Adult Primary Immune Thrombocytopenia Patients Research Articles

Fibrinolysis is impaired in patients with primary immune thrombocytopenia

BackgroundPatients with primary immune thrombocytopenia (ITP) have an increased risk of thrombosis, which may be due to altered fibrinolysis. ObjectivesTo elucidate the clinical impact of delayed fibrinolysis in ITP patients. MethodsA turbidimetric clot formation and lysis assay and a fluorometric plasmin generation (PG) assay were performed, and levels of plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA), tPA-PAI-1 complexes, α2-antiplasmin, thrombin activatable fibrinolysis inhibitor, and D-dimer were assessed in 86 adult primary ITP patients and 78 healthy controls (HCs). ResultsITP patients showed significantly delayed clot formation, increased clot density, and prolonged clot lysis time (CLT) compared with HCs, with a median (IQR) CLT of 28.0 (13.7-34.7) minutes in patients and 17.3 (12.0-28.0) minutes in HCs, while in the PG assay, only the lag time was prolonged. In ITP patients compared with controls, PAI-1 was higher (1.2 [0.8-2.6] vs 1.1 [0.6-2.1] U/mL) and tPA antigen and activity were lower (tPA antigen: 2.6 [1.1-4.4] vs 3.7 [3.2-4.7] ng/mL; tPA activity ≤ 0 U/mL: 26% vs 7%). TPA-PAI-1 complex levels were positively associated with CLT in multiple linear regression analysis (β = 0.241; P = .019), whereas PG parameters were not associated with CLT. Six patients who developed thrombosis during follow-up had higher levels of tPA-PAI-1 complexes. ConclusionProlonged CLT and delayed onset of PG may indicate a hypofibrinolytic tendency in ITP patients, as also indicated by high PAI-1 and low tPA levels. No association was found between fibrinolytic potential and the bleeding phenotype, whereas higher tPA-PAI-1 complex levels were associated with prolonged CLT and increased in patients with future thrombosis.

Plasma long noncoding RNAs lncDC and THRIL as potential diagnostic markers of adult primary immune thrombocytopenia.

Immune thrombocytopenia (ITP) is a common acquired hemorrhagic disease without "gold standard" for the diagnosis, long non-coding RNA (lncRNAs) can participate in regulating gene expression through various mechanisms and may play a role in immune intolerance in ITP. Several previous studies have confirmed that lncRNA lncDC and THRIL are involved in the development of autoimmune diseases. This study investigates the relationship between expression levels of two plasma lncRNAs (lncDC and THRIL) and clinical characteristics of adult primary ITP patients, ascertain their potential applications as diagnostic markers of ITP. We recruited 102 subjects, including 41 ITP patients, 41 healthy controls (HCs) and 20 patients under myelosuppression phase after chemotherapy (MS). qRT-PCR was used to detect the expression of two lncRNAs in the peripheral blood plasma of the three groups. Receiver operating characteristic (ROC) curves were used to test the diagnostic efficacy of lncDC and THRIL in ITP. The expression level of lncDC was downregulated in ITP patients compared with HCs (p=. 012) and MS (p=.035), whereas THRIL was significantly upregulated (p=.0005, p < . 0001). We further revealed that lncDC has a high sensitivity (78. 05%), while THRIL has a high specificity (97. 56%). The area under the curve (AUC) (0.869, 95% CI: 0.795-0.943, p < .0001) of the ROC curve for this combination increased significantly. THRIL and lncDC expression levels were changed in adult ITP patients. The lncRNAs lncDC and THRIL can serve as potential diagnostic markers for adult primary ITP.

Intermittent versus Daily Eltrombopag Dosage Protocols for the Treatment of Primary Immune Thrombocytopenia: Real-Life Experience

Introduction/AimEltrombopag is recommended for the treatment of refractory immune thrombocytopenia (ITP). Based on its half-life, it may be practical to use an intermittent dosage. Our aim was to compare the effectiveness and safety of intermittent vs daily eltrombopag dosage protocols for the treatment of primary ITP refractory to prior therapies.Patients and MethodsThis was a retrospective study, and 34 adult primary ITP patients refractory to prior therapies were included in our analysis. Eltrombopag was used in this study. The patients were divided into daily eltrombopag dosage and intermittent eltrombopag dosage groups. Eltrombopag effectiveness was assessed regarding platelet count and bleeding resolution. Safety was assessed via adverse events reporting.ResultsIn the daily eltrombopag dosage group, overall response (OR), complete response (CR), partial response (PR), and relapse rates were 69.23%, 53.85%, 15.38%, and 30.77%, respectively. In the intermittent eltrombopag dosage group, OR, CR, PR, and relapse rates were 68.75%, 50%, 18.75%, and 31.25%, respectively. Comparison between daily and intermittent eltrombopag dosage groups as regards CR, PR, relapse, relapse-free survival and adverse events showed insignificant differences.ConclusionIntermittent eltrombopag dosage is safe and effective in patients with ITP refractory to prior therapies and comparable to the daily eltrombopag dosage.

