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News from Nov. 11, 2014 Annals of Internal Medicine

Annals of Internal Medicine tip sheet

American College of Physicians

1. AABB releases new guidelines on the appropriate use of platelet transfusion in adult patients

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New guidelines from the AABB (formerly, the American Association of Blood Banks) specify clinical situations in which platelet transfusion is recommended in adult patients. The guidelines are being published in Annals of Internal Medicine. Platelet transfusions are administered to prevent or treat bleeding in patients with quantitative or qualitative platelet disorders. To inform its recommendations, researchers for the AABB conducted a systematic review of randomized, clinical trials and observational studies that reported clinical outcomes in patients receiving prophylactic or therapeutic platelet transfusions. They developed guidelines that address several common clinical situations and attempt to identify a platelet count threshold below which platelet transfusion may improve hemostatis and above which platelet transfusion is unlikely to benefit the patient. Based on strong evidence, the AABB recommends prophylactic platelet transfusion to reduce the risk for spontaneous bleeding in hospitalized adult patients with therapy-induced hypoproliferative thrombocytopenia and a platelet count of 10# x #109 cells/L. Weaker evidence suggests that prophylactic platelet transfusion should be administered in patients having elective central venous catheter placement with a platelet count of less than 20# x #109 cells/L or patients having elective diagnostic lumbar puncture or major elective nonneuraxial surgery with a platelet count less than 50# x #109 cells/L. The AABB recommends against routine prophylactic platelet transfusion in patients who are nonthrombocytopenic and have cardiac surgery with cardiopulmonary bypass but suggests (without recommending) that those with perioperative bleeding and thrombocytopenia or platelet dysfunction may benefit from transfusion.

Note: The URL for this story will be live when embargo lifts. For a PDF, please contact Megan Hanks. To interview the lead author, please contact Jessica Maki Caragher at jcaragher@partners.org or 617-525-6373.

2. Multidrug, multitarget regimen results in higher remission rates for lupus nephritis patients

A multidrug, multitarget regimen proves superior to intravenous cyclophosphamide (IVCY) as induction therapy for lupus nephritis (LN), according to a randomized, controlled trial being published in Annals of Internal Medicine. LN is the inflammation of the kidney caused by systemic lupus erythematosus. Treatment is challenging and usually consists of an initial induction phase to achieve rapid remission, followed by long-term maintenance. Complete remission with current induction therapy regimens remains low. Therefore, more effective induction regimens are needed. Researchers sought to assess the efficacy and safety of a multitarget therapy consisting of tacrolimus, mycophenolate mofetil, and steroid compared with IVCY and steroid as induction therapy for patients with LN. Three hundrend sixty-eight patients between the ages of 18 and 65 with LN were randomly assigned to one of two treatment groups. All participants received intravenous methylprednisolone pulse therapy for three days, followed by a dose of oral prednisone (0.6 mg/kg per day) each morning for four weeks. The dose of prednisone was tapered by 5 mg/d every day for two weeks, and then by 2.5 mg/d every two weeks. The maintenance dose of prednisone was 10 mg/d. After the initial treatment, the multitarget group received mycophenolate mofetil (0.5 g) and tacrolimus (2 mg) each two times per day. The IVCY group received cyclophosphamide at a dose of 0.75 g/m2 body surface area, and then adjusted the dose to 0.5 to 1.0 g/m2 body surface area every four weeks for six doses. The patients were evaluated at two and four weeks, and then every four weeks until 24 weeks for changes in levels of proteinuria and serum albumin, and drug-related adverse effects. Both groups had high adherence rates. Patients in the multitarget group had greater changes in urine protein and serum albumin and at week 24, approximately 84 percent of patients were in partial or complete remission compared to 63 percent of patients in the IVCY group. The authors suggest that the multitarget regimen should be considered as an alternative to conventional therapies for LN.

Note: The URL for this story will be live when embargo lifts. For a PDF, please contact Megan Hanks. The lead author, Dr. Zhi-Hong Liu, can be contacted directly at liuzhihong@nju.edu.cn or 13952093539.

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