Hematol Oncol Clin N Am 21 (2007) 743759

HEMATOLOGY/ONCOLOGY CLINICS
OF NORTH AMERICA

Immune Thrombocytopenic Purpura

Bethan Psaila, MDa, James B. Bussel, MDb,*
a

Division of Pediatric Hematology-Oncology, Weill-Cornell Medical College of Cornell University, 515 East 71st Street, S-724, New York, NY 10021, USA b Division of Pediatric Hematology-Oncology, Weill-Cornell Medical College of Cornell University, 525 East 68th Street, P-695, New York, NY 10021, USA

mmune thrombocytopenic purpura (ITP) is a disorder in which antiplatelet antibodies cause accelerated destruction of platelets, resulting in thrombocytopenia and a varying propensity for bleeding. In addition, it is now recognized that these antibodies may also impair platelet production, creating a dual cause of thrombocytopenia. Despite their central role in the immunopathology of ITP, measurement of antiplatelet antibodies remains unreliable, and the diagnosis is made by demonstrating isolated thrombocytopenia without an obvious cause. In most children and some adults, ITP is an acute, self-limited disease that resolves or improves spontaneously within months. In a small number of children and in many adults, ITP may be chronic and poorly responsive to treatment. Most thrombocytopenic patients experience only minor bleeding symptoms, such as epistaxis, petechiae, and bruising. Severe bleeding events, such as intracranial hemorrhage, protracted epistaxis, hematuria, hemoptysis, and gastrointestinal bleeding, are fortunately rare, although their prevention remains the main goal of management. Traditional treatment approaches have focused on inhibiting phagocyte-mediated destruction of antibody-coated platelets. Improved understanding of the disease pathogenesis has initiated development of several new treatments, and the repertoire of therapeutic options for ITP is thereby expanding dramatically. This expansion includes design of more specic inhibitors of platelet destruction that target Fcc receptors (FccRs), such as anti-FccR monoclonal antibodies and molecules that impede FccR-mediated signaling, and thrombopoietic agents that enhance platelet production [1,2].

B.P. is a Fulbright Scholar in Cancer Research and a recipient of a Kay Kendall Leukemia Fund Traveling Fellowship. This work was also partly supported by Dana Hammond Stubgen, the Childrens Blood and Cancer Foundation, and NIH grant U01 HL072186 (J.B.B.).

*Corresponding author. E-mail address: jbussel@med.cornell.edu (J.B. Bussel). 0889-8588/07/$ see front matter doi:10.1016/j.hoc.2007.06.007 2007 Elsevier Inc. All rights reserved. hemonc.theclinics.com

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TERMINOLOGY AND EPIDEMIOLOGY Terminology Terminology in ITP is controversial, even in the disease nomenclature. Paul Gottleib Werholf rst described a syndrome of isolated thrombocytopenia with petechiae and mucocutaneous bleeding in the 1700s, and named the condition morbus haemorrhagicus maculosus, later referred to as Werholfs syndrome. Today, ITP is referred to as immune, autoimmune, or idiopathic thrombocytopenic purpura. Because true ITP occurs secondary to antiplatelet antibodies, the former denition is more appropriate for use in most contexts. ITP may be classied as acute or chronic (ie, thrombocytopenia of less or more than 6 months in duration) [3]. This distinction suggests two different clinical courses that may be pathophysiologically distinct, and may warrant different treatment approaches.
Controversy in ITP terminology. Inconsistency in clinical denitions, classication, and variation in diagnostic and treatment regimens have hampered comparative meta-analyses and data interpretation in ITP. There is an increasing drive to standardize the denitions and terminology (eg, refractory ITP) and produce a common language for ITP [4].

