonSeattleWashingtonUSA
| | | | | | - Frederikus A. Klok
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Riten Kumar
- Dana Farber/Boston Children’s Cancer and Blood Disorders CenterBostonMassachusettsUSA
| | | | - Rustem I. Litvinov
- Department of Cell and Developmental BiologyUniversity of Pennsylvania School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Matthew D. Neal
- Trauma and Transfusion Medicine Research Center, Department of SurgeryUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - William A. E. Parker
- Cardiovascular Research Unit, Northern General HospitalUniversity of SheffieldSheffieldUK
| | - Roger J. S. Preston
- Irish Centre for Vascular Biology, Department of Pharmacy & Biomolecular SciencesRoyal College of Surgeons in IrelandDublin 2Ireland
| | | | - Alireza R. Rezaie
- Cardiovascular Biology Research ProgramOklahoma Medical Research FoundationOklahoma CityOklahomaUSA
| | - Lara N. Roberts
- King’s Thrombosis Centre, Department of Haematological MedicineKing’s College Hospital NHS Foundation TrustLondonUK
| | - Bianca Rocca
- Department of Safety and Bioethics, Section of PharmacologyCatholic University School of MedicineRomeItaly
| | - Susan Shapiro
- Oxford University Hospitals NHS Foundation TrustOxfordUK,Radcliffe Department of MedicineOxford UniversityOxfordUK
| | - Deborah M. Siegal
- Ottawa Hospital Research Institute and University of OttawaOttawaOntarioCanada
| | - Lirlândia P. Sousa
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de FarmáciaUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Katsue Suzuki‐Inoue
- Department of Clinical and Laboratory MedicineUniversity of YamanashiYamanashiJapan
| | - Tahira Zafar
- Frontier Medical CollegeAbbotabadPakistan,Hemophilia Treatment CenterRawalpindiPakistan
| | - Jiaxi Zhou
- Institute of Hematology & Blood Diseases HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeTianjinChina
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21
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Elshoury A, Schaefer JK, Lim MY, Skalla DP, Streiff MB. Update on Guidelines for the Prevention of Cancer-Associated Thrombosis. J Natl Compr Canc Netw 2022; 20:jnccn21298. [PMID: 35728777 DOI: 10.6004/jnccn.2021.7108] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 10/27/2021] [Indexed: 12/24/2022]
Abstract
Patients with cancer are at high risk of developing arterial and venous thromboembolism (VTE). They constitute 15% to 20% of the patients diagnosed with VTE. Depending on the type of tumor, cancer therapy, and presence of other risk factors, 1% to 25% of patients with cancer will develop thrombosis. The decision to start patients with cancer on primary thromboprophylaxis depends on patient preference, balancing risk of bleeding versus risk of thrombosis, cost, and adequate organ function. Currently, guidelines recommend against the use of routine primary thromboprophylaxis in unselected ambulatory patients with cancer. Validated risk assessment models can accurately identify patients at highest risk for cancer-associated thrombosis (CAT). This review summarizes the recently updated NCCN Guidelines for CAT primary prophylaxis, with a primarily focus on VTE prevention. Two main clinical questions that providers commonly encounter will also be addressed: which patients with cancer should receive primary thromboprophylaxis (both surgical and medical oncology patients) and how to safely choose between different anticoagulation agents.
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Affiliation(s)
- Amro Elshoury
- 1Western New York BloodCare (formerly Hemophilia Center of WNY), and.,2University at Buffalo, Buffalo, New York
| | - Jordan K Schaefer
- 3Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ming Y Lim
- 4Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Deidre P Skalla
- 5Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, New York; and
| | - Michael B Streiff
- 6Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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22
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Pedersen OB, Grove EL, Pasalic L, Ommen HB, Kristensen SD, Hvas AM. Cytoreductive treatment and association with platelet function and maturity in patients with essential thrombocythaemia. Br J Haematol 2022; 198:693-702. [PMID: 35675970 PMCID: PMC9540443 DOI: 10.1111/bjh.18303] [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: 03/17/2022] [Revised: 05/21/2022] [Accepted: 05/26/2022] [Indexed: 12/03/2022]
Abstract
Patients with essential thrombocythaemia (ET) have an increased risk of thromboembolic events, which may differ according to different cytoreductive drugs. We investigated the effect of cytoreductive treatment on platelet function and turnover in ET patients. Blood samples were obtained at 1 and 24 h after aspirin intake. Platelet function was evaluated by platelet aggregation and flow cytometry. Platelet turnover was assessed by immature platelet count, immature platelet fraction (IPF) and mean platelet volume (MPV). A total of 47 ET patients were included and grouped into 21 patients not receiving cytoreductive treatment, 15 patients receiving hydroxycarbamide and 11 patients receiving pegylated interferon alpha (peg‐IFN). Patients receiving peg‐IFN had significantly higher IPF and MPV than the other ET groups. Patients not receiving cytoreductive treatment had significantly higher platelet aggregation 24 h after aspirin intake than the other ET groups (p‐values from 0.03 to 0.0002). Patients receiving hydroxycarbamide had significantly higher expression of platelet granule makers, P‐selectin and CD63, than patients receiving peg‐IFN (p‐values ≤0.003). Cytoreduction provides more consistent platelet inhibition compared with no cytoreductive treatment. Moreover, peg‐IFN provides superior inhibition of platelet activation markers than hydroxycarbamide, which in part may explain differences in risk of thromboembolic events in ET patients.
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Affiliation(s)
- Oliver Buchhave Pedersen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Leonardo Pasalic
- Institute of Clinical Pathology and Medical Research and the Departments of Clinical and Laboratory Haematology, Westmead Hospital, Sydney, Australia.,Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hans Beier Ommen
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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23
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Leiva O, Hobbs G, Ravid K, Libby P. Cardiovascular Disease in Myeloproliferative Neoplasms: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:166-182. [PMID: 35818539 PMCID: PMC9270630 DOI: 10.1016/j.jaccao.2022.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 11/24/2022] Open
Abstract
Myeloproliferative neoplasms are associated with increased risk for thrombotic complications. These conditions most commonly involve somatic mutations in genes that lead to constitutive activation of the Janus-associated kinase signaling pathway (eg, Janus kinase 2, calreticulin, myeloproliferative leukemia protein). Acquired gain-of-function mutations in these genes, particularly Janus kinase 2, can cause a spectrum of disorders, ranging from clonal hematopoiesis of indeterminate potential, a recently recognized age-related promoter of cardiovascular disease, to frank hematologic malignancy. Beyond thrombosis, patients with myeloproliferative neoplasms can develop other cardiovascular conditions, including heart failure and pulmonary hypertension. The authors review the pathophysiologic mechanisms of cardiovascular complications of myeloproliferative neoplasms, which involve inflammation, prothrombotic and profibrotic factors (including transforming growth factor-beta and lysyl oxidase), and abnormal function of circulating clones of mutated leukocytes and platelets from affected individuals. Anti-inflammatory therapies may provide cardiovascular benefit in patients with myeloproliferative neoplasms, a hypothesis that requires rigorous evaluation in clinical trials.
