PRACTICAL RECOMMENDATIONS FOR THE MANAGEMENT OF PATIENTS WITH ITP DURING THE COVID-19 PANDEMIC Recommendation for ITP management during COVID
Main Article Content
Keywords
ITP; COVID; Vaccination
Abstract
The current COVID-19 pandemic requires revisiting our current approach to major blood disorders, including ITP (Immune Thrombocytopenia), stirring up the production of several disease-specific practical guidelines. This report describes an updated version of consensus-based practical guidelines on the management of ITP, adapted to the Italian health system and social context. It highlights the role of the hematologist in offering guidance for choosing differentiated approaches in relation to specific circumstances and is intended to provide them with a useful tool for sharing the decision-making process with their patients.
Probably, the greatest risk to avoid for a patient with suspected, ongoing or relapsed ITP - that is not severe enough to place him or her at risk for major bleeding - is to be infected in non-hospital and hospital healthcare settings. This risk must be carefully considered when adapting the diagnostic and therapeutic approach.
More in detail, the document first addresses the appropriate management for COVID-19 negative patients with newly diagnosed ITP or who experience a relapse of previous ITP, according to first and second-line lines of treatment s and then the management of COVID-19 positive patients according to their severity, from paucisymptomatic to those requiring admission to Intensive Cure Units (ICU). The pros and cons of the different treatments required to correct platelet count are discussed, as are some specific situations, including chronic ITP, splenectomy, thromboembolic complication and anti COVID-19 vaccination.
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References
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[36] Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, Perez JL, Pérez Marc G, Moreira ED, Zerbini C, Bailey R, Swanson KA, Roychoudhury S, Koury K, Li P, Kalina WV, Cooper D, Frenck RW Jr, Hammitt LL, Türeci Ö, Nell H, Schaefer A, Ünal S, Tresnan DB, Mather S, Dormitzer PR, Şahin U, Jansen KU, Gruber WC; C4591001 Clinical Trial Group. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020 ;383(27):2603-2615.
[37] Dashraath P, Nielsen-Saines K, Madhi SA, Baud D. COVID-19 vaccines and neglected pregnancy. Lancet. 2020 ;396(10252):e22.
[38] Rasmussen SA, Kelley CF, Horton JP, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) Vaccines and Pregnancy: What Obstetricians Need to Know. Obstet Gynecol. 2021 ;137(3):408-414.
[39] Agenzia Italiana del Farmaco (AIFA). Domande e risposte sui vaccini COVID-19. https://www.aifa.gov.it/documents/20142/1297852/domande_risposte_vaccini_COVID.pdf/141013bd-23dc-ebb0-3730-0d687cd561f3. (updated 15 March 2021)
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[2] Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines; Graham R, Mancher M, Miller Wolman D, et al., editors. Clinical Practice Guidelines We Can Trust. Washington (DC): National Academies Press (US). 2011.
[3] Pavord S, Thachil J, Hunt BJ, Murphy M, Lowe G, Laffan M, Makris M, Newland AC, Provan D, Grainger JD, Hill QA. Practical guidance for the management of adults with immune thrombocytopenia during the COVID-19 pandemic. Br J Haematol. 2020 ;189(6):1038-1043.
[4] Bussel J, Cines D, Cooper N, Dunbar C, Michel M, Rodeghiero F. COVID-19 and ITP: Frequently Asked Questions. https://www.hematology.org/covid-19/covid-19-and-itp. American Society of Hematology. (published 22 January 2021)
[5] Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, Zeng G, Yuen KY, Chen RC, Tang CL, Wang T, Chen PY, Xiang J, Li SY, Wang JL, Liang ZJ, Peng YX, Wei L, Liu Y, Hu YH, Peng P, Wang JM, Liu JY, Chen Z, Li G, Zheng ZJ, Qiu SQ, Luo J, Ye CJ, Zhu SY, Zhong NS; China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 ;382(18):1708-1720.
[6] Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020 ;18(5):1094-1099.
[7] Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 ;395(10223):497-506.
[8] Yang X, Yang Q, Wang Y, Wu Y, Xu J, Yu Y, Shang Y. Thrombocytopenia and its association with mortality in patients with COVID-19. J Thromb Haemost. 2020 ;18(6):1469-1472.
[9] Jiménez D, García-Sanchez A, Rali P, Muriel A, Bikdeli B, Ruiz-Artacho P, Le Mao R, Rodríguez C, Hunt BJ, Monreal M. Incidence of VTE and Bleeding Among Hospitalized Patients With Coronavirus Disease 2019: A Systematic Review and Meta-analysis. Chest. 2021;159(3):1182-1196.
[10] Marchandot B, Trimaille A, Curtiaud A, Matsushita K, Jesel L, Morel O. Thromboprophylaxis: balancing evidence and experience during the COVID-19 pandemic. J Thromb Thrombolysis. 2020 ;50(4):799-808.