Gut Microbiome and Metabolome Were Altered and Strongly Associated With Platelet Count in Adult Patients With Primary Immune Thrombocytopenia.

Gut microbiota has been implicated in the pathogenesis of many autoimmune diseases. This is still an area of active research given that the role of gut microbiota on the primary immune thrombocytopenia (ITP) remains unclear. In this study, fecal samples of 30 untreated adult primary ITP patients and 29 healthy controls (HCs) were used to investigate the gut microbial community and metabolite profiles. Our results show that fecal bacteria such as Blautia, Streptococcus, and Lactobacillus are enriched, whereas bacteria such as Bacteroides are depleted in ITP patients. Notably, fecal metabolites such as fatty acyls and glycerophospholipids are enriched and strongly correlate with discrepant gut microbiota. Furthermore, combinations of Weissella and Streptococcus anginosus, or Cer (t18:0/16:0), Cer (d18:1/17:0), and 13-hydroxyoctadecanoic acid could provide good diagnostic markers for ITP. Moreover, a strong negative correlation was found between platelet count and altered gut microbiota such as S. anginosus and gut metabolites such as Cer (t18:0/16:0) in ITP. In conclusion, dysbiosis of both gut microbiota and metabolome develops in ITP patients compared to HCs. Several ITP-altered gut bacteria and metabolites can be diagnostic biomarkers for ITP, and are highly correlated with platelet count, suggesting that they may also play a role in ITP pathogenesis.

Mean platelet volume and response to the first line therapy in newly diagnosed adult immune thrombocytopenia patients: a retrospective study

Background/aim Immune thrombocytopenia (ITP) is treated by corticosteroids and/or intravenous immune globulin as the first line treatment when necessary. Mean platelet volume (MPV) is a marker of platelet production and function. In this study, we aimed to search the relationship between the MPV and the treatment response in ITP patients and it was hypothesized that MPV can be used as a predictor of the response.Materials and methods The 70 newly diagnosed adult primary ITP patients and 70 of healthy people were included. MPV between ITP and healthy population, MPV in the diagnosis and after the treatment between the responders and the nonresponders were compared. ResultsThe responders had significantly higher MPV and the nonresponders had significantly lower MPV than the healthy population (11.09 and 10.21 fL, P = 0.03; 9.38 and 10.21 fL, P = 0.001). MPV in the diagnosis was significantly higher in the responders than the nonresponders (11.09 and 9.38 fL, P = 0.005). MPV significantly changed after the treatment in the responders (11.09 to 9.32 fL, P = 0.004). ConclusionMPV can be used as a predictor of early response to the first line treatment in newly diagnosed adult primary ITP patients.