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Key Words
- ASXL1, additional sex Combs-like 1
- CHIP, clonal hematopoiesis of indeterminate potential
- DNMT3a, DNA methyltransferase 3 alpha
- IL, interleukin
- JAK, Janus-associated kinase
- JAK2, Janus kinase 2
- LOX, lysyl oxidase
- MPL, myeloproliferative leukemia protein
- MPN, myeloproliferative neoplasm
- STAT, signal transducer and activator of transcription
- TET2, tet methylcytosine dioxygenase 2
- TGF, transforming growth factor
- atherosclerosis
- cardiovascular complications
- clonal hematopoiesis
- myeloproliferative neoplasms
- thrombosis
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Hobbs
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Katya Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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24
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Nathan DI, Feld J, El Jamal SM, Mascarenhas J, Tremblay D. Myelodysplastic syndrome/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis: Ringing in a new future. Leuk Res 2022; 115:106820. [DOI: 10.1016/j.leukres.2022.106820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/02/2022] [Accepted: 03/04/2022] [Indexed: 01/19/2023]
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25
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Walker J. Low-dose aspirin for the prevention of atherothrombosis across the cardiovascular risk continuum. Cardiology Plus 2022; 7:64-69. [DOI: 10.1097/cp9.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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26
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Goulart H, Mascarenhas J, Tremblay D. Low-risk polycythemia vera and essential thrombocythemia: management considerations and future directions. Ann Hematol 2022; 101:935-951. [PMID: 35344066 DOI: 10.1007/s00277-022-04826-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 02/10/2022] [Accepted: 03/21/2022] [Indexed: 01/06/2023]
Abstract
Thrombotic events are a distinctive feature of the myeloproliferative neoplasms (MPNs) polycythemia vera (PV) and essential thrombocythemia (ET). Patients with these MPNs may also experience a poor quality of life secondary to symptom burden, as well as progression of disease to acute leukemia or myelofibrosis. Over the years, various risk stratification methods have evolved in order to attempt to predict thrombotic risk, which is the largest contributor of morbidity and mortality in these patients. More than half of PV and ET patients are low- or intermediate-risk disease status at the time of diagnosis. While therapeutic development is presently focused on high-risk patients, there is a paucity of therapies, outside of aspirin and therapeutic phlebotomy, which can reduce the thrombotic risk or delay disease progression in low-risk patients. In this review, we first describe the various complications that patients with PV and ET experience, and then detail our evolving understanding of risk stratification in these diseases. We then highlight the available evidence on the management of low-risk PV and ET and include a description of novel therapies currently under investigation in this space. We conclude with recommendations for future directions to advance our understanding and improve the treatment of low-risk PV and ET.
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Affiliation(s)
- Hannah Goulart
- Division of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - John Mascarenhas
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, 10029, USA
| | - Douglas Tremblay
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, 10029, USA.
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27
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Tall AR, Fuster JJ. Clonal hematopoiesis in cardiovascular disease and therapeutic implications. Nat Cardiovasc Res 2022; 1:116-124. [PMID: 36337911 PMCID: PMC9631799 DOI: 10.1038/s44161-021-00015-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 12/21/2021] [Indexed: 05/25/2023]
Abstract
Clonal hematopoiesis arises from somatic mutations that provide a fitness advantage to hematopoietic stem cells and the outgrowth of clones of blood cells. Clonal hematopoiesis commonly involves mutations in genes that are involved in epigenetic modifications, signaling and DNA damage repair. Clonal hematopoiesis has emerged as a major independent risk factor in atherosclerotic cardiovascular disease, thrombosis and heart failure. Studies in mouse models of clonal hematopoiesis have shown an increase in atherosclerosis, thrombosis and heart failure, involving increased myeloid cell inflammatory responses and inflammasome activation. Although increased inflammatory responses have emerged as a common underlying principle, some recent studies indicate mutation-specific effects. The discovery of the association of clonal hematopoiesis with cardiovascular disease and the recent demonstration of benefit of anti-inflammatory treatments in human cardiovascular disease converge to suggest that anti-inflammatory treatments should be directed to individuals with clonal hematopoiesis. Such treatments could target specific inflammasomes, common downstream mediators such as IL-1β and IL-6, or mutations linked to clonal hematopoiesis.
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Affiliation(s)
- Alan R. Tall
- Division of Molecular Medicine, Department of Medicine, Columbia University, New York, NY, USA
| | - Jose J. Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- CIBER en Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
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28
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Barbui T, Carobbio A, De Stefano V. Thrombosis in myeloproliferative neoplasms during cytoreductive and antithrombotic drug treatment. Res Pract Thromb Haemost 2022; 6:e12657. [PMID: 35155976 PMCID: PMC8822262 DOI: 10.1002/rth2.12657] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [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: 09/28/2021] [Revised: 12/31/2021] [Accepted: 01/12/2022] [Indexed: 12/16/2022] Open
Abstract
A state-of-the-art lecture titled "Myeloproliferative Neoplasm-associated Thrombosis" was presented at the ISTH congress in 2021. We summarize here the main points of the lecture with two purposes: to report the incidence rates of major thrombosis in polycythemia vera and essential thrombocythemia and to discuss to what extent cytoreductive therapy and antithrombotic drugs have reduced the incidence of these events. Unfortunately, the incidence rate of thrombosis remains high, ranging between 2 and 5/100 person-years. It is likely that new drugs such as interferon and ruxolitinib can be more efficacious given their cytoreductive and anti-inflammatory activities. Despite prophylaxis with vitamin K antagonists and direct oral anticoagulants after venous thrombosis in either common sites or splanchnic or cerebral sites, the incidence rate is still elevated, as high as 4 to 5/100 person-years. Future studies with new drugs or new strategies should consider thrombosis as the primary endpoint or surrogate biomarkers only if previously validated.
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Affiliation(s)
- Tiziano Barbui
- FROM Research FoundationPapa Giovanni XXIII HospitalBergamoItaly
| | | | - Valerio De Stefano
- Section of HematologyDepartment of Radiological and Hematological SciencesCatholic UniversityFondazione Policlinico A. Gemelli IRCCSRomeItaly
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29
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Manoharan A, Gemmell R, Cavanaugh L, Shadood N. Thrombosis in Myeloproliferative Neoplasms: A Single Center Experience of Using Whole Blood Platelet Aggregation Studies for Risk Assessment and Thromboprophylaxis. Clin Appl Thromb Hemost 2022; 28:10760296221117482. [PMID: 35898172 PMCID: PMC9340402 DOI: 10.1177/10760296221117482] [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] [Indexed: 11/21/2022] Open
Abstract
Thromboembolic complications are the most common causes of morbidity and
mortality in patients with Philadelphia chromosome-negative myeloproliferative
neoplasms (MPN); and prevention of these complications remains a significant
clinical challenge. Effective thromboprophylaxis in MPN patients generally
requires use of anti-platelet therapy, commonly aspirin; however, there are no
standardized or universally accepted guidelines regarding the dose of aspirin.