Epidemiology ITP is a relatively common acquired bleeding disorder. For childhood ITP, European studies reported an incidence of 5.8 cases/100,000 children [5] and a prevalence of 4.6/100,000 [6]. The reported prevalence in North America is slightly higher, at 7.2/100,000 children aged 1 to 14 years [7]. In adults, the annual incidence is around 1.6/100,000, higher in middle age when a female preponderance is observed in contrast to the equal sex distribution amongst cases of childhood ITP (prevalence rate ratio of 1.9 for female to male) [7] and in the elderly. Examining the health care claims of all privately insured residents in Maryland in 2002 suggested a prevalence of adult ITP of 9.5/100,000 [7]. One important caveat to these statistics is that the epidemiologic studies of ITP vary in their denition and inclusion criteria; if incidental, asymptomatic cases (those with higher platelet counts) are included then the true incidence rate is likely higher. Seasonal Variation ITP shows seasonal and geographic variability. Primarily in children, there seems to be a peak in incidence in winter and early springtime [8], although the timing seems to be country-specic [5,8,9]. The seasonal patterning is believed to be attributable to triggering by a viral illness, usually an upper respiratory infection. A minority of cases of ITP (fewer than 8%) may also be preceded by vaccinations. PATHOPHYSIOLOGY Precise delineation of the pathophysiology of ITP would be challenging even without the marked heterogeneity among patients. The initiating event is not clear; acute infections often appear to be the initial trigger, but may also merely

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serve to perpetuate an already-established immunologic disturbance. B cells, T cells, macrophages, and bone marrow megakaryocytes may all play a role (Fig. 1). A better understanding of the underlying disease is necessary to enable more targeted and effective treatments. Antiplatelet Antibodies and Platelet Destruction In vivo plasma infusion studies by Harrington [10,11] in the 1950s rst demonstrated that a plasma factor found in most patients who had ITP resulted in thrombocytopenia in normal individuals. Subsequently, antiplatelet antibodies directed against platelet surface glycoproteins, such as IIB/IIIA, have been detected in around 50% to 70% of patients. The most common antigenic epitopes for antiplatelet antibodies in ITP are the platelet GPIIb/IIIa and GPIb-IX receptors [12]. By binding to these specic sites on the platelet surface, antibodies opsonize platelets for clearance by the FccR-bearing cells of the reticuloendothelial system (RES), primarily in the spleen. Antiplatelet antibodies against numerous surface glycoprotein receptors may develop by epitope spreading, whereby platelet destruction in the RES leads to the presentation of additional platelet antigens [13]. Antiplatelet antibodies rarely have a substantial effect on platelet function. Patients rarely suffer serious bleeding events, even when the platelet count is less than 50 109/L. The complement pathway may also contribute to the lysis of antibody-coated platelets in an unknown fraction of patients.
Usefulness of antiplatelet antibody measurement: an ongoing issue. Only detectable in fewer than 70% of patients who have ITP, platelet-associated antibodies to specic glycoproteins may also be detected in other disorders and thus are inadequately sensitive or specic to be of diagnostic usefulness. In patients who have apparent ITP the measurement of antiplatelet antibodies is not recommended as a routine, nor is it of prognostic signicance with currently available tests.

Role of T Cells The absence of detectable autoantibodies in 30% to 40% of patients suggests that additional mechanisms of platelet destruction may be important. Direct T-cell mediated cytotoxicity against megakaryocytes and platelets may be the primary mechanism of thrombocytopenia in a proportion of patients. A pivotal study published by Olsson and colleagues in Nature Medicine [14] suggested a key role for T cells, reporting an up-regulation of genes involved in cell-mediated cytotoxicity in CD3CD8 T cells from patients who had ITP. CD8 cytotoxic T cells and CD4 T-helper (Th) cells and their secretory factors regulate the biogenesis of antiplatelet antibody-secreting B-cell clones [15], and Th1-associated cytokines seem to predominate in ITP [16]. Suppression of Platelet Production It was assumed initially that platelet production would be enhanced in ITP to compensate for the accelerated platelet destruction. There is now much evidence, however, indicating that platelet production is in fact often decreased. Studies

