Should rituximab be used before or after splenectomy in patients with immune thrombocytopenic purpura?

Cooper, Nichola; Evangelista, Maria Laura; Amadori, Sergio; Stasi, Roberto

doi:10.1097/moh.0b013e3282c8ca50

Cited by 39 publications

(34 citation statements)

References 23 publications

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“…A splenectomy may lead to severe postoperative complications, including venous thromboembolism, serious infections, or bleeding [10], and even mortality, all of which are of even greater concern for elderly and frail patients [11,12]. Moreover, older ITP patients may be less likely to respond to splenectomy [8,13,14]. Our finding that rate of splenectomy was higher among patients with higher disease activity are consistent with the guidelines for cITP treatment.…”

Section: Discussionsupporting

confidence: 79%

Predictors for splenectomy among patients with primary chronic immune thrombocytopenia: a population-based cohort study from Denmark

et al. 2010

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Section: Discussionsupporting

confidence: 79%

Predictors for splenectomy among patients with primary chronic immune thrombocytopenia: a population-based cohort study from Denmark

et al. 2010

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“…The persistence of the response is a crucial issue to evaluate the role of rituximab in the treatment of resistant pITP and especially to evaluate if this drug could be a valid alternative to splenectomy. Cooper et al [20] reported that the long-term response rate of splenectomy is consistently higher than that obtained with rituximab. Godeau et al [8], in a prospective multicentric phase II study aimed at evaluating the efficacy and safety of rituximab in chronic ITP patients who were potential candidates for splenectomy, reported that at 2 years, 40% of patients (24/60) had a platelet count ≥30 × 10 9 /l off treatment.…”

Section: Discussionmentioning

confidence: 99%

Rituximab in Previously Treated Primary Immune Thrombocytopenia Patients: Evaluation of Short- and Long-Term Efficacy and Safety

et al. 2013

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The anti-CD20 chimeric monoclonal antibody rituximab has been effectively used in the treatment of patients with primary immune thrombocytopenia (pITP). We retrospectively evaluated 19 patients affected by pITP resistant to 2 or more lines of therapy who were treated with rituximab. Nine of the 19 patients showed an initial response (47.4%). The sustained response rate was 31.6% (6/19). The median follow-up of the patients was 53.2 months (range 9.2-92.9). Disease-free survival at 48 months was 62.2%. Following rituximab treatment, a proportion of patients (42%) recovered a normal B lymphocyte number. During the follow-up, no opportunistic or severe infectious complications were observed. These data confirm, over a long period of observation, the efficacy and safety of rituximab treatment in the management of patients with resistant pITP.

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“…8 Whether it could be an effective and safe splenectomy-avoiding strategy in adults with chronic ITP remains unresolved. 22 To assess rituximab efficacy and safety in nonsplenectomized adults with chronic ITP (duration Ն 6 months), we conducted a prospective, multicenter, open-label, single-arm phase 2 trial using Fleming singlestage design. …”

mentioning

confidence: 99%

Rituximab efficacy and safety in adult splenectomy candidates with chronic immune thrombocytopenic purpura: results of a prospective multicenter phase 2 study

Godeau

Porcher

Fain

et al. 2008

Blood

236

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IntroductionImmune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by low platelet counts and may be responsible for mucocutaneous bleeding of variable severity. 1 ITP is usually chronic (Ͼ 6 months) in adults and, after this time, the probability of spontaneous remission is low. Standard management is to initiate steroids, anti-Rh 0 (D) immune globulins, and/or intravenous immunoglobulins (IVIgs) for the more severe forms. [2][3][4][5] The response rate is high but most often transient. That the spleen plays a major role in the removal of damaged platelets has long been known and, to date, splenectomy is still considered the "gold standard" treatment in many countries for the management of chronic ITP with platelet counts less than 30 ϫ 10 9 /L, especially when hemorrhagic complications are present. Approximately two thirds of chronic ITP patients who undergo splenectomy achieve lasting responses. 6 As suggested in the guidelines of the American Society of Hematology (ASH) 7 and the British Committee for Standards in Hematology (BCSH), 8 splenectomy should be considered the main second-line therapy for patients who fail to respond durably to first-line therapy, with persistent platelet counts less than 30 ϫ 10 9 /L. However, increasing numbers of patients are reluctant to undergo splenectomy and physicians are hesitant to recommend it. 9,10 In addition, the risk of overwhelming postsplenectomy infections, although rare, is not predictable and represents a major concern. 11-13 Moreover, some authors reported that, despite initial good responses to splenectomy, the risk of late relapse persists during long-term follow-up 14,15 and severe morbidity resulting from surgery is associated with 11% to 30% postoperative complications requiring prolonged hospitalization or readmission. 11,16 For these reasons, an effective and safe alternative to splenectomy would improve management of chronic ITP.Rituximab is a chimeric, humanized monoclonal antibody directed against the CD20 determinant on B cells. It was initially developed for the treatment of malignant lymphoma but has also been used in autoantibody-mediated disorders, such as rheumatoid arthritis, 17 systemic lupus erythematosus, 18 autoimmune hemolytic anemia, 19 or thrombotic thrombocytopenic purpura. 20 Case reports and several uncontrolled studies described its promising results in ITP patients. Arnold et al 21 conducted a systematic review of published reports on rituximab use in adults with chronic ITP. A complete response, usually observed 3 to 8 weeks after the first infusion, was obtained in 46% of patients. The median response duration was 10.5 months (interquartile range [IQR]: 6.3-17.8 months), but long-term For personal use only. on May 10, 2018. by guest www.bloodjournal.org From responses were not mentioned in all published studies. Arnold et al 21 pointed out the heterogeneity of patients' prior rituximab use and particularly their splenectomy status. Moreover, the short follow-up in some reports and the possible bias due to th...

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Should rituximab be used before or after splenectomy in patients with immune thrombocytopenic purpura?

Cited by 39 publications

References 23 publications

Predictors for splenectomy among patients with primary chronic immune thrombocytopenia: a population-based cohort study from Denmark

Predictors for splenectomy among patients with primary chronic immune thrombocytopenia: a population-based cohort study from Denmark

Rituximab in Previously Treated Primary Immune Thrombocytopenia Patients: Evaluation of Short- and Long-Term Efficacy and Safety

Rituximab efficacy and safety in adult splenectomy candidates with chronic immune thrombocytopenic purpura: results of a prospective multicenter phase 2 study

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