This study evaluates the usefulness of whole blood platelet aggregation (WBPA)
studies to identify patients at risk for thrombosis and to achieve safe and
effective long term thromboprophylaxis. One hundred and thirty-two consecutive
patients were enrolled into this study. WBPA studies were performed at diagnosis
in 125 patients to identify those with platelet hyperactivity (deemed to be at
risk for thrombosis) and repeated 4 weeks after commencement of anti-platelet
therapy to ascertain the efficacy. In patients with incomplete drug effect,
treatment was revised and the study repeated until optimum effect was achieved.
Results of the WBPA studies and anti-platelet therapy requirements were
correlated with the underlying driver mutations and various international
prognostic score of thrombosis for essential thrombocythemia (IPSET- Thrombosis)
sub-groups. WBPA studies showed varying degrees of platelet hyper-activity in
115 patients. Based on these results, the patients were commenced on
anti-platelet therapy comprising aspirin (dose ranging from 100mg twice or
thrice weekly to 400mg daily) and clopidogrel (75mg daily) alone or in
combination with aspirin or odorless garlic. None of the patients developed
thrombosis during the follow up period ranging from 1-23 years (median 8yrs),
while on the prescribed, individualized anti-platelet therapy. No significant
differences were noted in terms of aspirin dose requirements between the JAK-2
positive and CALR or MPL positive patients, and, among the four IPSET-Thrombosis
sub-groups. Patients with normal (9) or hypo (1) – activity were not given any
anti-platelet therapy at diagnosis.
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Affiliation(s)
- Arumugam Manoharan
- Southern Sydney Haematology, St George Private Hosipital, Sydney, Australia.,Faculty of Health, Medicine & Applied Sciences, 8691University of Wollongong, Wollongong, New South Wales, Australia
| | - Rosalie Gemmell
- Department of Haematology, ST. George Hospital, Sydney, Australia
| | - Lauren Cavanaugh
- Department of Haematology, ST. George Hospital, Sydney, Australia
| | - Noor Shadood
- Department of Haematology, ST. George Hospital, Sydney, Australia
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30
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Papageorgiou L, Elalamy I, Vandreden P, Gerotziafas GT. Thrombotic and Hemorrhagic Issues Associated with Myeloproliferative Neoplasms. Clin Appl Thromb Hemost 2022; 28:10760296221097969. [PMID: 35733370 PMCID: PMC9234921 DOI: 10.1177/10760296221097969] [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] [Indexed: 12/04/2022] Open
Abstract
Thrombotic and hemorrhagic complications are related to a significant rate of
morbidity and mortality in patients with myeloproliferative neoplasms (MPNs),
they are therefore called “thrombohemorrhagic” syndromes. Several clinical
factors, such as age and presence of cardiovascular comorbidities are
responsible for thrombotic complications. High blood counts, platelet
alterations, presence of JAK2 mutation and possibly of other CHIP mutations such
as TET2, DNMT3A, and ASXL1, procoagulant microparticles, NETs formation,
endothelial activation and neo-angiogenesis are some of the parameters
accounting for hypercoagulability in patients with myeloproliferative neoplasms.
Bleeding complications emerge as a result of platelet exhaustion. They can be
also linked to a functional deficiency of von Willebrand factor, when platelet
counts rise above 1000G/L. The mainstay of management consists on preventing
hemostatic complications, by antiplatelet and/or anticoagulant treatment and
myelosuppressive agents in high-risk patients.Circumstances related to a high
thrombohemorrhagic risk, such as pregnancy and the perioperative period, prompt
for specific management with regards to anticoagulation and myelosuppression
treatment type. In order to apply a patient-specific treatment strategy, there
is a need for a risk score assessment tool encompassing clinical parameters and
hemostasis biomarkers.
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Affiliation(s)
- Loula Papageorgiou
- Hrombosis Center, 432215Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France.,Faculty of Medicine, Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Sorbonne University, Paris, France
| | - Ismail Elalamy
- Hrombosis Center, 432215Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France.,Faculty of Medicine, Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Sorbonne University, Paris, France.,The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Patrick Vandreden
- Faculty of Medicine, Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Sorbonne University, Paris, France.,Clinical Research Department, Diagnostica Stago, Gennevilliers, France
| | - Grigoris T Gerotziafas
- Hrombosis Center, 432215Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France.,Faculty of Medicine, Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Sorbonne University, Paris, France
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31
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Dou H, Kotini A, Liu W, Fidler T, Endo-Umeda K, Sun X, Olszewska M, Xiao T, Abramowicz S, Yalcinkaya M, Hardaway B, Tsimikas S, Que X, Bick A, Emdin C, Natarajan P, Papapetrou EP, Witztum JL, Wang N, Tall AR. Oxidized Phospholipids Promote NETosis and Arterial Thrombosis in LNK(SH2B3) Deficiency. Circulation 2021; 144:1940-1954. [PMID: 34846914 PMCID: PMC8663540 DOI: 10.1161/circulationaha.121.056414] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Supplemental Digital Content is available in the text. Background: LNK/SH2B3 inhibits Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling by hematopoietic cytokine receptors. Genome-wide association studies have shown association of a common single nucleotide polymorphism in LNK (R262W, T allele) with neutrophilia, thrombocytosis, and coronary artery disease. We have shown that LNK(TT) reduces LNK function and that LNK-deficient mice display prominent platelet–neutrophil aggregates, accelerated atherosclerosis, and thrombosis. Platelet–neutrophil interactions can promote neutrophil extracellular trap (NET) formation. The goals of this study were to assess the role of NETs in atherosclerosis and thrombosis in mice with hematopoietic Lnk deficiency. Methods: We bred mice with combined deficiency of Lnk and the NETosis-essential enzyme PAD4 (peptidyl arginine deiminase 4) and transplanted their bone marrow into Ldlr–/– mice. We evaluated the role of LNK in atherothrombosis in humans and mice bearing a gain of function variant in JAK2 (JAK2V617F). Results: Lnk-deficient mice displayed accelerated carotid artery thrombosis with prominent NETosis that was completely reversed by PAD4 deficiency. Thrombin-activated Lnk–/– platelets promoted increased NETosis when incubated with Lnk–/– neutrophils compared with wild-type platelets or wild-type neutrophils. This involved increased surface exposure and release of oxidized phospholipids (OxPL) from Lnk–/– platelets, as well as increased priming and response of Lnk–/– neutrophils to OxPL. To counteract the effects of OxPL, we introduced a transgene expressing the single-chain variable fragment of E06 (E06-scFv). E06-scFv reversed accelerated NETosis, atherosclerosis, and thrombosis in Lnk–/– mice. We also showed increased NETosis when human induced pluripotent stem cell–derived LNK(TT) neutrophils were incubated with LNK(TT) platelet/megakaryocytes, but not in isogenic LNK(CC) controls, confirming human relevance. Using data from the UK Biobank, we found that individuals with the JAK2VF mutation only showed increased risk of coronary artery disease when also carrying the LNK R262W allele. Mice with hematopoietic Lnk+/– and Jak2VF clonal hematopoiesis showed accelerated arterial thrombosis but not atherosclerosis compared with Jak2VFLnk+/+ controls. Conclusions: Hematopoietic Lnk deficiency promotes NETosis and arterial thrombosis in an OxPL-dependent fashion. LNK(R262W) reduces LNK function in human platelets and neutrophils, promoting NETosis, and increases coronary artery disease risk in humans carrying Jak2VF mutations. Therapies targeting OxPL may be beneficial for coronary artery disease in genetically defined human populations.