Macrophage

6 Fc Receptor 4
T Cell B Cell Antiplatelet antibodies

Potential targets for antiplatelet antibodies GP llb/llA

5
GP la/lla Platelet GP Ib

Platelets Bone Marrow 1

3 2
Thrombopoietin

Megakaryocyte

Fig. 1. A diagramatic representation of the contributory pathophysiologic mechanisms underlying ITP, and the usefulness of specic laboratory investigations for diagnosis and monitoring of ITP. (1) Bone marrow histology: Bone marrow studies are no longer performed routinely in ITP, but are recommended if there is a suggestion of an alternative diagnosis, particularly in patients older than 50 to 60 years in whom myelodysplasia is more common. A normal or increased number of megakaryocytes may be found in ITP. (2) Thrombopoietin (TPO) levels: Measurement of TPO levels are not believed to be currently useful in diagnosis or monitoring of ITP. The primary mechanism for clearance of circulating TPO is by way of the c-Mpl receptor on platelets, but TPO levels in patients who have ITP are not increased as might be expected given the degree of thrombocytopenia. This further supports the hypothesis that thrombopoiesis is suboptimal in ITP, although the mechanisms underlying the failure to up-regulate TPO in this condition are unclear. In the future if the assay is readily available it may be possible to measure TPO levels in place of doing bone marrow studies if the question to be answered is solely whether there are normal numbers of megakaryocytes. (3) Immature platelet fraction (IPF): Newly produced, reticulated platelets may be identied by their content of RNA, which is lost as the platelet matures. The IPF parameter, analogous to the platelet reticulocyte count, may be assessed as part of an extended CBC differential using the Sysmex-XE100 automated analyzer and may be used as an assessment of thrombopoietic state. The usefulness of the IPF% for differentiating consumptive and aplastic causes of thrombocytopenia has been demonstrated [42], and the IPF may also be studied for insight into mechanism of treatment effect [43]. (4) B cell: The extent of B-cell depletion following treatment with rituximab, an anti-CD20 monoclonal antibody under study for use in ITP, has been shown to correlate with duration and extent of response to treatment with this agent [67]. (5) Antiplatelet antibody: Currently, antiplatelet antibody assays are inadequately specic or sensitive to be of clinical usefulness in the diagnosis of ITP. There is evidence that antiplatelet antibodies subtypes may mediate thrombocytopenia by way of distinct mechanisms. For example, anti-GPIIB/IIIA antibodies, detected in around 70% of patients who have ITP, are believed to act by way of Fc-dependent mechanisms, whereas anti-GPIba antibodies seem to be Fc-independent [51]. Correlating antiplatelet antibody subtype with response to treatment with certain agents, such as IVIg, may be an interesting area for future study. (6) Fcc receptor (FccR) proling: specic FccR alleles based on single nucleotide polymorphisms may confer higher binding afnity for therapeutic IVIg or monoclonal antibody treatment (ie, rituximab), and therefore an individuals FccR prole may determine response to treatment with this agent [76,77].

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have described megakaryocyte damage and dysfunction in ITP, mediated by either direct antibody cytotoxicity or by immune cellderived cytokine dysregulation, resulting in impaired megakaryocyte maturation and thrombopoiesis [17,18]. One review of bone marrow ultrastructure in 11 patients who had ITP demonstrated megakaryocytes with morphologic abnormalities and increased activated caspase-3, suggesting dysregulated apoptosis [19]. It is not clear at this time to what extent apoptosis is part of the normal physiology of thrombopoiesis. Two studies showed that plasma from patients who had ITP reduced the differentiation of megakaryocytes from placental hematopoietic progenitor cells by around 50%. Notably, this effect exclusively occurred with plasma samples in which antiplatelet antibodies were detectable; plasma from patients who were antibody negative had minimal (<10%) effect [20]. Platelet kinetic studies using indium (In111) labeling of autologous platelets has demonstrated relatively long platelet half-lives, (23 days), suggesting reduced platelet turnover and therefore that suboptimal thrombopoiesis occurs in ITP. In these studies, the rates of platelets entering the circulation in patients who had ITP were up to ve times lower than normal [21]. Furthermore, thrombopoietin (TPO) levels are not elevated as would be expected in response to the thrombocytopenia of ITP, in contrast to aplastic anemia, amegakaryocytic thrombocytopenia, and myeloablation, in which TPO levels are high. TPO is constitutively produced by hepatocytes and cleared by way of the cMpl receptor on platelets and megakaryocytes [22,23]. Only in one patient thus far has anti-TPO antibody neutralization of thrombopoietin been conrmed [23].
Accelerated platelet destruction and reduced platelet production. Both increased platelet destruction and suppressed platelet production contribute to the thrombocytopenia of ITP. The relative importance of each mechanism is likely to vary among patients, and may explain some of the heterogeneity observed in pathophysiology and treatment response. In light of this, treatment strategies should consider inhibiting phagocyte-mediated platelet consumption and enhancing suboptimal platelet production.

