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Long-Term Management of Thrombocytosis in Essential Thrombocythaemia Gunnar Birgegård

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Long-Term Management of Thrombocytosis in Essential Thrombocythaemia Gunnar Birgegård Long-term management of thrombocytosis in essential thrombocythaemia Gunnar Birgegård To cite this version: Gunnar Birgegård. Long-term management of thrombocytosis in essential thrombocythaemia. Annals of Hematology, Springer Verlag, 2008, 88 (1), pp.1-10. 10.1007/s00277-008-0531-7. hal-00477960 HAL Id: hal-00477960 https://hal.archives-ouvertes.fr/hal-00477960 Submitted on 30 Apr 2010 HAL is a multi-disciplinary open access L’archive ouverte pluridisciplinaire HAL, est archive for the deposit and dissemination of sci- destinée au dépôt et à la diffusion de documents entific research documents, whether they are pub- scientifiques de niveau recherche, publiés ou non, lished or not. The documents may come from émanant des établissements d’enseignement et de teaching and research institutions in France or recherche français ou étrangers, des laboratoires abroad, or from public or private research centers. publics ou privés. Ann Hematol (2009) 88:1–10 DOI 10.1007/s00277-008-0531-7 REVIEW ARTICLE Long-term management of thrombocytosis in essential thrombocythaemia Gunnar Birgegård Received: 4 April 2008 /Accepted: 4 June 2008 / Published online: 16 July 2008 # The Author(s) 2008 Abstract Essential thrombocythaemia (ET) is an acquired effective for platelet reduction, the use of interferon-α is myeloproliferative disorder with a prolonged clinical course restricted by psychiatric side effects. Our knowledge of the and a near-normal life expectancy. Therapy is stratified optimum pharmacotherapy for each patient with ET according to risk of thrombohaemorrhagic events. In high- continues to evolve through research and clinical trials, risk patients, platelet reduction is generally recommended. particularly into the molecular basis of the disease. In intermediate-risk patients, therapy should be considered depending on the severity of associated risk factors, Keywords Essential thrombocythaemia . Anagrelide . especially cardiovascular. In low-risk patients, a watch- Hydroxycarbamide . Interferon . Myeloproliferative disorder and-wait approach is appropriate. Hydroxycarbamide is generally first-line therapy. Concerns for possible leukemo- genicity make anagrelide or interferon-α possible choices Introduction in younger patients and those who are resistant or intolerant to hydroxycarbamide. Each pharmacotherapy is associated Essential thrombocythaemia (ET) is an acquired myelopro- with specific long-term risks and benefits. The potential liferative disorder (MPD), characterised by persistent risk of major bleeding is the main drawback of aspirin. peripheral thrombocytosis and a tendency for thrombosis Hydroxycarbamide is an established, effective drug for ET, and haemorrhage [1]. For example, in a study of 93 patients but it may increase the risk of transformation to acute with ET, at a median follow-up of 70 months, 16% of myeloid leukaemia and may give mucocutaneous ulcers. patients developed thrombosis, 14% developed haemor- Anagrelide is a licensed treatment that also reduces platelet rhage and 17% developed microvascular complications [2]. counts and is generally well tolerated, with evidence that ET can proceed in some cases to myelofibrosis, acute some common side effects diminish over time. Anagrelide myeloid leukaemia (AML), myelodysplastic syndromes can have cardiac effects due to inhibition of phosphodies- (MDS) or polycythaemia vera (PV) [3]. The estimated terase III and therefore requires cautious use in patients annual incidence of ET based on World Health Organiza- with cardiac insufficiency. There is no evidence of tion (WHO) criteria is 1–2.5/100,000 individuals [4]. leukaemogenicity with anagrelide or interferon-α therapy. However, the true incidence is likely to be higher as many Interferon-α is the only treatment suitable for use during patients are without symptoms, and thus undiagnosed. Even pregnancy, although it is not licensed in ET. While it is though ET is a rare disease, the prevalence is high at 30/ 100,000 general population [1], reflecting the near-normal life expectancy of patients with the condition [5]. Financial support: This manuscript was supported by an unrestricted Several lines of evidence suggest that ET is a heteroge- educational grant from Shire. neous disease entity, though the existence of distinct G. Birgegård (*) subgroups is difficult to validate. Molecular evidence Department of Haematology, Division of Medicine, includes the patient’s JAK2 mutation status (i.e. the Institution for Medical Sciences, University Hospital, Uppsala 75185, Sweden presence or absence of the Janus kinase 2 mutation e-mail: [email protected] JAK2V617F)[3], variation in X-chromosome