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Affiliation(s)
- Huijuan Dou
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.)
| | - Andriana Kotini
- Department of Oncological Sciences, Tisch Cancer Institute, Black Family Stem Cell Institute, and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (A.K., M.O., E.P.P.)
| | - Wenli Liu
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.)
| | - Trevor Fidler
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.)
| | - Kaori Endo-Umeda
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.).,Division of Biochemistry, Department of Biomedical Sciences, Nihon University School of Medicine, Tokyo, Japan (K.E.-U.)
| | - Xiaoli Sun
- Department of Medicine, University of California, San Diego (X.S., S.T., X.Q., J.L.W.)
| | - Malgorzata Olszewska
- Department of Oncological Sciences, Tisch Cancer Institute, Black Family Stem Cell Institute, and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (A.K., M.O., E.P.P.)
| | - Tong Xiao
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.)
| | - Sandra Abramowicz
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.)
| | - Mustafa Yalcinkaya
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.)
| | - Brian Hardaway
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.)
| | - Sotirios Tsimikas
- Department of Medicine, University of California, San Diego (X.S., S.T., X.Q., J.L.W.)
| | - Xuchu Que
- Department of Medicine, University of California, San Diego (X.S., S.T., X.Q., J.L.W.)
| | - Alexander Bick
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (A.B.)
| | - Conor Emdin
- Cardiovascular Research Center, Massachusetts General Hospital, Boston (C.E., P.N.).,Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA (C.E., P.N.).,Department of Medicine, Harvard Medical School, Boston, MA (C.E., P.N.)
| | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, Boston (C.E., P.N.).,Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Cambridge, MA (C.E., P.N.).,Department of Medicine, Harvard Medical School, Boston, MA (C.E., P.N.)
| | - Eirini P Papapetrou
- Department of Oncological Sciences, Tisch Cancer Institute, Black Family Stem Cell Institute, and Department of Medicine, Icahn School of Medicine at Mount Sinai, New York (A.K., M.O., E.P.P.)
| | - Joseph L Witztum
- Department of Medicine, University of California, San Diego (X.S., S.T., X.Q., J.L.W.)
| | - Nan Wang
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.)
| | - Alan R Tall
- Molecular Medicine, Columbia University Medical Center, New York (H.D., W.L., T.F., K.E.-U., T.X., S.A., M.Y., B.H., N.W., A.R.T.)
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32
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Putti MC, Bertozzi I, Randi ML. Essential Thrombocythemia in Children and Adolescents. Cancers (Basel) 2021; 13:6147. [PMID: 34885256 DOI: 10.3390/cancers13236147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 02/02/2023] Open
Abstract
Simple Summary Among chronic Ph-negative myeloproliferative neoplasms, essential thrombocythemia is found in children with low but increasing incidence. The diagnostic and clinical features do not completely overlap with ET of adult age. A significant number of cases, in fact, do not meet the criteria of clonality, and many cases require extensive clinical evaluation to exclude secondary, reactive forms. Therefore, histological analysis of bone marrow biopsy is necessary, and its use should be enforced. The clinical course appears to be more benign, at least within the first decades of observation, with the incidence of thrombotic events being much lower than in adults (4 % vs. 30%). Hemorrhages are mostly irrelevant. Therefore, the management should be carefully adapted to the individual patient, balancing the risk of future complications with long-term collateral effects of any drug. This review analyzes the peculiarities of the disease facing similarities and differences with adult scenarios. Abstract This paper reviews the features of pediatric essential thrombocythemia (ET). ET is a rare disease in children, challenging pediatric and adult hematologists alike. The current WHO classification acknowledges classical Philadelphia-negative MPNs and defines diagnostic criteria, mainly encompassing adult cases. The presence of one of three driver mutations (JAK2V617F, CALR, and MPL mutations) represent the proof of clonality typical of ET. Pediatric ET cases are thus usually confronted by adult approaches. These can fit only some patients, because only 25–40% of cases present one of the driver mutations. The diagnosis of hereditary, familial thrombocytosis and the exclusion of reactive/secondary thrombocytosis must be part of the diagnostic process in children and can clarify most of the negative cases. Still, many children present a clinical, histological picture of ET, with a molecular triple wild-type status. Moreover, prognosis seems more benign, at least within the first few decades of follow-up. Thrombotic events are rare, and only minor hemorrhages are ordinarily observed. As per the management, the need to control symptoms must be balanced with the collateral effects of lifelong drug therapy. We conclude that these differences concert a compelling case for a very careful therapeutic approach and advocate for the importance of further cooperative studies.
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33
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Tefferi A, Vannucchi AM, Barbui T. Polycythemia vera: historical oversights, diagnostic details, and therapeutic views. Leukemia 2021; 35:3339-3351. [PMID: 34480106 PMCID: PMC8632660 DOI: 10.1038/s41375-021-01401-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
Polycythemia vera (PV) is a relatively indolent myeloid neoplasm with median survival that exceeds 35 years in young patients, but its natural history might be interrupted by thrombotic, fibrotic, or leukemic events, with respective 20-year rates of 26%, 16%, and 4%. Current treatment strategies in PV have not been shown to prolong survival or lessen the risk of leukemic or fibrotic progression and instead are directed at preventing thrombotic complications. In the latter regard, two risk categories are considered: high (age >60 years or thrombosis history) and low (absence of both risk factors). All patients require phlebotomy to keep hematocrit below 45% and once-daily low-dose aspirin, in the absence of contraindications. Cytoreductive therapy is recommended for high-risk or symptomatic low-risk disease; our first-line drug of choice in this regard is hydroxyurea but we consider pegylated interferon as an alternative in certain situations, including in young women of reproductive age, in patients manifesting intolerance or resistance to hydroxyurea therapy, and in situations where treatment is indicated for curbing phlebotomy requirement rather than preventing thrombosis. Additional treatment options include busulfan and ruxolitinib; the former is preferred in older patients and the latter in the presence of symptoms reminiscent of post-PV myelofibrosis or protracted pruritus. Our drug choices reflect our appreciation for long-term track record of safety, evidence for reduction of thrombosis risk, and broader suppression of myeloproliferation. Controlled studies are needed to clarify the added value of twice- vs once-daily aspirin dosing and direct oral anticoagulants. In this invited review, we discuss our current approach to diagnosis, prognostication, and treatment of PV in general, as well as during specific situations, including pregnancy and splanchnic vein thrombosis.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Alessandro M Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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34
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Tosetto A, Rocca B, Petrucci G, Betti S, Soldati D, Rossi E, Timillero A, Cavalca V, Porro B, Iurlo A, Cattaneo D, Bucelli C, Dragani A, Di Ianni M, Ranalli P, Palandri F, Vianelli N, Beggiato E, Lanzarone G, Ruggeri M, Carli G, Elli EM, Priolo S, Randi ML, Bertozzi I, Loscocco GG, Ricco A, Specchia G, Vannucchi AM, Rodeghiero F, De Stefano V, Patrono C. Association of Platelet Thromboxane Inhibition by Low-Dose Aspirin With Platelet Count and Cytoreductive Therapy in Essential Thrombocythemia. Clin Pharmacol Ther 2021; 111:939-949. [PMID: 34743317 PMCID: PMC9299058 DOI: 10.1002/cpt.2485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/27/2021] [Indexed: 01/14/2023]
Abstract
Essential thrombocythemia (ET) is a myeloproliferative neoplasm characterized by enhanced platelet production and thrombotic complications. The inhibition of platelet cyclooxygenase (COX) activity by the standard once‐daily aspirin is mostly incomplete due to accelerated thrombopoiesis. The phase II Aspirin Regimens in EsSential thrombocythemia (ARES) trial has recently compared the efficacy of once‐ vs. twice‐ or three‐times daily low‐dose aspirin in inhibiting platelet thromboxane (TX) A2 production, as reflected by serum (s) TXB2 measurements. The present substudy characterized the determinants of the highly variable response to the standard aspirin 100 mg once‐daily regimen in fully compliant patients with ET and the effects of the experimental dosing regimens on response variability. By multivariable analysis, the platelet count (directly) and cytoreductive treatment (inversely) were significantly associated with sTXB2 values in 218 patients with ET. However, the platelet count positively correlated with sTXB2 in patients not being treated with cytoreductive drugs (ρ = 0.51, P < 0.01, n = 84), but not in patients on cytoreduction. Patients in the lowest sTXB2 quartile were older, more often on cytoreductive drugs, had lower platelet count and Janus‐Associated Kinase2 (JAK2)‐V617F allele frequency as compared with patients in the upper sTXB2 quartiles. After 2 weeks of a twice‐ or 3‐times daily aspirin regimen, the association between the platelet count and sTXB2 became similar in cytoreduced and non‐cytoreduced patients. In conclusion, the platelet count appears the strongest determinant of TXA2 inhibition by once‐daily low‐dose aspirin in ET, with different patterns depending of cytoreductive treatment. More frequent aspirin dosing restores adequate platelet inhibition and reduces interindividual variability, independently of cytoreduction.