Infections and Autoimmunity in Immune Thrombocytopenic Purpura Acute infections are implicated in instigating ITP and in acutely exacerbating the thrombocytopenia. Worsening thrombocytopenia associated with infection is a well-known clinical phenomenon and has been recently characterized in a mouse model [24]. Viral-specic antibodies that cross-react with platelets have been demonstrated in several children who had varicella-induced acute ITP and in HIV-associated ITP [25,26]. Recently, the role of Helicobacter pylori infection in ITP has been examined. H pylori eradication has lead to apparent increases in platelet counts in several studies, although not in others [27,28]. For HIV-associated thrombocytopenia, a clear relationship is demonstrable between HIV viral load and the likelihood and degree of thrombocytopenia, which occurs in 30% or more of untreated patients who have HIV. Suppressing the viral load with antiretroviral therapy results in a substantial platelet

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increase. The immunopathology of HIV-associated thrombocytopenia may be different from that of classic ITP. Severe T-cell depletion and consequent immune dysregulation occurs in HIV. In addition, megakaryocytes express HIV receptors CD4, CXCR4, and CCR5 and therefore may be susceptible to direct viral cytotoxicity [29]. Furthermore, antiplatelet immune complexes instead of antiplatelet antibodies are believed to be found on platelets in HIV [30]. The pathophysiology of hepatitis C (HCV)associated thrombocytopenia remains unclear because HCV is known to be associated with an increase in several autoantibodies [31] but bleeding in these patients may also be a result of cryoglobulins [32].
H pylori and ITP: a role in initiation? More than 30 reports have been published on the association between H pylori and ITP and yet no consensus has been reached. Results of the largest prospective study examined serum markers of gastritis and anticytotoxin-associated gene A (anti-CagA) antibodies in 116 patients who had ITP in Japan, before and after H pylori eradication therapy. Here, 58% of the patients were H pylori positive, 85% of whom demonstrated an increase in platelet count and a shortened duration of ITP after eradication therapy associated with a signicant decrease in antiCagA [33]. This nding supports previous studies demonstrating cross-reactivity between anti-CagA antibodies and platelet antigens [34].

CLINICAL FEATURES: DIAGNOSIS AND ONGOING ASSESSMENT Diagnostic Criteria Following identication of thrombocytopenia on a complete blood count, the exclusion of other causes of thrombocytopenia is integral to the diagnosis of ITP. The three key diagnostic criteria for ITP are:
Isolated thrombocytopenia with otherwise normal peripheral complete blood count and smear An absence of hepatosplenomegaly and lymphadenopathy on physical examination Platelet response to classic ITP therapy (usually intravenous immunoglobulin [IVIg], IV anti-D, and possibly steroids)

A history of isolated thrombocytopenia in relatives or congenital organ defects, such as skeletal, cardiac, renal, or neurologic problems, suggesting rare inherited thrombocytopenic disorders should be sought. Secondary causes of thrombocytopenia, including pregnancy, chronic infection with HIV and hepatitis C, immunodeciency, and especially lymphoproliferative malignancy, should also be explored. A personal or family history of other autoimmune disorders, such as Hashimoto thyroiditis, supports the likelihood of ITP, and careful medication history, including dietary supplements (eg, quinine), may point to drug-induced thrombocytopenia. The onset of ITP may be acute or insidious, and because asymptomatic cases may be detected on routine blood count, the spectrum of clinical manifestations