PS1580 PREVALENCE AND RISK FACTORS FOR THROMBOSIS IN ADULT ITP PATIENTS TREATED WITH TPO‐RA

Background:Thrombopoietin‐receptor‐agonists (TPO‐RA) are effective treatments of immune thrombocytopenia (ITP). Previous long‐term TPO‐RA clinical trials have shown that thrombotic events occurred in 6% of TPO‐RA‐treated ITP patients, with thrombotic events appearing to be more frequent in patients of older age and having at least 1 general risk factor for thrombosis.Aims:To evaluate the prevalence of venous and arterial thrombosis in patients with primary ITP during treatment with TPO‐RA.Methods:Multicenter retrospective study that included 121 adult primary ITP patients from 19 secondary and tertiary Spanish hospitals who had initiated treatment with Romiplostim (ROM) or Eltrombopag (ELT) as long‐term therapy between January 2012 and December 2014. Information on patient characteristics was collected from medical records to assess and compare risk factors of ITP patients with and without vascular events (VE).Results:A total of 121 patients (median age 63 years, range 19–96 years; 68% chronic phase), initiated TPO‐RA (ROM 54; EPG 67). During a 329.3 patient‐year time under treatment (exposure to ROM and ELT of 161.03 and 168.27 patient‐year, respectively) 15 patients experienced 17 vascular episodes (9 arterial, 8 venous). One patient presented antiphospholipid antibodies, five had been diagnosed with neoplasia, one with vascular peripheral disease, two with hypothyroidism –one of whom also had renal disease‐. Seven events occurred with ROM, and 10 with ELT. The annualized risk was 4.2 and 5.9 VE/100 patient‐years in ROM and ELT treated patients, respectively (median 5.2). Most VE occurred in the first year of TPO‐RA therapy (median 276 days; 5–1183), with a trend toward earlier events under ROM than ELT (127 days vs 360 days, respectively; p = 0.070). In the case of ischemic events the median time to arterial events was 165 vs. 606 days in ROM and ELT treated patients; P = 0.029. There were no significant differences in the 15 patients vs. the 106 patients that did not suffer from vascular events in terms of gender, age, diabetes, hypertension, previous vascular events, nor time on prednisone as 1st line therapy. In patients experiencing VE on TPO‐RA, a significant association with previous splenectomy (53.3% vs. 25.5%, P = 0.026), and chronic phase of the disease (93.3% vs. 64.1%, P = 0.024) compared with those not having such characteristic was detected. Surprisingly previous malignancy significantly associated with VE under TPO‐RA treatment (33% vs. 2.8%, P = 0.000009). All patients were reported to have sustained complete remission of previous neoplasias (1 colon carcinoma; 1 Burkitt lymphoma; 1 bladder cancer; 1 breast cancer; 1 patient with history of thyroid, breast and ovarian tumors) and were not receiving antineoplastic therapies. In multivariate analysis with logistic regression only previous malignancy predicted significantly higher odds of VE (Table 1).Summary/Conclusion:In this study, we describe an annualized risk of 5.2 vascular events/100 patient‐years in TPO‐RA treated patients. Venous and arterial thromboembolism are not frequent complications in ITP patients under TPO‐RA, except in particular settings, such as in splenectomized and chronic patients. Our data revealed a novel association of history of previous neoplasia with thrombotic events in patients with TPO‐RA. These results suggest that a history of prior cancer should be systematically screened before TPO‐RA initiation, and if so, alternative therapy should be considered; however, due to the limited sample size, further research is warranted.image

PF339 BIOLOGICAL AND CLINICAL FACTORS THAT FAVOR THE USE OF A SPECIFIC TPO‐RA IN ITP PATIENTS. RESULTS FROM A SPANISH MULTICENTER STUDY

Background:To date there are no head‐to‐head randomized controlled trials comparing romiplostim (ROM) with eltrombopag (ELT) for the management of patients with primary immune thrombocytopenia (ITP). Having different routes of administration, which is the best choice of a thrombopoietin receptor agonist (TPO‐RA) for an individual patient is not clear.Aims:To analyze biological and clinical factors leading physicians and/or patients to the use of a particular TPO‐RA.Methods:We collected retrospectively the clinical data of 146 adult primary ITP patients who had initiated treatment with ROM or ELT between January 2012 and December 2014. Data on patient characteristics were collected from medical records in a multicenter study from 19 secondary and tertiary Spanish hospitals.Results:A minority of patients (n = 25) started TPO‐RA as short‐term therapy with an intention to treat of &lt;2 months (14 ROM, 11 ELT). The most frequent single indication for a transient use of TPO‐RA was to increase platelet counts before a scheduled surgery; all patients (n = 6) received ROM in this scenario. No differences were observed between ROM and ELT in terms of sex, baseline platelet counts, time to achieve platelets &gt;50x109/l, nor maximal platelet counts after short‐time TPO‐RA treatment. The majority of patients (n = 121, median age 63 years; range 19–96 years; 58.7% female) initiated TPO‐RA as long term treatment (ROM 54; ELT 67). Sixty‐eight percent of the patients met criteria for chronic, 16% for newly diagnosed and 16% for persistent ITP. There was a trend towards a preferential use of ELT in patients ≥65years (52.2% vs. 35.2% for ROM, P = 0.061). Neither gender, liver disease, history of previous neoplasia or vascular events, phase of the disease, or responses to earlier lines of therapy associated with the choice of TPO‐RA. We assessed the bleeding severity both at diagnosis and before initiation of TPO‐RA therapy according to the Page score (Br J Haematol. 2007;138:245–8). In univariate analysis, ROM was preferentially given to patients presenting with bleeding symptoms at diagnosis (66.7% of those receiving ROM) compared to 41.8% of bleeders among those receiving ELT (P = 0.006). The cumulative bleeding scale at diagnosis was also higher in those patients elected for treatment with ROM than ELT (median bleeding score at diagnosis 2 vs. 0, p = 0.003). At the time when TPO‐RA was initiated, the risk of hemorrhage (platelet counts 18x109/l vs. 25 x109/l for ROM and ELT, respectively; P = 0.014), and bleeding manifestations (bleeding score of 1 and 0 for ROM and ELT, respectively; P = 0.037) were also correlated with the selection of TPO‐RA. Additionally, six months before the start of TPO‐RA, the requirement for hospital care (emergency treatment or hospital admission) was higher in patients that were subsequently treated with ROM than those elected for ELT (55.6% vs. 31.8%, P = 0.009). In multivariate analysis with logistic regression, platelet counts before TPO‐RA and the need for hospital care 6 months before TPO‐RA correlated with the selection of TPO‐RA (Table 1).Summary/Conclusion:Our study shows a trend towards the use of ELT in older patients, but no influence of other patient characteristics, or previous therapies on the choice of TPO‐RA. While previous indirect data comparing ROM and ELT suggest that there is no substantial difference in the efficacy of these agents, real world data from this analysis indicates that the risk and severity of bleeding before starting TPO‐RA influences the selection of TPO‐RA in the clinical practice.image