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Affiliation(s)
| | - Bianca Rocca
- Department of Safety and Bioethics Section of Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanna Petrucci
- Department of Safety and Bioethics Section of Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Silvia Betti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Denise Soldati
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elena Rossi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Radiological and Hematological Sciences, Section of Hematology, Catholic University School of Medicine, Rome, Italy
| | | | | | | | - Alessandra Iurlo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Daniele Cattaneo
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | - Cristina Bucelli
- Hematology Division, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milano, Milano, Italy
| | | | - Mauro Di Ianni
- Hematology Department, S. Spirito Hospital, Pescara, Italy
| | - Paola Ranalli
- Hematology Department, S. Spirito Hospital, Pescara, Italy
| | - Francesca Palandri
- Dipartimento Attività Integrata, Dipartimento di Oncologia e di Ematologia, Azienda Ospedaliero, Universitaria di Bologna IRCCS Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Nicola Vianelli
- Dipartimento Attività Integrata, Dipartimento di Oncologia e di Ematologia, Azienda Ospedaliero, Universitaria di Bologna IRCCS Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Eloise Beggiato
- Department of Oncology, Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Giuseppe Lanzarone
- Department of Oncology, Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Ruggeri
- Hematology Department, Ospedale San Bortolo, Vicenza, Italy
| | - Giuseppe Carli
- Hematology Department, Ospedale San Bortolo, Vicenza, Italy
| | - Elena Maria Elli
- Division of Haematology and Bone Marrow Transplantation Unit, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | - Stefania Priolo
- Division of Haematology and Bone Marrow Transplantation Unit, Ospedale San Gerardo, ASST Monza, Monza, Italy
| | | | - Irene Bertozzi
- Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Giuseppe Gaetano Loscocco
- Department of Experimental and Clinical Medicine, CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Firenze, Firenze, Italy
| | - Alessandra Ricco
- Department of Emergency and Organ Transplantation (DETO), Hematology Section, University of Bari Aldo Moro, Bari, Italy
| | | | - Alessandro Maria Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM-Center of Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Firenze, Firenze, Italy
| | | | - Valerio De Stefano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Radiological and Hematological Sciences, Section of Hematology, Catholic University School of Medicine, Rome, Italy
| | - Carlo Patrono
- Department of Safety and Bioethics Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
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35
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Abstract
Myeloproliferative neoplasms (MPNs) are a group of malignant disorders of the bone marrow where a dysregulated balance between proliferation and differentiation gives rise to abnormal numbers of mature blood cells. MPNs encompass a spectrum of disease entities with progressively more severe clinical features, including complications with thrombosis and hemostasis and an increased propensity for transformation to acute myeloid leukemia. There is an unmet clinical need for markers of disease progression. Our understanding of the precise mechanisms that influence pathogenesis and disease progression has been limited by access to disease-specific cells as biosources. Here, we review the landscape of MPN pathology and present blood platelets as potential candidates for disease-specific understanding. We conclude with our recent work discovering progressive platelet heterogeneity by subtype in a large clinical cohort of patients with MPN.
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Affiliation(s)
- Sally Thomas
- Department of Oncology and Metabolism, University of Sheffield and Department of Haematology, Royal Hallamshire Hospital, United Kingdom (S.T.)
| | - Anandi Krishnan
- Department of Pathology, Stanford University School of Medicine, CA (A.K.)
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36
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Coltro G, Loscocco GG, Vannucchi AM. Classical Philadelphia-negative myeloproliferative neoplasms (MPNs): A continuum of different disease entities. Int Rev Cell Mol Biol 2021; 365:1-69. [PMID: 34756241 DOI: 10.1016/bs.ircmb.2021.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Classical Philadelphia-negative myeloproliferative neoplasms (MPNs) are clonal hematopoietic stem cell-derived disorders characterized by uncontrolled proliferation of differentiated myeloid cells and close pathobiologic and clinical features. According to the 2016 World Health Organization (WHO) classification, MPNs include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). The 2016 revision aimed in particular at strengthening the distinction between masked PV and JAK2-mutated ET, and between prefibrotic/early (pre-PMF) and overt PMF. Clinical manifestations in MPNs include constitutional symptoms, microvascular disorders, thrombosis and bleeding, splenomegaly secondary to extramedullary hematopoiesis, cytopenia-related symptoms, and progression to overt MF and acute leukemia. A dysregulation of the JAK/STAT pathway is the unifying mechanistic hallmark of MPNs, and is guided by somatic mutations in driver genes including JAK2, CALR and MPL. Additional mutations in myeloid neoplasm-associated genes have been also identified, with established prognostic relevance, particularly in PMF. Prognostication of MPN patients relies on disease-specific clinical models. The increasing knowledge of MPN biology led to the development of integrated clinical and molecular prognostic scores that allow a more refined stratification. Recently, the therapeutic landscape of MPNs has been revolutionized by the introduction of potent, selective JAK inhibitors (ruxolitinib, fedratinib), that proved effective in controlling disease-related symptoms and splenomegaly, yet leaving unmet critical needs, owing the lack of disease-modifying activity. In this review, we will deal with molecular, clinical, and therapeutic aspects of the three classical MPNs aiming at highlighting either shared characteristics, that overall define a continuum within a single disease family, and uniqueness, at the same time.
