Diagnosis and management of autoimmune cytopenias in adults

1. Diagnosis and management of autoimmune cytopenias in adults Dupe Elebute

2. Autoimmune disorders • >80 known AI disorders • Affects 5% population • Loss of tolerance to self antigen(s) • Clinical syndromes caused by activation of T cells, B cells or both • Organ-specific • Opsonized cells removed by RES • Cause unknown

3. Practical points! • May occur in isolation or in combination with each other • Commonly associated with other disorders • Making the diagnosis is not always straightforward; exclude other causes of cytopenia(s) • Does patient need Rx? • Aim of Rx is to achieve a ‘safe’ count; avoid over Rx!

4. Autoimmune haematological diseases • Autoimmune haemolytic anaemia • Immune thrombocytopenia purpura • Autoimmune neutropenia

5. Autoimmune haemolytic anaemias (AIHA) Excellent review in Postgraduate Haematology, 5th edition by Gordon-Smith & Marsh

6. Autoimmune haemolytic anaemia (AIHA) • Warm type 80-90% • Cold type 10-15% • cold haemagglutinin disease (CHAD) • paroxysmal cold haemoglobinuria (PCH) • Mixed warm and cold type (rare) • Drug-induced 10-15%

7. Causes of warm AIHA • Primary • Secondary • lymphoproliferative disorders • other autoimmune disorders: SLE, RA, Sjogren’s ITP (Evan’s syndrome) • drugs: Methyldopa, Fludarabine (may be severe) • immunodeficiency • non-lymphoid neoplasms: ovarian ca (and cysts) AIHA may precede presentation of underlying dx

8. Evan’s syndrome • Combination of AIHA and ITP • Higher incidence of: • immunodeficiency or autoimmune lymphoproliferative disease in children • SLE and T-cell lymphoma in adults • More refractory to treatment

9. Warm AIHA • High affinity IgG autoantibodies; most active at 37oC • Usually extravascular haemolysis • (Can be intravascular haemolysis if complement is fixed) • DAT usually IgG (IgG1 and IgG3) +/- C3d • 5% DAT neg: subthreshold IgG, occasional IgM or IgA)

10. Acute or insidious onset Can be precipitated by trauma, surgery, infection, pregnancy Anaemia, jaundice, fever, mild hepato-splenomegaly Range of severity from mild compensated to hyper-acute haemolysis Risk of thrombosis (25-30%), lupus anticoagulant/ACLA+ in many; consider prophylaxis Spherocytosis Reticulocytosis, polychromasia, nucleated red cells Bone marrow: erythroid hyperplasia Indirect hyperbilirubinaemia, elevated LDH Clinical features Laboratory features

11. First line management • Folic acid for all • Corticosteroids • prednisolone 1 - 2mg / kg / day • methylprednisolone 100-200mg / day • 70-80% improve within 3 weeks • 15-20% complete remission and discontinue steroids • 10% no remission • Blood transfusion can be life-saving • Don’t withhold blood if incompatible cross-match (give least incompatible or group specific)

12. Splenectomy • Splenectomy reserved for • non-responders • those requiring chronic prednisolone >15mg/day • Best responders in DAT IgG+ only • 60-75% effective • Risk of infection with encapsulated bacteria

13. Immunosuppressive agents • Cyclophosphamide 60mg/m2 • Azathioprine 80mg /m2 - 40-60% response - Bone marrow suppression, alopecia, sterility, haemorrhagic cystitis, risk of second malignancy • Other approaches: • Plasma exchange, IVIg, Danazol, Cyclosporin A • New approaches: Rituximab

14. Cold type AIHA

15. Cold type AIHA • Primary • Often monoclonal IgMk with anti-I specificity • Secondary • Infection: Mycoplasma (anti-I), EBV (anti-i) • Lymphoproliferative disease (anti-I or i) • Paroxysmal cold haemoglobinuria

16. Mild chronic haemolytic anaemia exacerbated by cold environment Can be transient if infection related Acrocyanosis, Raynaud’s phenomenon, skin ulceration and necrosis Acute intravascular haemolysis with haemoglobinuria Spherocytosis infrequent Red cell agglutination on PB Falsely elevated MCV; test sample at 37oC Clinical features Laboratory features Clinical features Macroscopic agglutination Red cell agglutination

17. Cold type AIHA: Serological features • IgM antibodies, most are low titre, binding with low affinity in the cold (4oC) • <5% patients, more severe haemolysis with high titre antibodies and wide thermal amplitude • Predominantly intravascular haemolysis • DAT usually C3d positive only; IgM not detected because eluted in vitro • Anti-I and anti-i specificity

18. Management of cold AIHA • Depends on the severity of the haemolysis • Avoid the cold • Treat underlying cause where possible • Folic acid supplements • Prednisolone and splenectomy rarely helpful • Chlorambucil or cyclophosphamide • Red cell transfusion - blood warmer • Rituximab (anti CD20): 45-55% response

