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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2022;158:e1" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Guidelines of the Spanish ITP Group for the diagnosis, treatment and follow-up of patients with immune thrombocytopenia" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "e1" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones del Grupo Español de PTI para el diagnóstico, tratamiento y seguimiento de pacientes con trombocitopenia inmune" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Luis Callejas Rubio, Raquel Ríos Fernandez, Paloma García Martín" "autores" => array:3 [ 0 => array:2 [ "nombre" => "José Luis" "apellidos" => "Callejas Rubio" ] 1 => array:2 [ "nombre" => "Raquel" "apellidos" => "Ríos Fernandez" ] 2 => array:2 [ "nombre" => "Paloma" "apellidos" => "García Martín" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775321006278" "doi" => "10.1016/j.medcli.2021.09.019" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775321006278?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020622002200?idApp=UINPBA00004N" "url" => "/23870206/0000015800000011/v1_202206190623/S2387020622002200/v1_202206190623/en/main.assets" ] ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Reply" "tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e2" "paginaFinal" => "e3" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "María Luisa Lozano Almela, Miguel Ángel Sanz Alonso, Vicente Vicente García" "autores" => array:3 [ 0 => array:4 [ "nombre" => "María Luisa" "apellidos" => "Lozano Almela" "email" => array:1 [ 0 => "mllozano@um.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Miguel Ángel" "apellidos" => "Sanz Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Vicente" "apellidos" => "Vicente García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital JM Morales Meseguer, Universidad de Murcia, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We appreciate the comments of Callejas et al. regarding the special feature recently published in this journal<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and would like to point out to interested readers that additional information on immune thrombocytopenia (ITP) can be found in a more extensive consensus document prepared by the Immune Thrombopenia Working Group (ITWG).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We agree that there is heterogeneity in the relevance that <span class="elsevierStyleItalic">Helicobacter pylori</span> (<span class="elsevierStyleItalic">H. pylori</span>) may have on the pathophysiology of ITP and the likelihood of platelet responses following its eradication, which is largely dependent on the geographical origin of the patient. The term standardization document prepared in 2009 establishes that, considering the high prevalence of this infection, a diagnosis of ITP associated with <span class="elsevierStyleItalic">H. pylori</span> requires demonstration of complete resolution of ITP after bacterial eradication.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Neither the international<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> nor the Spanish<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> consensus guidelines contemplate the need to routinely analyse all patients with ITP for the presence of <span class="elsevierStyleItalic">H. pylori</span>, while this recommendation is established in the Japanese guidelines.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This is in line with the results of a recent international survey showing that the assessment of <span class="elsevierStyleItalic">H. pylori</span> in ITP patients is twice as high in Asian and Middle Eastern countries compared to Europe and North America, and that in the former the perception of platelet responses after eradication treatment is higher.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It can be argued that universal screening could spare some patients from immunosuppressive treatments, especially corticosteroids. Against this, it is also postulated that thrombocytopenias related to <span class="elsevierStyleItalic">H. pylori</span> are generally mild and do not usually require treatment, so universal screening and eradication treatment in positive cases may not be cost-effective.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> As established in the Spanish guidelines,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> well-designed studies are required to confirm the relationship between bacterial infection and autoimmune disease in different geographical areas. The only study conducted in our country was not able to demonstrate a causal relationship between eradication treatment and ITP resolution.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Therefore, screening for <span class="elsevierStyleItalic">H. pylori</span> (either by breath or stool test) may be recommended in adults with moderate thrombocytopenia and gastrointestinal symptoms, or who originate from endemic areas (mainly Asia).</p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding the management of ITP secondary to systemic lupus erythematosus (SLE), all data are based on retrospective studies; Spanish guidelines state that treatment should be started in case of a platelet count below 20 × 10<span class="elsevierStyleSup">9</span>/L or if there are bleeding symptoms.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> As in primary ITP, a first line with corticosteroids and/or intravenous immunoglobulins is recommended, but in the event that a second line is required, rituximab would be the first choice.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Also, the current literature would support not only the use of other immunosuppressants, such as azathioprine, mycophenolate mofetil, cyclosporin A, or cyclophosphamide, but also traditional antirheumatic drugs such as hydroxychloroquine as relatively well-tolerated, effective agents likely to favourably affect the overall activity of SLE as well as thrombocytopenia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Although the response rate to splenectomy or thrombopoietin receptor agonists (TPO-RA) is similar to primary ITP, caution should be exercised in the use of these strategies when lupus anticoagulant is present, due to thrombotic risk.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The hypothesis that reducing the number of long-lived plasma cells persisting in a BAFF-rich environment through belimumab could increase platelet responses in primary ITP has recently been evaluated in a phase IIb trial.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Fifteen patients received two doses of rituximab, followed by five infusions of belimumab. Compared with historical response rates to rituximab of 40%–50%, the combination with belimumab doubled this percentage, although the duration of this response remains to be determined. Taking these promising results into account, a randomized, double-blind Phase 3 trial is planned to start in 2022 to test the efficacy and safety of belimumab versus placebo in combination with rituximab in the treatment of patients with primary ITP. We agree with Callejas et al. that, in the future, therapies aimed at reducing factors that promote plasma cell tissue survival may be an effective and safe option to treat both the underlying disease and the associated thrombocytopenia in some patients with SLE and secondary ITP. We hope that prospective studies will confirm this.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0020" class="elsevierStylePara elsevierViewall">This original paper has not received funding of any kind.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0025" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lozano Almela ML, Sanz Alonso MÁ, Vicente García V. Respuesta. Med Clin (Barc). 2022;158:e2–e3.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines of the Spanish ITP Group for the diagnosis, treatment and follow-up of patients with immune thrombopenia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.L. Lozano" 1 => "M.A. Sanz" 2 => "V. Vicente" 3 => "Grupo Español de PTI (GEPTI)" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medcli.2021.03.017" "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)." 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