High-Dose Dexamethasone Corrects the Elevated Level of IL-16 in Immune Thrombocytopenia

Introduction: Adult primary immune thrombocytopenia (ITP) is an autoimmune-mediated haemorrhagic disorder characterized by excessive platelet destruction and decreased platelet production. ITP patients have a Th1 dominant profile, which was involved in the pathogenesis of ITP. Interleukin-16 (IL-16) can directly affect cellular or humoral immunity by mediating the cellular cross-talk among T cells, B cells and dendritic cells. Several studies have focused on IL-16 as an immunomodulatory cytokine that takes part in Th1 polarization in autoimmune diseases, but the roles of IL-16 in ITP remain unknown. Treatment with high-dose dexamethasone (HD-DXM) as a single-agent for four days has been widely recognized as the first-line therapy for ITP patients in need of clinical management. The aim of this study is to investigate the roles of IL-16 and effect of HD-DXM on IL-16 in ITP.Methods: We investigated the differences in IL-16 expression in the bone marrow and peripheral blood between ITP patients and healthy controls by ELISA. The mRNA expression of pro-IL-16, caspase-3 and T-bet in active ITP patients and healthy controls were quantified by real-time PCR. Furthermore, we detected changes in IL-16 concentration and gene expression before and after the 4-day HD-DXM therapy. Bone marrow samples were obtained from 23 patients and 10 healthy bone marrow donors, and peripheral blood samples were obtained from 64 patients (among them, 21 received single-agent HD-DXM therapy, the peripheral blood samples were obtained before HD-DXM therapy and 28 days after HD-DXM administration) and 38 healthy blood donors. Adult primary ITP patients with active disease were enrolled in this study between May 2015 and January 2018 at the Department of Haematology, Qilu Hospital, Shandong University, Jinan, China.Results: The concentration of IL-16 in the bone marrow supernatants and plasma of active ITP patients was significantly higher compared with that of the healthy controls (P < 0.05) (Fig. 1A, B). Gene expression of pro-IL-16 and caspase-3 in bone marrow mononuclear cells (BMMCs) in ITP patients elevated compared with healthy controls (P < 0.05) (Fig. 2A). Besides, gene expression of pro-IL-16, caspase-3 and T-bet in peripheral blood mononuclear cells (PBMCs) in ITP patients elevated (P < 0.05) (Fig. 2B). Among the 21 patients which received single-agent HD-DXM therapy, 18 responded effectively to the HD-DXM therapy according to the standard definition. The post-treatment plasma (n=21) IL-16 level decreased significantly compared with that of pre-treatment level (P < 0.05), and the level of IL-16 in the plasma of ITP patients before and after HD-DXM treatment was significantly higher than that of healthy controls (P < 0.05) (Fig. 1C). There was no correlation between IL-16 levels in the bone marrow supernatant or plasma and platelet count (data not shown). In addition, pro-IL-16, caspase-3, T-bet mRNA expression was significantly decreased after treatment with HD-DMX (P < 0.05) (Fig. 2C), although the corresponding values in patients were not statistically higher than those of healthy controls. The correlation between the plasma IL-16 concentration and pro-IL-16, caspase-3 and T-bet mRNA levels was also analysed in ITP patients (n = 21). The results demonstrated that the mRNA levels of the three detected factors were positively correlated with plasma IL-16 concentration (r2 = 0.5846, P < 0.05, r2 = 0.3980, P < 0.05 and r2 = 0.3145, P <0.05 for pro-IL-16, caspase-3 and T-bet, respectively) (Fig. 2D-F).Conclusions: ITP is an autoimmune disorder; complex interactions among antigen-presenting cells, T cells and B cells are pivotal to its pathogenesis. Our data suggest that IL-16 plays an important role in the pathogenesis of ITP by polarization of Th1. Furthermore, by modulating the abnormal IL-16 level associated with the Th1 imbalance via treatment with pulsed HD-DXM provided us with new insights into the immune regulatory mechanisms for the treatment of ITP. In our future study, we will use an in vitro study system to test and verify if the anti-IL-16 antibody can be used to treat adult ITP. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Alternate use of thrombopoietin receptor agonists in adult primary immune thrombocytopenia patients: A retrospective collaborative survey from Italian hematology centers.