inactivation 2 Ann Hematol (2009) 88:1–10 patterns in females [6] and differences in PV rubra vera-1 The ideal therapeutic agent? (PRV1) mRNA expression (discriminating two types of ET) [7], while immunohistochemical evidence includes hetero- A number of pharmacotherapies have been investigated for geneous c-mpl expression [8]. Differences have also been use in ET. The ideal therapeutic treatment should rapidly observed between patients with ET in the growth of lower platelet counts to normal levels, reduce ET-related erythropoietin-independent colonies (EEC). In a study of complications and symptoms, have limited side effects and molecular markers, growth of EEC was observed in 50– no long-term safety concerns. Long-term benefits and risks 69% of ET patients [7, 9]. Furthermore, as a group, ET of pharmacotherapy are of particular relevance to patients patients with the JAK2V617F mutation and/or low serum with ET, who require prolonged treatment over a lifetime. erythropoietin levels seem to have a more PV-like pheno- This article considers the long-term effects of several ET type with slightly higher white blood cell counts and treatment options, focusing on the anti-platelet agent, haemoglobin levels [3, 10, 11]. aspirin, and three cytoreductive therapies: hydroxycarba- mide, anagrelide and interferon-α. Taking these findings into consideration, a risk-based treatment algorithm for ET Diagnosis is proposed. The diagnosis of ET includes detection of specific changes in bone marrow morphology, as well as exclusion of Literature search secondary thrombocytosis caused by other conditions [12]. Recently, an advisory group to the WHO proposed This article contains information from a number of sources, revised diagnostic criteria for ET (Table 1)[12]. Using including relevant searches of PubMed (conducted on 14 these criteria, diagnosis is supported by demonstration of a November 2007), the author’s own reference database and clonal marker of the condition (e.g. JAK2V617F, present in the reference lists of recent review articles. It is not approximately 50% of ET patients) [3]; however, identifi- intended as a systematic review. cation of this mutation cannot differentiate between ET and other MPDs. Several investigators suggest that some ET patients diagnosed according to the guidelines of the Acetylsalicyclic acid (aspirin) Polycythaemia Vera Study Group actually have an early stage chronic primary myelofibrosis (PMF-0 or ‘false ET’) Since it was first synthesised in 1897, the use of aspirin has [13, 14]. This prefibrotic condition is known to progress to extended from analgesia to encompass prevention of overt myelofibrosis in a high proportion of patients, thus cardiovascular events such as myocardial infarction and differing from ‘true ET’ which does not [15–17]. If this ischaemic stroke [19]. Theoretically, aspirin also has a place distinction is valid, it is an important consideration when in the management of ET, particularly as it has been shown evaluating treatment strategies. However, the feasibility of to suppress excess thromboxane synthesis [20], evident in distinguishing ET from PMF-0 is not generally accepted patients with ET and PV [20, 21]. Several studies have among pathologists in clinical practice [18]. confirmed this theory, showing that aspirin reduces throm- botic complications associated with ET [22, 23] as well as microvascular events (e.g. neurological symptoms and Table 1 New World Health Organization (WHO) proposed classifi- erythromelalgia) [24, 25]. cation for essential thrombocythaemia [12] The only randomised controlled trial investigating use of All the following criteria must be met to diagnose essential aspirin in this area was performed in patients with PV, a thrombocythaemia: related MPD [26], which calls into question the direct appli- cability of the results. In the placebo-controlled European & ≥ 9 ≥ 9 Sustained platelet count 450×10 /l (reduced from 600×10 /l) Collaboration on Low-dose Aspirin in PV (ECLAP) study, & Bone marrow biopsy specimen showing proliferation mainly of the megakaryocytic lineage with increased numbers of enlarged, low-dose aspirin (100 mg/day) significantly reduced the risk mature megakaryocytes; no significant increase or left-shift of of thrombotic complications (non-fatal myocardial infarction neutrophil granulopoiesis or erythropoiesis and stroke, death from cardiovascular causes, pulmonary & Does not meet the WHO criteria for polycythaemia vera, primary embolism and major venous thrombosis) [26]. myelofibrosis, chronic myelogenous leukaemia, myelodysplastic Any long-term therapeutic benefit of aspirin should be syndromes or other myeloid neoplasms weighed against the potential risk of a major bleeding & JAK2V617F Demonstration of mutation or other clonal marker, or in episode and gastrointestinal side effects. The relative risk of the absence of a clonal
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