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is wide. Bleeding symptoms are typically mucocutaneous, such as petechiae, as distinct from the slowly evolving large hematomas that characterize nonplatelet coagulation disorders. Petechiae and ecchymoses are common; wet purpura or mucosal bleeding is associated with a more unstable disease state and may indicate a higher risk for intracranial hemorrhage (ICH). Epistaxis and menorrhagia may be troubling for a proportion of patients, but life-threatening bleeding events, such as ICH, gastrointestinal bleeding, severe hematuria, and respiratory hemorrhage, are, fortunately, rare. Clinical Findings Physical examination in ITP should be normal aside from bleeding manifestations, such as petechiae, ecchymoses, and purpura. Hepatosplenomegaly and lymphadenopathy suggest an alternative diagnosis, as do abnormalities of the radial ray, although coexisting disorders may be found. Laboratory Analyses An isolated, usually severe thrombocytopenia with an otherwise normal complete blood count occurs in ITP. Artefactual low platelet counts caused by clumping in ethylenediamine tetraacetic acid can occur; platelet counting using alternative anticoagulants (eg, sodium citrate) or direct review of a blood smear may be performed to exclude this phenomenon [35]. Features of other nonimmune thrombocytopenic disorders should be sought, including leukemia, myelodysplasia, megaloblastic anemia, and microangiopathic anemia. Examination of the peripheral blood smear frequently reveals large platelets in ITP (2060 fL) [36], but too many platelets that are very large suggest alternative disorders, such as Bernard-Soulier and MYH9-related disorders (previously known as May-Hegglin). A coagulation screen is expected to be normal, and an autoimmune screen may be performed to identify coexisting diseases, such as subclinical hypothyroidism. Antiphospholipid antibodies occur in around 15% of patients, and immune globulin measurements may be useful particularly in the elderly patient, but further investigations are not routinely required. The sensitivity and specicity of antiplatelet antibody assays are not sufcient to justify the routine use of these assays for diagnostic purposes. Similarly, measurement of the TPO level for diagnosis or monitoring is unhelpful; if marrow aplasia is suspected, a bone marrow examination is more direct and the results are obtained more quickly than from TPO assay. Bone marrow aspiration and biopsy are no longer routinely performed in ITP, but are recommended if there is failure to respond to ITP treatment, particularly in patients older than 50 to 60 years in whom myelodysplasia is more common [37]. A typical bone marrow examination in ITP is normocellular with normal erythropoiesis and myelopoiesis; megakaryocytes may be normal or increased in number.
Immature platelet fraction: a diagnostic marker? The immature platelet fraction (IPF) is analogous to the platelet reticulocyte count. The Sysmex XE-100 system enables automated measurement of the IPF as part of routine CBC

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analysis [38]. The IPF as a percentage of total platelet count has been examined as a diagnostic tool to differentiate aplastic and consumptive thrombocytopenic states [39,40], and the IPF may also be used to provide an insight into therapeutic mechanisms of effect [41].

Specic laboratory investigations that may be considered at diagnosis or for monitoring are depicted in Fig. 1 and their clinical usefulness discussed. TREATMENT STRATEGIES IN IMMUNE THROMBOCYTOPENIC PURPURA The goal of management for ITP is to increase the platelet count and prevent serious hemorrhage while minimizing treatment-related toxicity from therapy. In addition, recent studies of quality of life suggest that improved platelet counts may be linked to a better general well-being [42]. Therapeutic regimens depend on the perceived risk for severe bleeding events as indicated by current signs and symptoms, platelet count, the patients past history of bleeding, and other factors [43]. Few large-scale randomized clinical trials have comprehensively evaluated and compared treatments, and therefore specialists opinions may vary based on perceived risks and benets of given treatments. In an attempt to standardize management, American and British guidelines have been published by expert groups [37,44]; the former is being re-evaluated.
Treatment at diagnosis: when and whom to treat, and with which agent? In general, patients who have platelet counts greater than 30 109/L with no signicant bleeding require no treatment unless they have a particular risk, such as undergoing an invasive procedure. Treatment is advisable if platelets are less than 20 109/L and moderate symptoms are present (particularly mucosal bleeding) or if platelets are less than 10 109/L. First-line treatments to achieve a rapid platelet response include highdose parenteral corticosteroids, IVIg, and intravenous anti-D. Treatment should be tailored to the individual patient, however, and is often dictated by availability and local experience.