Sequential use of the TPO-RAs romiplostim and eltrombopag in ITP patients failing either agent was retrospectively evaluated to assess efficacy and impact of clinical characteristics on outcome. Patients were grouped into 5 categories: efficacy issues: 1st TPO-RA failure; loss of response; non-efficacy issues: platelet fluctuations; patient's preference; adverse event development. Either one TPO-RA sequence was analyzed at 3 month and at last follow-up. 106/546 patients on TPO-RA underwent switch and 65% achieved, regained or maintained a short- term response independent of switch sequence, gender or age; lower response rates were associated with lines of previous therapy; disease duration lowers probability to respond. Clinically, patients switched for efficacy issue did not differ from those switched for non-efficacy issues. Response was achieved/regained in 57.8% of patients switched for efficacy issues, the lowest response rates were observed in non-responders to 1st TPO-RA; 80% of patients switched for non-efficacy issues maintained a response. Platelet fluctuation resolved in 44.4%. Of the 49 patients evaluable for long-term outcome, 27 were in response on therapy; 16 discontinued the TPO-RA for reasons other than efficacy, while only 6 were non responders. We confirm the efficacy of TPO-RA switch; once achieved, response to the 2nd TPO-RA seems durable.

Thrombopoietin receptor agonist switch in adult primary immune thrombocytopenia patients: A retrospective collaborative survey involving 4 Spanish centres.

To describe the reasons for and result of thrombopoietin receptor agonists (TPO-RA) switching in adult immune thrombocytopenia (ITP) patients of 4 Spanish centres. We retrospectively analysed all patients who received sequential treatment with both TPO-RA between 2010 and 2015 recording clinical and biological parameters. Twenty-six patients were included; 17 received first romiplostim and 9 received first eltrombopag. Reasons for switching were inefficacy (n=10), patient preference (n=8), side effects (n=5) and excessive platelet count fluctuation (n=3). When the switch was due to inefficacy, 100% of patients who received romiplostim first and 66% who received eltrombopag first responded to the second drug. It is significant that none of the patients who received romiplostim first reached the maximum recommended dose before switching. When the change was due to patient preference or because of side effects, 100% of the patients responded to both TPO-RA. Three patients changed from romiplostim to eltrombopag due to platelet count fluctuation; one did not respond and the fluctuation persisted in the remaining 2 patients. We also found 4 sustained remissions after administering the second TPO-RA, 2 of these with inefficacy of the first drug. TPO-RA switching is a feasible strategy in different scenarios with high probability of success.

Megakaryocyte Apoptosis in the Bone Marrow of Patients with Immune Thrombocytopenia