19. Paroxysmal cold haemoglobinuria • Rare • Usually in children, post measles, mumps, chicken pox • Cold antibody BUT is IgG (Donath Landsteiner antibody) • Reacts with red cells <20oC in periphery • As red cells warmed at 37oC in central vessels →lysis by complement activation • Ab has specificity for the P antigen • Self limiting, avoid the cold, may need blood transfusion

20. ITP

21. Causes of ITP • Primary/idiopathic in most cases • Secondary • Lymphoproliferative disorders: CLL, Lymphoma • Systemic autoimmune disorders: SLE, AIHA • Infections: HIV, Hepatitis C, EBV, CMV, Helicobacter • Common variable immunodeficiency

22. Diagnosis of ITP • Take detailed drug history • Over-the-counter drugs • Herbal remedies • Quinine!! • Exclude other types of drug induced thrombocytopenia* • Social history (alcohol) • Family history (inherited thrombocytopenias) • Recent transfusion (post-transfusion purpura) • Other medical history • HIV • lymphoproferative disorder • other autoimmune disorders? * Aster, NEJM 2007; 357: 586 (An excellent review)

23. Examine a blood film Why? Is a bone marrow needed? Large platelets Is there platelet clumping? Dysplastic features? Megaloblastic changes? CLL? Spherocytes (DAT+)? Red cell fragments (MAHA, TTP)? Megakaryocytes  or N Yes if: - ‘Atypical features’ - > 60yr age - Considering splenectomy - Relapse of ITP Investigations required for ITP - 1

24. Investigations required for ITP - 2 • Is platelet antibody testing required? • Other investigations • screen for Helicobacter pylori in refractory patients • Hepatitis C, HIV • Autoantibodies (exclude SLE, RA, Sjogren’s…) • DAT (Evan’s syndrome)

25. Lab tests Direct immunofluorescent test (PIFT) for PAIg Indirect PIFT for serum antibodies But, lack sensitivity and specificity When are they justified? ITP refractory to 1st and 2nd line Rx Bone marrow failure and ?ITP Drug-dependent immune TP Unexplained TP Acquired autoantibody mediated platelet dysfunction Laboratory testing for platelet autoantibodies

26. Acquired autoantibody mediated platelet dysfunction Platelet autoantibodies may target ligand binding sites: • Clinical features: • severe bleeding • degree of bleeding does not correlate with platelet count • bleeding may persist despite recovery of platelet count

27. Natural history of ITP • Benign course in most, good outcome • Cerebral haemorrhage in 3% • Risk of cerebral haemorrhage increased in: • Deaths from effects of therapy as well as bleeding • Aim is a ‘safe’ platelet count and not cure • Avoid unnecessary or over-treatment • Head trauma • Patients with bleeding • Drugs: aspirin, NSAIDs • Coagulation disorders • No response to Rx Portielje et al, Blood 97, (2001) Lee & Kim Neurol 50, (1998) George & Raskob SeminHematol 35 (1998)

28. Dentistry (fillings)10 Extractions30 Regional dental block30 Minor surgery50 Major surgery80 Pregnancy: Vaginal delivery ≥ 50 (30-50) Caesarian section ≥ 80 Epidural ≥ 80 If asymptomatic, no treatment of ITP indicated if ≥ 20 “Safe” platelet counts BCSH Guidelines 2003 Brit. J. Haem

29. Platelets >30 x 109/l Observe Or treat if: - Bleeding - Planned procedure likely to induce bleeding Platelets <30 x 109/l Observe if no symptoms/signs Or treat if: - Platelets <10 x109/L - Clinical problems - Planned procedure Pred 1mg/kg/day x 2-4/52 then  IVIg (effective in 75% but not sustained) or anti-D First line therapy

30. Approach to poor response to 1st line therapy Psaila and Bussel, BJH. 2008 (Cinel and Bussel, Blood 2005; 106:2244-51 How I treat ITP)

31. ITP : second line - splenectomy • 2/3 will respond • Need platelets >30 x 109/L for splenectomy • Vaccination • Pneumovax, Hib, Meningococcal C • 2 weeks pre-op • Other prophylaxis • Penicillin 250-500mg bd (or equivalent) ?for life ?2 years • Annual flu vaccine + Pneumovax booster 5 yearly • Can one predict response?