CLASSIC FIRST-LINE THERAPIES Corticosteroids Since its introduction in the 1950s, the standard therapy for patients who require medical intervention at diagnosis has been prednisone, usually at a starting dose of 1.0 to 2.0 mg/kg [37] for 2 to 4 weeks with tapering if a platelet response occurs. Using this protocol, an initial response rate of 60% to 70% adult patients is typical, 10% to 20% of whom go on to enter long-term complete remission. The rate of response is better for children, and treatment may not be required for prolonged periods because of the 80% who enter long-term remission, many do so within 2 to 8 weeks from onset. Pulsed Oral High-Dose Dexamethasone Pulsed high-dose oral dexamethasone at 40 mg/d for 4 days is an alternative to standard IV or oral methylprednisolone and seems to be more effective [45]. In

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a study of 95 previously untreated patients (adults and children), 4-day pulses were administered every 14 days for four cycles. Initial response rates were around 85%, with response maintained long term in 74.4% (lasting for a median of 8 months), and the treatment was said to be well tolerated [45]. Because no signicant increase in overall initial response rate was seen after completion of the third cycle, three therapy cycles could be sufcient. An earlier study suggested that a single cycle was enough in certain patients. Further study will clarify the optimal dosing schedule and formal comparison to conventional prednisone regimens is planned. Immune Globulins IVIg at a dose of 0.4 to 1 g/kg/day for 1 to 3 days, or IV anti-D at 50 to 75 mcg/kg may be given for initial therapy at diagnosis or for relapses in chronic disease; repeated treatment courses may avoid splenectomy by allowing time for spontaneous recovery in patients who have recently diagnosed ITP [46]. A meta-analysis of randomized controlled trials reported that IVIg treatment yields a more rapid increase in platelet count than corticosteroids in children [47]. Adverse events include nausea, headache, fever, and chills. The cost of IVIg is considerable, and both IVIg and anti-D treatment carry small risks of transmission of infection, although no cases are known to have occurred with current products. Around three fourths of patients who have ITP respond to IVIg treatment. Preclinical studies have suggested that the type of antiplatelet antibody underlying the thrombocytopenia may determine response to IVIg [48,49]; studies of the predictive value of these antibodies in patients will be forthcoming. IV anti-D is less expensive than IVIg, has a substantially shorter infusion time (minutes compared with hours), and is derived from a smaller donor pool [46]. It is only effective in patients who are rhesus positive, and works better in non-splenectomized patients. As would be expected, anti-D causes hemolysis, and a hemoglobin decrease of 0.5 to 2 g/L occurs in most patients. Doses exceeding 75 mcg/kg are associated with greater degrees of hemolysis [50]. In general, 70% of adults [51] and children who have acute or chronic ITP achieve a platelet count increase greater than 20 109/L within 1 day [52], and doses of 75 mcg/kg have been shown to result in similar responses as following IVIg [53,54]. Mechanism of Action of Immune Globulin Therapy The precise mechanism by which immune globulin therapy inhibits phagocytic clearance of antibody-coated platelets has been a subject of much interest and debate. Early studies demonstrated that IVIg inhibited clearance of IgG-coated red cells, and by inference antibody-coated platelet clearance [55]. More recently, transgenic knock-out and knock-in mouse models enabled more detailed study of the molecular mechanisms underlying this effect. The prevailing theory has been that the Fc portion of the Ig molecule mediates the anti-inammatory effect by binding to inhibitory FccR on phagocytes. Administration of dendrite cells preincubated with IVIg in vitro was shown to ameliorate murine ITP, recapitulating the therapeutic effect of IVIg [56]. These IVIg-primed leucocytes only had effect when the recipient mouse expressed the inhibitory Fcc receptor, FccRIIB,

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although FccRIIB was not required on the initiator dendritic cells. The authors concluded that FccRIIB is not the direct target of IVIg but that this receptor mediates downstream effects, and the effect of IVIg was a consequence of activating FccR-chain signaling on the dendritic cell [56]. Work by other groups has shown that the sialylated-enriched fraction of IVIg is far more efcacious than nonenriched IVIg [57]. These ndings raise the possibility that in the future, sialylated-enriched IVIg preparations may replace pooled immunoglobulin preparations for treatment of ITP and other autoimmune conditions. Anti-D immunoglobulin causes immune-mediated clearance of sensitized erythrocytes that are believed to compete for the activating Fc receptors, thereby minimizing clearance of antibody-coated platelets.
IVIg in ITP: no role for cytokines? Whether cytokine modulation is functionally important for the treatment effect remains controversial. Transient increases in several anti-inammatory cytokines are observed in human studies [5860] but knock-out of cytokine genes or use of anticytokine antibodies did not alter the effects of IVIg in mouse models of antibodyinduced thrombocytopenia. One important caveat to these preclinical studies is that in human ITP, cytokines triggered by infusion of IVIg may impact secretion of antiplatelet antibody or, by interacting with the neonatal Fc receptor, accelerate antibody elimination [61]. Furthermore, cytokine modulation may be more important in the later phases of the therapeutic response not captured in the acute murine disease model.