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Affiliation(s)
- Giacomo Coltro
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giuseppe G Loscocco
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro M Vannucchi
- CRIMM, Center for Research and Innovation of Myeloproliferative Neoplasms, AOU Careggi, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
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37
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Moliterno AR, Ginzburg YZ, Hoffman R. Clinical insights into the origins of thrombosis in myeloproliferative neoplasms. Blood 2021; 137:1145-53. [PMID: 33237986 DOI: 10.1182/blood.2020008043] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/18/2020] [Indexed: 02/06/2023] Open
Abstract
Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs), polycythemia vera, essential thrombocythemia, and primary myelofibrosis, are hematopoietic stem cell disorders that are defined by activating mutations in signal transduction pathways and are characterized clinically by the overproduction of platelets, red blood cells, and neutrophils, significant burden of disease-specific symptoms, and high rates of vascular events. The focus of this review is to critically reevaluate the clinical burden of thrombosis in MPNs, to review the clinical associations among clonal hematopoiesis, JAK2V617F burden, inflammation, and thrombosis, and to provide insights into novel primary and secondary thrombosis-prevention strategies.
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38
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Pedersen OB, Hvas AM, Ommen HB, Kristensen SD, Grove EL. Lower Antiplatelet Effect of Aspirin in Essential Thrombocythemia than in Coronary Artery Disease. TH Open 2021; 5:e230-e238. [PMID: 34235392 PMCID: PMC8255105 DOI: 10.1055/s-0041-1731309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 02/02/2021] [Accepted: 04/16/2021] [Indexed: 01/02/2023] Open
Abstract
Background
Patients with essential thrombocythemia (ET) and coronary artery disease (CAD) have increased risk of thromboembolic complications. In addition, a reduced antiplatelet effect of aspirin has been demonstrated in both patient groups. As ET is a platelet disorder, platelets may be more important for the thromboembolic risk in ET than in CAD. We aimed to investigate the antiplatelet effect of aspirin and platelet turnover in ET versus CAD patients.
Methods
We included 48 ET patients and an age-matched group of 48 CAD patients. The effect of aspirin was evaluated by thromboxane B
2
(TXB
2
) levels and platelet aggregation. Platelet turnover was assessed by immature platelet count (IPC) and immature platelet fraction (IPF).
Results
ET patients had reduced effect of aspirin compared with CAD patients, demonstrated by significantly higher TXB
2
levels (median of differences = 22.3 ng/mL,
p
< 0.0001) and platelet aggregation (median of differences = 131.0 AU*min,
p
= 0.0003). Furthermore, ET patients had significantly higher IPC (
p
< 0.0001) and IPF (
p
= 0.0004) than CAD patients.
Conclusion
ET patients have lower 24-hour antiplatelet effect of aspirin than CAD patients. This may be explained by an increased platelet production and turnover counteracting the antiplatelet effect of aspirin. These findings strengthen the rationale for exploring novel antiplatelet regimens in ET patients to reduce the risk of cardiovascular events.
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Affiliation(s)
- Oliver Buchhave Pedersen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Hans Beier Ommen
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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39
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Zeeh FC, Meyer SC. Current Concepts of Pathogenesis and Treatment of Philadelphia Chromosome-Negative Myeloproliferative Neoplasms. Hamostaseologie 2021; 41:197-205. [PMID: 34192778 DOI: 10.1055/a-1447-6667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Philadelphia chromosome-negative myeloproliferative neoplasms are hematopoietic stem cell disorders characterized by dysregulated proliferation of mature myeloid blood cells. They can present as polycythemia vera, essential thrombocythemia, or myelofibrosis and are characterized by constitutive activation of JAK2 signaling. They share a propensity for thrombo-hemorrhagic complications and the risk of progression to acute myeloid leukemia. Attention has also been drawn to JAK2 mutant clonal hematopoiesis of indeterminate potential as a possible precursor state of MPN. Insight into the pathogenesis as well as options for the treatment of MPN has increased in the last years thanks to modern sequencing technologies and functional studies. Mutational analysis provides information on the oncogenic driver mutations in JAK2, CALR, or MPL in the majority of MPN patients. In addition, molecular markers enable more detailed prognostication and provide guidance for therapeutic decisions. While JAK2 inhibitors represent a standard of care for MF and resistant/refractory PV, allogeneic hematopoietic stem cell transplantation remains the only therapy with a curative potential in MPN so far but is reserved to a subset of patients. Thus, novel concepts for therapy are an important need, particularly in MF. Novel JAK2 inhibitors, combination therapy approaches with ruxolitinib, as well as therapeutic approaches addressing new molecular targets are in development. Current standards and recent advantages are discussed in this review.
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Affiliation(s)
- Franziska C Zeeh
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | - Sara C Meyer
- Division of Hematology, University Hospital Basel, Basel, Switzerland.,Division of Hematology and Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
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40
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O'Sullivan LR, Meade-Murphy G, Gilligan OM, Mykytiv V, Cahill MR, Young PW. Platelet hyperactivation and hyporesponsiveness at diagnosis in multiple myeloma persists during treatment initiation. Thromb Res 2021; 203:186-9. [PMID: 34033940 DOI: 10.1016/j.thromres.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/16/2021] [Accepted: 05/06/2021] [Indexed: 11/22/2022]
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Patrono C, Rocca B. Aspirin at 120: Retiring, recombining, or repurposing? Res Pract Thromb Haemost 2021; 5:e12516. [PMID: 34095732 PMCID: PMC8162399 DOI: 10.1002/rth2.12516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/24/2021] [Accepted: 03/14/2021] [Indexed: 12/12/2022] Open
Abstract
During the past 20 years, we have witnessed the following trends in aspirin usage: (i) a "dropping" trend, characterized by the early discontinuation of low-dose aspirin from dual antiplatelet therapy or triple antithrombotic therapy (oral anticoagulation plus dual antiplatelet therapy in patients with atrial fibrillation) following an acute coronary syndrome or after percutaneous coronary intervention; (ii) a "combinatorial" trend, featuring the addition of a lower dose of a P2Y12 inhibitor or direct oral anticoagulant drug to low-dose aspirin for the long-term treatment of stable patients with atherosclerotic cardiovascular disease; and (iii) a "repurposing" trend, characterized by growing interest in the oncologic community to assess the chemopreventive effect of aspirin against certain types of cancers (particularly of the gastrointestinal tract), both as primary prevention and adjuvant therapy. The aim of this review is to present the mechanistic rationale underlying these trends, discuss the design and findings of trials testing novel treatments or new therapeutic applications of aspirin, and report on the ISTH Congress results on this topic.