Introduction: Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder in which autoantibodies promote the destruction and underproduction of platelets. Recent evidence suggests that immune-mediated destruction of bone marrow megakaryocytes is associated with the pathogenesis of this disease. In addition, the attenuation of megakaryocyte apoptosis can lead to platelet underproduction since this process appears to be involved in thrombopoiesis. In the current study, we investigated megakaryocyte apoptosis as a possible mechanism in the pathogenesis of ITP.Patients/Methods: Bone marrow biopsy sections from ITP patients and controls were stained with anti-human CD61 to enumerate megakaryocytes. Terminal deoxynucleotidyl transferase (TdT) dUTP Nick-End Labeling (TUNEL) staining was performed as a measure of megakaryocyte apoptosis. The samples were coded and reviewed by an experienced hematopathologist who was blinded to the diagnosis. Adult primary ITP patients had isolated thrombocytopenia with no underlying cause and a platelet count less than 100 x109/L at the time of bone marrow biopsy procurement. Patients with secondary ITP (in the context of medications, lymphoproliferative disease, HIV, hepatitis B or C infection) were excluded, as were patients who received prior treatment with thrombopoietin receptor agonists or other hematopoietic growth factors. Thrombocytopenic controls were patients with myelodysplastic syndrome (MDS) who had platelet counts below 100 x109/L. Control patients with normal platelet counts had bone marrow biopsies performed as part of investigations for lymphoma or plasma cell dyscrasia with negative test results.Results: The average platelet count for ITP patients, MDS patients, and controls were 18 x109/L (range 2-76 x109/L), 29 x109/L (range 9-60 x109/L), and 281 x109/L (range 171-400 x109/L), respectively. Elevated megakaryocyte counts were observed in the bone marrow sections of 5/14 (36%) ITP patients, 0/8 (0%) MDS patients, and 2/11 (18%) controls. Megakaryocyte apoptosis was comparable between ITP patients and MDS patients [2/14 (14%) vs 1/8 (13%) (p=1.00)], while fewer ITP patients exhibited megakaryocyte apoptosis compared to controls with normal platelet counts [2/14 (14%) vs 7/11 (64%) (p=0.02)]. In the entire study cohort, the average platelet counts of patients with negative and positive TUNEL staining were 66 x109/L (range 2-378 x109/L) and 206 x109/L (range 20-400 x109/L), respectively (p=0.01). In addition, the normalized megakaryocyte counts (per high powered field) were 8.2 ± 5.5 and 5.4 ± 2.5 in patients with negative and positive TUNEL staining, respectively (p=0.05).Conclusion: Megakaryocyte apoptosis was reduced in ITP bone marrow samples compared to controls with normal platelet counts, but was also low in thrombocytopenic MDS patients. Reduced megakaryocyte apoptosis was found to be associated with a low platelet count, and may be related to thrombocytopenia regardless of etiology. Our study is consistent with the hypothesis that attenuated megakaryocyte apoptosis is relevant in the context of platelet underproduction in ITP. DisclosuresArnold:Novartis: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy; UCB: Consultancy; Amgen: Consultancy, Research Funding.

Successful discontinuation of eltrombopag after complete remission in patients with primary immune thrombocytopenia.

Eltrombopag is effective and safe in immune thrombocytopenia (ITP). Some patients may sustain their platelet response when treatment is withdrawn but the frequency of this phenomenon is unknown. We retrospectively evaluated 260 adult primary ITP patients (165 women and 95 men; median age, 62 years) treated with eltrombopag after a median time from diagnosis of 24 months. Among the 201 patients who achieved a complete remission (platelet count >100 × 10(9) /l), eltrombopag was discontinued in 80 patients. Reasons for eltrombopag discontinuation were: persistent response despite a reduction in dose over time (n = 33), platelet count >400 × 10(9) /l (n = 29), patient's request (n = 5), elevated aspartate aminotransferase (n = 3), diarrhea (n = 3), thrombosis (n = 3), and other reasons (n = 4). Of the 49 evaluable patients, 26 patients showed sustained response after discontinuing eltrombopag without additional ITP therapy, with a median follow-up of 9 (range, 6-25) months. These patients were characterized by a median time since ITP diagnosis of 46.5 months, with 4/26 having ITP < 1 year. Eleven patients were male and their median age was 59 years. They received a median of 4 previous treatment lines and 42% were splenectomized. No predictive factors of sustained response after eltrombopag withdrawal were identified. Platelet response following eltrombopag cessation may be sustained in an important percentage of adult primary ITP patients who achieved CR with eltrombopag. However, reliable markers for predicting which patients will have this response are needed.

Exposure to Corticoid-Sparing Treatments in Adult Primary Immune Thrombocytopenia before the Chronic Phase in the Era of Thrombopoietin Receptor Agonists in France. a Nationwide Population-Based Study