[11] Nopp S, Moik F, Jilma B, Pabinger I, Ay C. Risk of venous thromboembolism in patients with COVID-19: A systematic review and meta-analysis. Res Pract Thromb Haemost. 2020 ;4(7):1178–91.
[12] Violi F, Pastori D, Cangemi R, Pignatelli P, Loffredo L. Hypercoagulation and Antithrombotic Treatment in Coronavirus 2019: A New Challenge. Thromb Haemost. 2020 ;120(6):949-956.
[13] Ministero della Salute, Istituto Superiore di Sanità. Nota tecnica ad interim. Test di laboratorio per SARS-CoV-2 e loro uso in sanità pubblica. https://www.iss.it/documents/20126/0/COVID+19_+test+v4k_last.pdf/9ab1f211-7d88-bcb1-d454-cfed04aa8b05?t=1604483686312 . (updated 23 October 2020).
[14] Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, Ghanima W, Godeau B, González-López TJ, Grainger J, Hou M, Kruse C, McDonald V, Michel M, Newland AC, Pavord S, Rodeghiero F, Scully M, Tomiyama Y, Wong RS, Zaja F, Kuter DJ. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv. 2019 ;3(22):3780-3817.
[15] Neunert C, Terrell DR, Arnold DM, Buchanan G, Cines DB, Cooper N, Cuker A, Despotovic JM, George JN, Grace RF, Kühne T, Kuter DJ, Lim W, McCrae KR, Pruitt B, Shimanek H, Vesely SK. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019 ;3(23):3829-3866. doi: 10.1182/bloodadvances.2019000966. Erratum in: Blood Adv. 2020 ;4(2):252.
[16] Mahévas M, Moulis G, Andres E, Riviere E, Garzaro M, Crickx E, Guillotin V, Malphettes M, Galicier L, Noel N, Darnige L, Terriou L, Guerveno C, Sanchis-Borja M, Moulinet T, Meunier B, Ebbo M, Michel M, Godeau B. Clinical characteristics, management and outcome of COVID-19-associated immune thrombocytopenia: a French multicentre series. Br J Haematol. 2020 ;190(4):e224-e229.
[17] Magdi M, Rahil A. Severe Immune Thrombocytopenia Complicated by Intracerebral Haemorrhage Associated with Coronavirus Infection: A Case Report and Literature Review. Eur J Case Rep Intern Med. 2019 ;6(7):001155.
[18] Ghanima W, Cooper N, Rodeghiero F, Godeau B, Bussel JB. Thrombopoietin receptor agonists: ten years later. Haematologica. 2019 ;104(6):1112-1123.
[19] Rodeghiero F. Is ITP a thrombophilic disorder? Am J Hematol. 2016 ;91(1):39-45.
[20] Nazi I, Kelton JG, Larché M, Snider DP, Heddle NM, Crowther MA, Cook RJ, Tinmouth AT, Mangel J, Arnold DM. The effect of rituximab on vaccine responses in patients with immune thrombocytopenia. Blood. 2013;122(11):1946-53.
[21] Xie Y, Cao S, Dong H, Li Q, Chen E, Zhang W, Yang L, Fu S, Wang R. Effect of regular intravenous immunoglobulin therapy on prognosis of severe pneumonia in patients with COVID-19. J Infect. 2020 ;81(2):318-356.
[22] RECOVERY Collaborative Group, Horby P, Lim WS, Emberson JR, Mafham M, Bell JL, Linsell L, Staplin N, Brightling C, Ustianowski A, Elmahi E, Prudon B, Green C, Felton T, Chadwick D, Rege K, Fegan C, Chappell LC, Faust SN, Jaki T, Jeffery K, Montgomery A, Rowan K, Juszczak E, Baillie JK, Haynes R, Landray MJ. Dexamethasone in Hospitalized Patients with Covid-19. N Engl J Med. 2021 ;384(8):693-704.
[23] Ackermann M, Verleden SE, Kuehnel M, Haverich A, Welte T, Laenger F, Vanstapel A, Werlein C, Stark H, Tzankov A, Li WW, Li VW, Mentzer SJ, Jonigk D. Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19. N Engl J Med. 2020 ;383(2):120-128.
[24] Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant KM, Kaptein FHJ, van Paassen J, Stals MAM, Huisman MV, Endeman H. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020 ;191:145-147.
[25] Middeldorp S, Coppens M, van Haaps TF, Foppen M, Vlaar AP, Müller MCA, Bouman CCS, Beenen LFM, Kootte RS, Heijmans J, Smits LP, Bonta PI, van Es N. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost. 2020 ;18(8):1995-2002.