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Affiliation(s)
- Carlo Patrono
- Department of SafetySection of PharmacologyCatholic University School of MedicineRomeItaly
| | - Bianca Rocca
- Department of SafetySection of PharmacologyCatholic University School of MedicineRomeItaly
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Gangat N, Tefferi A. Myeloproliferative neoplasms and pregnancy: Overview and practice recommendations. Am J Hematol 2021; 96:354-366. [PMID: 33296529 DOI: 10.1002/ajh.26067] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 01/08/2023]
Abstract
Pregnancy in the context of myeloproliferative neoplasms (MPN) poses unique fetal and maternal challenges. Current literature in this regard mostly involves essential thrombocythemia (ET) and less so polycythemia vera (PV) or myelofibrosis. In ET, live birth rate is estimated at 70% with first trimester fetal loss (˜ 30%) as the major complication. Risk of pregnancy-associated complications is higher in PV, thus mandating a more aggressive treatment approach. Herein, we appraise the relevant literature, share our own experience and propose management recommendations. Aspirin therapy may offer protection against fetal loss; however the additive benefit of systemic anticoagulation or cytoreductive therapy, in the absence of high risk disease, is unclear. We recommend cytoreductive therapy in the form of interferon alpha in all high risk and select low-risk ET and PV patients with history of recurrent fetal loss, prominent splenomegaly or suboptimal hematocrit control with phlebotomy. In addition, all women with PV should maintain strict hematocrit control <45% with the aid of phlebotomy. Systemic anticoagulation with low molecular weight heparin is advised in patients with history of venous thrombosis. Further clarification awaits prospective clinical trials that implement risk adapted therapeutic interventions.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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Tremblay D, Kosiorek HE, Dueck AC, Hoffman R. Evaluation of Therapeutic Strategies to Reduce the Number of Thrombotic Events in Patients With Polycythemia Vera and Essential Thrombocythemia. Front Oncol 2021; 10:636675. [PMID: 33665170 PMCID: PMC7921696 DOI: 10.3389/fonc.2020.636675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/30/2020] [Indexed: 12/13/2022] Open
Abstract
Thrombosis is the largest contributor to morbidity and mortality in patients with polycythemia vera (PV) and essential thrombocythemia (ET). Our understanding of the risk factors and pathophysiology of thrombosis in PV and ET patients is developing, including recent insights into the role of aberrant platelet-neutrophil interactions, JAK2 mutated endothelial cells and the pro-thrombotic inflammatory milieu. To date, few available therapies have demonstrated the ability to reduce the thrombotic burden in patients with these diseases. Although numerous therapeutic agents have been investigated in both PV and ET patients, few studies are designed to assess their impact on thrombotic events. In this review, we first describe the burden of thrombosis in patients with these myeloproliferative neoplasms (MPNs) and briefly explore their pathophysiologic mechanisms. We then critically assess and summarize the evidence behind currently available therapies with attention toward thrombotic endpoints. Finally, we describe a path forward for clinical research in MPNs that involves surrogate endpoint validation, biomarker development, and clinical trial design strategies in order to accurately assess reduction of thrombotic events when evaluating novel therapies.
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Affiliation(s)
- Douglas Tremblay
- Hematology/Oncology Section, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Heidi E. Kosiorek
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, United States
| | - Amylou C. Dueck
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, United States
| | - Ronald Hoffman
- Hematology/Oncology Section, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Falanga A, Marchetti M, Schieppati F. Prevention and Management of Thrombosis in BCR/ABL-Negative Myeloproliferative Neoplasms. Hamostaseologie 2021; 41:48-57. [PMID: 33588455 DOI: 10.1055/a-1334-3259] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Myeloproliferative neoplasms (MPNs) are clonal disorders of the hematopoietic stem cell. Classical BCR/ABL-negative MPNs include polycythemia vera (PV), essential thrombocythemia (ET), and primary myelofibrosis (PMF). Thrombotic events are a major cause of morbidity and mortality in these patients. Pathogenesis of blood clotting activation involves various abnormalities of platelets, erythrocytes, and leukocytes, as well as dysfunctions of endothelial cells. Patients with MPN can be stratified in "high risk" or "low risk" of thrombosis according to established risk factors. ET and PV clinical management is highly dependent on the patient's thrombotic risk, and a risk-oriented management strategy to treat these diseases is strongly recommended. In this review, we give an overview of risk factors, pathogenesis, and thrombosis prevention and treatment in MPN.
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Affiliation(s)
- Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy.,University of Milano-Bicocca, Department of Medicine and Surgery, Monza, Italy
| | - Marina Marchetti
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Francesca Schieppati
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
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Abstract
More than a century after its synthesis, daily aspirin, given at a low dose, is a milestone treatment for the secondary prevention of cardiovascular disease (CVD). Its role in primary prevention of CVD is still debated. Older randomized controlled trials showed that aspirin reduced the low incidence of myocardial infarction but correspondingly increased the low incidence of serious gastrointestinal bleeds without altering mortality. More recent trials see the benefit attenuated, perhaps obscured by other cardioprotective practices, while the bleeding risk remains, especially in older patients. Indirect evidence, both preclinical and clinical, suggests that aspirin may protect against sporadic colorectal cancer and perhaps other cancers. However, further studies are still necessary to warrant the consumption of aspirin for primary prevention of CVD and cancer by apparently healthy individuals.
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Affiliation(s)
- Emanuela Ricciotti
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA; , .,Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Garret A FitzGerald
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA; , .,Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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46
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Abstract
Essential thrombocythemia (ET) is a chronic myeloproliferative neoplasm characterized by a persistently elevated platelet count in the absence of a secondary cause. The clinical consequences of uncontrolled thrombocytosis can include both thrombosis and hemorrhage. Patients with features conferring a “high risk” of vascular events benefit from reduction of the platelet count through cytoreductive therapy. The management of patients who lack such high-risk features has until recently been less well defined, but it is now apparent that many require minimal or even no intervention. In this review, we discuss the diagnostic pathway for younger patients with unexplained thrombocytosis, including screening molecular investigations, the role of bone marrow biopsy, and investigations in those patients negative for the classic myeloproliferative neoplasm driver mutations (JAK2, CALR, MPL). We discuss conventional and novel risk stratification methods in essential thrombocythemia and how these can be best applied in clinical practice, particularly in the era of more comprehensive genomic testing. The treatment approach for “low risk” patients is discussed including antiplatelets and the options for cytoreductive therapy, if indicated, together with areas of clinical need for future study.
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Badimon L, Vilahur G, Rocca B, Patrono C. The key contribution of platelet and vascular arachidonic acid metabolism to the pathophysiology of atherothrombosis. Cardiovasc Res 2021; 117:2001-2015. [PMID: 33484117 DOI: 10.1093/cvr/cvab003] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/17/2020] [Accepted: 01/08/2021] [Indexed: 02/06/2023] Open
Abstract
Arachidonic acid is one of the most abundant and ubiquitous ω-6 polyunsaturated fatty acid, present in esterified form in the membrane phospholipids of all mammalian cells and released from phospholipids by several phospholipases in response to various activating or inhibitory stimuli. Arachidonic acid is the precursor of a large number of enzymatically and non-enzymatically derived, biologically active autacoids, including prostaglandins (PGs), thromboxane (TX) A2, leukotrienes, and epoxyeicosatetraenoic acids (collectively called eicosanoids), endocannabinoids and isoprostanes, respectively. Eicosanoids are local modulators of the physiological functions and pathophysiological roles of blood vessels and platelets. For example, the importance of cyclooxygenase (COX)-1-derived TXA2 from activated platelets in contributing to primary haemostasis and atherothrombosis is demonstrated in animal and human models by the bleeding complications and cardioprotective effects associated with low-dose aspirin, a selective inhibitor of platelet COX-1. The relevance of vascular COX-2-derived prostacyclin (PGI2) in endothelial thromboresistance and atheroprotection is clearly shown by animal and human models and by the adverse cardiovascular effects exerted by COX-2 inhibitors in humans. A vast array of arachidonic acid-transforming enzymes, downstream synthases and isomerases, transmembrane receptors, and specificity in their tissue expression make arachidonic acid metabolism a fine-tuning system of vascular health and disease. Its pharmacological regulation is central in human cardiovascular diseases, as demonstrated by biochemical measurements and intervention trials.