32. 111In labelled autologous platelet scan (Royal London Hospital) spleen liver Pattern 5-30years >30years Splenic 96% remission 91% remission Mixed/hepatic 15% response Najean, BJH 1997; 97, 547-550

33. Rationale for monoclonal antibody therapies • Powerful immunosuppressive agents • May re-set immune system • Targeted therapy • Avoidance of more generalised side effects • Alopecia • Infertility • 2 tumours • MDS

34. Rituximab (anti-CD20) Dose 375mg/m2 weekly x 4 Meta-analysis, n = 306 • CR in 43%, overall R (> 50 x 109/l) in 62% • Med. time to response = 5wk (3-6.5) • Med. duration response = 10mo (6-17) • Relapse = 10% Arnold et al, Ann. Int. Med. 2007; 146: 25 Excellent review of Rituximab in the treatment of autoimmune haematological disorders. Garvey, BJH 2008; 141:149-69

35. Thrombopoietin receptor (TPO-R) agonists Kuter et al, Lancet 2008; 371: 395 Protein (‘peptibody’), no sequence homology to TPO Weekly s/c injection • Romiplostim (AMG 531) 2. Eltrombopag Bussel J, NEJM 2007;357:2237 Oral, small molecule, non-peptide,TPO-R agonist • Response in ~ 80% patients • Response starts at 5-10 days, peaks at 14 d • Well tolerated • Very few side effects ( BM reticulin, thrombosis,  blasts in MDS)

36. Autoimmune neutropenia(AIN)

37. Clinical presentation of AIN • Recurrent fevers, mouth ulcers • Profound lethargy • Skin sepsis, gingivitis, URTI/pneumonia • Symptoms of associated autoimmune disease or malignancy • May be asymptomatic

38. Laboratory findings in AIN (adults) Antibodies are usually: • IgG but IgM often also present • HNA specificity rarely identified; reactivity against CD16 (FcRIIIb) • Ab activity may fluctuate during course of disorder • Ab may disappear rapidly after treatment with steroids • In severe, assumed autoantibody reactive against early progenitor Cytotoxic T-cell mediated immunity may be involved • Oligoclonal CD8 T-cell expansion occurs in some unexplained chronic neutropenias

39. Lab. tests for neutrophil autoantibodies • Direct & indirect immunofluorescence tests (GIFT/LIFT) • Granulocyte chemiluminescence test • MAIGA (monoclonal antibody-specific immobilisation of granulocyte antigens) assay • HNA typed panel cells

40. Bone marrow findings in AIN BM findings in AIN Maturation arrest Absence of granulocytic precursors OR

41. Primary Secondary Other autoimmune disorders: - SLE, RA, Felty’s syndrome, Sjogren’s - ITP, AIHA, T-LGL Malignancy: CLL, lymphoma, thymoma Drugs: penicillin, cephalosporins Viruses: EBV, CMV, HIV Hypogammaglobulinaemia Post BMT Causes of AIN in adults

42. Exclude other causes of neutropenia • Drug induced neutropenia • ‘Chronic idiopathic neutropenia’ • Viral infection: Hep A, B, influenza, RSV, rubella, measles, varicella, parvovirus, EBV, CMV • Bacterial infection: TB, typhoid, brucella, severe sepsis • Cyclical neutropenia • Severe congenital neutropenia, Schwachmann- Diamond syndrome

43. Treatment in AIN • May not be indicated in many patients • Small % have severe and life-threatening dx • Decision to start specific treatment: • degree of neutropenia • frequency of infections • Early antibiotics

44. G-CSF: first line therapy for AIN • Effective in most cases • Starting dose 5g/kg/d, but overshoot of neutrophils common • ‘Maintenance’: lower dose / intermittent use • Time to response: depends on BM picture • Not always well tolerated: bone pain, flu-like symptoms

45. AIN: other therapies • Immunosuppressants • Azathioprine, MMF, cyclophosphamide • Prednisolone • variable response, high doses needed • Splenectomy usually ineffective • Experimental • Cyclosporin, ATG, • Alemtuzumab, (Rituximab)

46. Monoclonal antibody therapy for AIN Killick, BJH 1997; 97, 306-308 Dungarwalla, Annals of Hematol, 2007; 86, 191-197

47. Autologous Stem Cell Transplantation for Refractory Autoimmune Cytopenias J.R. Passweg, M. Rabusin, M. Musso, Y. Beguin, G. Ehninger, L. Jost, V. Koza, I. Lisukov, A. Marmont, P. Philippe, P. Quartier, J. Vavrinec, J. Vormoor, A. Tyndall, A. Gratwohl for the Autoimmune Disease Working Party of the EBMT

48. Behcet 8 Cryoglobulinemia 8 Wegener 6 IBD 5 MCTD 3 ALS 2 Ankylosing Spondylitis 2 Myasthenia 2 PAN 2 Polyneuropathy 2 etc EBMT Autoimmune Disease WP database (n=702) MS 204 SSc 120 RA 85 SLE 77 JCA 64 ITP 16 AIHA 11 Evans 9 PRCA 7 PWCA 2 Pancytopenia 1 TTP 3 Updated Nov 2005

49. SCT for AIC: Treatment related mortality ITP SLE JIA SSc MS RA Gratwohl, BMT 2005

50. Final thoughts…… • Not all patients need treatment and most will respond to 1st (or 2nd ) line treatment • Refractory autiommune cytopenias can be life-threatening; investigate further • Does patient need treatment? – it may be worse than the disease • Gradual move away from non-selective cytotoxic immune suppressant (MoAbs, TPO-R agonists..)