Objectives:The aim of this study was to describe the exposure to corticoid-sparing treatments (CST) in adult primary immune thrombocytopenia (ITP) patients during the year before the chronic phase at a nationwide level in the era of thrombopoietin-receptor agonists (TPO-RAs).Methods:Study population was the 2009-2011 cohort of the French Adult Immune Thrombocytopenia: a French pHarmacoepidemiological study (FAITH, n°ENCEPP/SDPP/4574). The FAITH cohort is the cohort of all incident persistent or chronic adult primary ITP patients treated in France, built through the nationwide French health insurance database, named SNIIRAM. It collects prospectively all data regarding hospitalizations, disabling diseases, drug and procedure reimbursements. They are linkable with demographic data. On the 2009-2011 SNIIRAM data, ITP patients were identified with hospital and disabling disease diagnosis codes (D69.3 code of the International Classification of diseases, version-10). The date of diagnosis was refined thanks to out-hospital drug exposures. Secondary ITPs were excluded thanks to diagnosis codes of diseases associated to ITP, searched in the year before and the semester after the diagnosis. We restricted to incident patients, excluding those with a diagnosis during the first semester of the study, and then to patients followed at least 12 months and with at least one exposure to CST during the year after the diagnosis.Exposure to CST was searched through out-hospital dispensing, and during hospital stays for splenectomy, rituximab and polyvalent intravenous immunoglobulins (IVIg). A single dispensing defined exposure, except for IVIg (3 monthly dispensing were mandatory to differentiate IVIg used as CST from acute exposure to treat a serious bleeding). We described the percentage of patients exposed to the distinct CST at least once during the year after ITP diagnosis and detailed the lines of therapy. We compared the patients aged <65 years and those ≥65 years.Results:Out of 2334 adult incident primary ITPs, 1556 were persistent or chronic. Among them, 443 patients were followed at least one year after ITP diagnosis and were exposed to at least one CST during this period. Mean age was 52.7 ± 20.8 years and 59.1% of the patients were females. Patients aged ≥65 years had more frequently mucosal or internal bleeding at ITP onset, and had a higher Charlson’s comorbidity score. Mean time from diagnosis to CST was 3.5 months.CSTs used in >10% of the patients at any time during the year after ITP diagnosis were, by decreasing frequency: rituximab (57.8%), splenectomy (22.1%), TPO-RAs (16.8%), IVIg (15.0%), danazol (14.4%) and dapsone (10.8%). Hydroxychloroquine was used in 6.5% of the patients and immunosupressant (azathioprine, mycophenolate or ciclosporin) in 5.9%. The CST the most frequently used was rituximab in both age groups. Splenectomy was more frequently used in patients aged less than 65 years (25.2% versus 16.4%, p=0.03). In contrast, TPO-RAs and dapsone were more frequently used in patients aged over 65 years (respectively, 24.8% versus 12.8%, p=0.01, and 17.6% versus 7.2%, p=0.0008).The mean number of lines of therapy after corticosteroids was 1.5 (extremes: 1-6) and was not different between the two age groups.As regards CSTs used in second line after corticosteroids, rituximab was the most used (45.4%), followed by IVIg (12.0%), splenectomy (11.3%), danazol (10.1%), dapsone (7.9%) and TPO-RAs (6.3%). There were discrepancies according to the age groups: 11.8% of the patients aged ≥65 years had been exposed to TPO-RAs as second-line compared with 3.5% of younger patients (p=0.0006). Similarly, dapsone was more frequently used as second-line treatment in older patients (13.8% versus 5.2%, p=0.0003), while splenectomy was more frequently used in patients aged <65 years (13.8% versus 6.5%, p=0.02). When detailing the successive lines of therapy, the use of rituximab decreased, while the use of splenectomy and TPO-RA increased in both age groups.Conclusions: Rituximab was the leading CST used as second and third line of therapy in adult primary ITP before the chronic phase in France, whatever the age group. TPO-RAs have modified treatment strategy of persistent primary ITP as soon as they have been marketed. They were mainly used in accordance with their labeling (after two lines of treatment including corticosteroids). DisclosuresNo relevant conflicts of interest to declare.

Exposure to non-corticosteroid treatments in adult primary immune thrombocytopenia before the chronic phase in the era of thrombopoietin receptor agonists in France. A nationwide population-based study

The objective of this study was to describe the exposure to non-corticosteroid treatments in adult primary immune thrombocytopenia (ITP) patients before the chronic phase at a nationwide level.Study population is derived from the 2009–2011 cohort of the French Adult Immune Thrombocytopenia: a French pHarmacoepidemiological study (FAITH, no. ENCEPP 4574). The FAITH cohort includes all incident and persistent or chronic adult primary ITP patients treated in France. It was built through the nationwide French health insurance database, called SNIIRAM. For the present study, we included FAITH patients who were followed by at least 12months and who had at least one exposure to a non-corticosteroid treatment before the ITP chronic phase. Exposure to non-corticosteroid treatments was searched through in- and out-hospital dispensing. Predictors of the choice among first-line non-corticosteroid treatments (rituximab, splenectomy or other drugs) were studied using a multinomial regression.The study population included 443 patients. Non-corticosteroid treatments used in more than 10% of the patients at any time before the chronic phase were: rituximab (57.8%), splenectomy (22.1%), TPO-RAs (16.8%), repeated intravenous immunoglobulin (IVIg) courses (15.0%), danazol (14.4%) and dapsone (10.8%). Rituximab was the most used first-line non-corticosteroid treatment (45.4%). TPO-RAs and dapsone were more frequently used after 65years of age (respectively, 24.8% versus 12.8%, p=0.01 and 17.6% versus 7.2%, p=0.0008), unlike splenectomy (16.4% versus 25.2%, p=0.03). Age over 65years was the sole independent predictor of first-line non-corticosteroid treatment choice.In conclusion, rituximab was the leading non-corticosteroid treatment used before the chronic phase. TPO-RAs were mainly used in accordance with their labeling. IVIgs were consistently used as a chronic non-corticosteroid treatment.