Splenectomy Splenectomy can be safely performed laparoscopically and restores normal platelet counts long term in about two thirds of patients for at least 510 years post procedure [62]. This procedure entails removal of a healthy organ, and carries long-term risks for infection with encapsulated organisms. Furthermore, it is not possible to predict whether a patient will respond and the possibility of side effects 20 to 30 years after surgery remains unexplored. As pharmacologic options to treat chronic ITP are improving, many physicians try other approaches rst. Low-Dose Chemotherapy For chronic refractory ITP, immunosuppressive chemotherapeutic agents, such as cyclophosphamide, vincristine, azathioprine, mycophenolate mofetil, and cyclosporine, may be used, either as single agents or in combination. Signicant side effects, including nephrotoxicity, infection, and malignancy, limit their usefulness for long-term use. The use of these agents is reviewed elsewhere [63]. THERAPEUTIC STRATEGIES FOR IMMUNE THROMBOCYTOPENIC PURPURA CURRENTLY UNDER STUDY A better understanding of the immunopathologic mechanisms at play has lead to the design of several new specic treatment strategies that target specic steps in the biogenesis of the thrombocytopenia (Table 1).

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Table 1 New treatments under study for use in immune thrombocytopenic purpura Strategy Enhance platelet production Drug AMG531, eltrombopag, AKR501 Molecular target Bind to the TPO receptor on megakaryocytes (at a different site to endogenous TPO), and by way of induction of JAK2- and STAT5signaling pathways these agents promote megakaryocyte differentiation, proliferation, and thrombopoiesis A monoclonal antibody to CD20 that depletes B cells and therefore prevents production of antiplatelet antibodies A human monoclonal antibody to the activating Fcc receptor, FccRIII Syk kinase inhibitor, inhibits downstream signaling of FccR Stage of development Phase II/III clinical trials (short term), phase III studies of long-term use underway Studied for use in adults or children Adults; considered for trial in children

Inhibit antiplatelet antibody production

Rituximab

Currently licensed for lymphoma Used in phase IV trials in ITP (no phase III) Phase II/III