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Affiliation(s)
- Lina Badimon
- Cardiovascular Program-ICCC, Research Institute-Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain; CIBERCV, Instituto Salud Carlos III, Madrid, Spain.,Cardiovascular Research Chair Autonomous University of Barcelona (UAB), Barcelona, Spain
| | - Gemma Vilahur
- Cardiovascular Program-ICCC, Research Institute-Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain; CIBERCV, Instituto Salud Carlos III, Madrid, Spain
| | - Bianca Rocca
- Department of Bioethics and Safety, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy.,Gemelli' Foundation, IRCCS, Rome, Italy
| | - Carlo Patrono
- Department of Bioethics and Safety, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy.,Gemelli' Foundation, IRCCS, Rome, Italy
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Mainoli B, Duarte GS, Costa J, Ferreira J, Caldeira D. Once- versus Twice-Daily Aspirin in Patients at High Risk of Thrombotic Events: Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 2021; 21:63-71. [PMID: 32394295 DOI: 10.1007/s40256-020-00409-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acetylsalicylic acid (ASA) is a frequently used antiplatelet agent, although some individuals have reduced antiplatelet responses on ASA, with recurrent ischemic events. It has been proposed that shortening the ASA dosing interval may overcome the time-dependent renewal of the drug target, leading to a greater antiplatelet effect. We conducted a systematic review of randomized controlled trials (RCTs) to determine the efficacy of once- versus twice-daily ASA in conditions with increased platelet turnover. METHODS We conducted a systematic review and meta-analysis by searching the CENTRAL, MEDLINE, and Embase databases for RCTs assessing once- versus twice-daily ASA. Data were screened, extracted, and appraised by two independent reviewers, and were pooled using a random-effects model. The primary outcomes were major adverse cardiovascular events (MACEs) and serum thromboxane B2 (TxB2). Other pharmacodynamic measures were retrieved as secondary outcomes. Results were reported as mean differences with corresponding 95% confidence intervals (CIs). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Seven RCTs were included, enrolling 379 participants overall. None of the studies reported clinical outcomes. Pooled results showed that compared with once-daily ASA, twice-daily ASA was associated with a decrease in mean TxB2 of 1.42 ng/mL (95% CI - 2.71 to - 0.13; I2 = 66%). We found no differences in subgroup analyses based on disease subtype, trial blinding, or trial design. A greater antiplatelet activity of the twice-daily regimen was also found when using PFA-100-ADP methods, although not when using the VerifyNow, LTA-AA, and multiplate methods. CONCLUSIONS Twice-daily ASA was associated with a greater antiplatelet effect compared with standard once-daily ASA.
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Abstract
PURPOSE OF REVIEW Thrombocytosis is common to all myeloproliferative neoplasms (MPN), including essential thrombocythemia (ET), polycythemia vera (PV), and myelofibrosis. Despite the traditionally held belief amongst many clinicians that thrombocytosis correlates with thrombosis risk, there is little evidence in the literature to support that claim. Herein we critically analyze the literature to better understand the relationship between thrombocytosis and risk of thrombosis in MPN. RECENT FINDINGS Both retrospective and prospective studies argue against associations between thrombocytosis and risk of thrombosis in patients with ET and PV. Rather, most studies suggest that the presence of extreme thrombocytosis is instead associated with an increased risk of hemorrhagic events, a paradoxical phenomenon with important clinical implications. Thrombosis risk has a multifactorial set of etiologies in MPNs. While qualitative abnormalities of the platelets may contribute, associations between platelet quantity and thrombosis risk are weak in MPN patients.
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50
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Tefferi A, Barbui T. Polycythemia vera and essential thrombocythemia: 2021 update on diagnosis, risk-stratification and management. Am J Hematol 2020; 95:1599-1613. [PMID: 32974939 DOI: 10.1002/ajh.26008] [Citation(s) in RCA: 170] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022]
Abstract
DISEASE OVERVIEW Polycythemia vera (PV) and essential thrombocythemia (ET) are myeloproliferative neoplasms (MPN) respectively characterized by clonal erythrocytosis and thrombocytosis; other disease features include leukocytosis, splenomegaly, thrombosis, bleeding, microcirculatory symptoms, pruritus and risk of leukemic or fibrotic transformation. DIAGNOSIS Bone marrow morphology remains the cornerstone of diagnosis. In addition, the presence of JAK2 mutation is expected in PV while approximately 90% of patients with ET express mutually exclusive JAK2, CALR or MPL mutations (so called driver mutations). In ET, it is most important to exclude the possibility of prefibrotic myelofibrosis. SURVIVAL Median survivals are approximately 15 years for PV and 18 years for ET; the corresponding values for patients age 40 or younger were 37 and 35 years. Certain mutations (mostly spliceosome) and abnormal karyotype might compromise survival in PV and ET. Life-expectancy in ET is inferior to the control population. Driver mutations have not been shown to affect survival in ET but risk of thrombosis is higher in JAK2 mutated cases. Leukemic transformation rates at 10 years are estimated at <1% for ET and 3% for PV. THROMBOSIS RISK In PV, two risk categories are considered: high (age > 60 years or thrombosis history present) and low (absence of both risk factors). In ET, four risk categories are considered: very low (age ≤ 60 years, no thrombosis history, JAK2 wild-type), low (same as very low but JAK2 mutation present), intermediate (age > 60 years, no thrombosis history, JAK2 wild-type) and high (thrombosis history present or age > 60 years with JAK2 mutation). RISK-ADAPTED THERAPY The main goal of therapy in both PV and ET is to prevent thrombohemorrhagic complications. All patients with PV require phlebotomy to keep hematocrit below 45% and once-daily or twice-daily aspirin (81 mg), in the absence of contraindications. Very low risk ET might not require therapy while aspirin therapy is advised for low risk disease. Cytoreductive therapy is recommended for high-risk ET and PV, but it is not mandatory for intermediate-risk ET. First-line drug of choice for cytoreductive therapy, in both ET and PV, is hydroxyurea and second-line drugs of choice are interferon-α and busulfan. We do not recommend treatment with ruxolutinib in PV, unless in the presence of severe and protracted pruritus or marked splenomegaly that is not responding to the aforementioned drugs. NEW TREATMENT DIRECTIONS Controlled studies are needed to confirm the clinical outcome value of twice-daily vs once-daily aspirin dosing and the therapeutic role of pegylated interferons and direct oral anticoagulants.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota
| | - Tiziano Barbui
- Research Foundation Papa Giovanni XXIII Hospital Bergamo Italy
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