TNF-α promoter single nucleotide polymorphisms and haplotypes associate with susceptibility of immune thrombocytopenia in Chinese adults

ObjectiveTumor necrosis factor-alpha (TNF-α) participates as a candidate susceptibility factor for immune thrombocytopenia (ITP). This study attempted to investigate the association between five single nucleotide polymorphisms (SNPs) spanning the TNF-α promoter and the susceptibility of primary ITP in Chinese Han adults. MethodsIn 215 adult primary ITP patients and 206 healthy controls, SNPs were detected by PCR-RFLP and PCR-SSP. The χ2 test or fisher’s exact test was used to compare frequencies of genotypes and alleles between patients and controls. Haplotypes were analyzed with the SHEsis online program. TNF-α, IFN-γ and Galectin-9 mRNA of 35 newly diagnosed adult ITP patients and 35 healthy controls were detected by qRT-PCR. ResultsThe haplotype GGC (−238G/−308G/−857C) of TNF-α promoter was significantly associated with a decreased susceptibility of primary ITP, especially in males. The relative levels of mRNA expression of TNF-α, IFN-γ and Gal-9 in adult active primary ITP patients was significantly up-regulated compared with patients in remission and controls. ConclusionsThis study represented the first report that the haplotype GGC of TNF-α was differentially associated with the susceptibility of primary ITP in Chinese Han adults. The up-regulation of TNF-α, IFN-γ and Galectin-9 was significantly correlated with active primary ITP in adult patients.

Aberrant frequency of IL-10-producing B cells and its association with Treg/Th17 in adult primary immune thrombocytopenia patients.

Background. Regulatory B cells (Breg) are a distinct B cell subset with immunoregulatory properties. Pivotal to Breg function is interleukin-10. This study was to investigate the role of IL-10-producing B cell (B10) and its association with Treg and Th17 subsets in immune thrombocytopenia (ITP) patients. Methods. Peripheral blood mononuclear cells from ITP patients and controls were stimulated with PMA, ionomycin, and Brefeldin A. The frequencies of CD19+IL-10+ B cells, CD3+CD4+IL-17+ Th17 cells, and CD4+CD25hiFoxp3+ Treg cells were analyzed by flow cytometry. The mRNA expression of Foxp3 and RORγt was detected by real-time quantitative PCR. Results. The number of B10 cells was elevated in ITP patients. After first-line therapies, it remained at high level in patients who achieved complete or partial response but decreased in those who acquired no response. There was a positive correlation between B10 cells and Tregs in ITP both before and after therapies. The ratio of Treg/Th17 decreased in ITP, and it strongly correlated with B10 cells. Conclusions. The frequency of B10 cells is elevated in ITP and it correlates with both the Tregs counts and the Treg/Th17 ratio. B10 cells to regulate functional T cell subsets might be impaired in patients with ITP.

Rituximab versus splenectomy in persistent or chronic adult primary immune thrombocytopenia: an adjusted comparison of mortality and morbidity

Splenectomy and rituximab are both recommended as second-line treatment in immune thrombocytopenia (ITP), but they have never been directly compared. We compared their efficacy and serious adverse outcomes in a retrospective cohort of 105 adult primary ITP patients exposed to one or other of these treatments. Primary outcome was composite: death from hemorrhage or from infection and hospitalization for bleeding or for infection. Secondary outcomes were overall mortality, hospitalization for bleeding, hospitalization for infection, as well as response and complete response (international definitions). Analyses were adjusted on a propensity score. Patients treated with rituximab (n = 43) were older and had more comorbidities than the splenectomized patients (n = 62). Mean follow-up was, respectively, 3 and 8.4 years. After adjustment on the propensity score, there was no difference between the two groups regarding the primary and other clinical outcomes. In the multivariate analysis, only a history of mucosal bleeding (HR 3.2 95% CI [1.2-8.5]) and a Charlson score ≥1 (HR 4.2 95% CI [1.8-9.6]) were associated with the primary outcome. These two factors were also associated with hospitalization for bleeding. As expected, response, complete response and maintenance rates were higher in the splenectomy group. Splenectomy compared with rituximab was independently associated with a response at 12 months (OR 4.4, 95% CI [1.7-11.8]). Then, adjusted analyses in this real-life cohort confirmed the better results of splenectomy compared with rituximab.