Both

Inhibit Fc receptor-mediated antibody-coated platelet destruction

GMA161

Adults

R788

Phase II/III

Adults

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Rituximab Rituximab, a monoclonal anti-CD20 antibody that transiently depletes CD20 B cells, is licensed for treatment of non-Hodgkin lymphoma, and has been undergoing study in ITP. A recent systematic review summarizes the efcacy and safety of rituximab treatment for more than 300 adult patients who had ITP, and reports that overall in 62.5% of patients a platelet response occurred [64]. In a study of 57 splenectomized and non-splenectomized patients who had platelet counts less than 30 109/L, more than 50% of patients responded, with 32% achieving a platelet count greater than 150 109/L and a partial response of platelet counts increasing to 50 109/L to 150 109/L occurred in 22% [65]. One third of the patients who were complete responders following initial treatment had their response last more than 1 year from initial treatment. In a follow-up study of patients whose response to rituximab had lasted at least 12 months from initial treatment, 49% were projected to continue their response with no additional therapy for at least a further 5 years; relapse was uncommon after 2.5 years of maintained response [66]. Rituximab has also been used in two studies of children who had ITP with roughly similar initial response [67,68]. Rituximab is usually well tolerated; manageable side effects occurring at rst infusion include transient fever, chills, and a rash. Serum sickness occurs in a minority of children (<10%). Given the favorable safety prole, rituximab may be preferable to splenectomy particularly in young patients who are at higher risk for infection with encapsulated organisms. Although this offers a promising durability of response for patients who have refractory ITP, the proportion of patients who have lasting response is far less than ideal. Further study is required to determine if augmented or combination therapy may be more efcacious and whether there are long-term immunologic effects that have heretofore been unrecognized. Thrombopoietin Agents TPO growth factors have been recently developed for use as therapy in thrombocytopenia. The rst TPO agents were recombinant forms of human TPO pegylated recombinant human (rHu) megakaryocyte growth and development factor (PEG-rHuMGDF) and of unmodied rHuTPO. Further development of these agents ceased, however, after neutralizing antibodies that cross-reacted with endogenous TPO occurred, resulting in signicant thrombocytopenia in several recipients, including previously healthy donors [69,70]. Focus then shifted to second-generation c-Mpl peptide agonists that share no sequence homology with native TPO [71]. Two of these, AMG531 [1] and eltrombopag (GSK) [2], have completed phase three clinical trials for ITP and also, for eltrombopag, for hepatitis-C-associated thrombocytopenia [1,2,72]. AMG531 and eltrombopag promote megakaryocyte differentiation, proliferation, and platelet production by inducing phosphorylation of JAK2 and STAT5 signaling pathways. Both are well tolerated. Results of the rst two trials of AMG531 were published recently, demonstrating that a weekly subcutaneous injection for 1 to 6 weeks lead to doubling of the platelet counts and an

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increase to greater than 50 109/L in most treated patients with minimal side effects [1,73]. Eltrombopag, an oral treatment given daily in a randomized double-blind placebo-controlled trial resulted in platelet counts increasing to greater than 50 109/L in 70% and 81% of patients treated with 50-mg and 75-mg daily doses, respectively [2,74]. A trial of eltrombopag in hepatitis C treatment has demonstrated similar efcacy and lack of toxicity as seen in ITP [75]. Both agents have been used for short-term therapy in adults who have chronic ITP with apparently minimal toxicity. One concern is that two patients treated with AMG 531 developed a treatment-induced increase in bone marrow reticulin on therapy, which returned to or near baseline following cessation of AMG531 treatment. The increased marrow reticulum may be a universal effect with this class of agents; bone marrow histology was not regularly examined as part of the trials with either agent. To date, only AMG531 has been reported for longer-term usage. There are other thrombopoietic agents in development that seem promising in trials in normal volunteers, such as AKR-501. Further study will reveal the potential of these agents for long-term maintenance therapy, and the usefulness of these agents in children who have ITP. Specic Inhibitors of Phagocyte-Mediated Consumption of Platelets The thrombocytopenia in ITP results at least in part from an interaction between platelet surface-bound immunoglobulin and FccRIII receptors on macrophages. Specic antibodies of FccRIII have therefore been designed as potential therapy to prevent platelet clearance. Early trials with a murine anti-human FccRIII antibody demonstrated the feasibility of this approach, but treatment could not be repeated as a result of universal development of human antimouse antibodies. A humanized antibody, GMA-161, has been developed and used in low dose in four adults who had chronic refractory ITP. In these initial studies, responses were fairly short-lived. Further study is required to demonstrate the applicability of specic FccRIII targeting in the treatment of ITP and other autoimmune disorders. An inhibitor of syk kinase (R788) that targets the FccR signaling pathway is also in early trial with promising results. SUMMARY Many new therapies are now in early stages of development for the treatment of ITP. These new treatments have diverse mechanisms of action, aimed at amelioration of platelet destruction and enhancing platelet production. This progress has resulted from a sustained commitment to improving our understanding of megakaryopoiesis, thrombopoiesis, and autoimmunity, and a further elucidation of the mechanism of action of traditional therapies. Additional work is required to optimize efcacy and response rates, although given the natural heterogeneity in diseased pathophysiology among patients who have a diagnosis of ITP, it is unlikely that any single treatment will be universally applicable. Further detailing of the pathologic factors underlying the variation among patients in clinical course and treatment response is required

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to enable further progress in drug development and will improve selection of the most appropriate management strategies for patients who have ITP. Acknowledgments The authors thank Elan Bomsztyk for his artistic assistance with the gure. References
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