[26] Rodeghiero F. A critical appraisal of the evidence for the role of splenectomy in adults and children with ITP. Br J Haematol. 2018 ;181(2):183-195.
[27] Corbett V, Hassouna H, Girgis R. In Situ Thrombosis of the Pulmonary Arteries: An Emerging Perspective on Pulmonary Embolism. Medical Student Research Journal. 2015;4(Winter):54-8.
[28] Marongiu F, Grandone E, Barcellona D. Pulmonary thrombosis in 2019-nCoV pneumonia? J Thromb Haemost. 2020 ;18(6):1511-1513.
[29] Fox SE, Akmatbekov A, Harbert JL, Li G, Quincy Brown J, Vander Heide RS. Pulmonary and cardiac pathology in African American patients with COVID-19: an autopsy series from New Orleans. Lancet Respir Med. 2020 ;8(7):681-686.
[30] Tsantes AE, Tsantes AG, Kokoris SI, Bonovas S, Frantzeskaki F, Tsangaris I, Kopterides P. COVID-19 Infection-Related Coagulopathy and Viscoelastic Methods: A Paradigm for Their Clinical Utility in Critical Illness. Diagnostics (Basel). 2020 ;10(10):817.
[31] Mazur-Bialy AI, Kołomańska-Bogucka D, Tim S, Opławski M. Pregnancy and Childbirth in the COVID-19 Era-The Course of Disease and Maternal-Fetal Transmission. J Clin Med. 2020 ;9(11):3749.
[32] Zaigham M, Andersson O. Maternal and perinatal outcomes with COVID-19: A systematic review of 108 pregnancies. Acta Obstet Gynecol Scand. 2020 ;99(7):823-829.
[33] Ferrazzi EM, Frigerio L, Cetin I, Vergani P, Spinillo A, Prefumo F, Pellegrini E, Gargantini G. COVID-19 Obstetrics Task Force, Lombardy, Italy: Executive management summary and short report of outcome. Int J Gynaecol Obstet. 2020 ;149(3):377-378.
[34] Alzamora MC, Paredes T, Caceres D, Webb CM, Valdez LM, La Rosa M. Severe COVID-19 during Pregnancy and Possible Vertical Transmission. Am J Perinatol. 2020 ;37(8):861-865.
[35] Baden LR, El Sahly HM, Essink B, Kotloff K, Frey S, Novak R, Diemert D, Spector SA, Rouphael N, Creech CB, McGettigan J, Khetan S, Segall N, Solis J, Brosz A, Fierro C, Schwartz H, Neuzil K, Corey L, Gilbert P, Janes H, Follmann D, Marovich M, Mascola J, Polakowski L, Ledgerwood J, Graham BS, Bennett H, Pajon R, Knightly C, Leav B, Deng W, Zhou H, Han S, Ivarsson M, Miller J, Zaks T; COVE Study Group. Efficacy and Safety of the mRNA-1273 SARS-CoV-2 Vaccine. N Engl J Med. 2021 ;384(5):403-416.
[36] Polack FP, Thomas SJ, Kitchin N, Absalon J, Gurtman A, Lockhart S, Perez JL, Pérez Marc G, Moreira ED, Zerbini C, Bailey R, Swanson KA, Roychoudhury S, Koury K, Li P, Kalina WV, Cooper D, Frenck RW Jr, Hammitt LL, Türeci Ö, Nell H, Schaefer A, Ünal S, Tresnan DB, Mather S, Dormitzer PR, Şahin U, Jansen KU, Gruber WC; C4591001 Clinical Trial Group. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020 ;383(27):2603-2615.
[37] Dashraath P, Nielsen-Saines K, Madhi SA, Baud D. COVID-19 vaccines and neglected pregnancy. Lancet. 2020 ;396(10252):e22.
[38] Rasmussen SA, Kelley CF, Horton JP, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) Vaccines and Pregnancy: What Obstetricians Need to Know. Obstet Gynecol. 2021 ;137(3):408-414.
[39] Agenzia Italiana del Farmaco (AIFA). Domande e risposte sui vaccini COVID-19. https://www.aifa.gov.it/documents/20142/1297852/domande_risposte_vaccini_COVID.pdf/141013bd-23dc-ebb0-3730-0d687cd561f3. (updated 15 March 2021)
[40] Centers for Disease Control and Prevention (CDC). Information about COVID-19 Vaccines for People who Are Pregnant or Breastfeeding. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html. (updated 18 March 2021)
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Apr 29, 2021
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Rodeghiero, F. (2021) “ PRACTICAL RECOMMENDATIONS FOR THE MANAGEMENT OF PATIENTS WITH ITP DURING THE COVID-19 PANDEMIC : Recommendation for ITP management during COVID”, Mediterranean Journal of Hematology and Infectious Diseases, 13(1), p. e2021032. doi: 10.4084/MJHID.2021.032.
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