Immune thrombocytopenia resulting from sensitivity to metabolites of naproxen and acetaminophen

Blood ◽  
2001 ◽  
Vol 97 (12) ◽  
pp. 3846-3850 ◽  
Author(s):  
Daniel Bougie ◽  
Richard Aster
Keyword(s):  
Clinical Picture ◽  
Immune Thrombocytopenia ◽  
Drug Induced ◽  
Inflammatory Drug ◽  
Drug Metabolites ◽  
Suspect Drug ◽  
Negative Results ◽  
Responsible Agent ◽  
Drug Dependent

In patients suspected of having drug-induced immune thrombocytopenia, antibodies reactive with normal platelets in the presence of the suspect drug can sometimes be identified, but negative results are often obtained. One reason for this is that drug metabolites, formed in vivo, can be the sensitizing agents, but very little is known about the specific metabolites that can cause this complication. Five patients were studied who developed thrombocytopenia after taking the nonsteroidal anti-inflammatory drug naproxen (3 cases) or acetaminophen (2 cases) but in whom drug-dependent antibodies could not be detected by means of the unmodified drugs. In each case, antibodies that reacted with normal target platelets in the presence of a known drug metabolite (naproxen glucuronide or acetaminophen sulfate) were identified. Four of the antibodies were specific for the glycoprotein (GP) IIb/IIIa complex, but one acetaminophen sulfate–dependent antibody reacted preferentially with GPIb/IX/V. In patients with a clinical picture suggestive of drug-induced immune thrombocytopenia, tests for metabolite-dependent antibodies can be helpful in identifying the responsible agent.

scholarly journals Drug-dependent clearance of human platelets in the NOD/scid mouse by antibodies from patients with drug-induced immune thrombocytopenia

Blood ◽  
2010 ◽  
Vol 116 (16) ◽  
pp. 3033-3038 ◽  
Author(s):  
Daniel W. Bougie ◽  
Dhirendra Nayak ◽  
Brian Boylan ◽  
Peter J. Newman ◽  
Richard H. Aster
Keyword(s):  
Scid Mouse ◽  
Immune Thrombocytopenia ◽  
Small Animal ◽  
Study Drug ◽  
Human Platelets ◽  
Antibody Detection ◽  
Human Antibody ◽  
Drug Induced ◽  
Drug Dependent

Abstract Drug-induced immune thrombocytopenia (DITP) is a relatively common and sometimes life-threatening condition caused by antibodies that bind avidly to platelets only when drug is present. How drug-dependent antibodies (DDAbs) are induced and how drugs promote their interaction with platelets are poorly understood, and methods for detecting DDAbs are suboptimal. A small animal model of DITP could provide a new tool for addressing these and other questions concerning pathogenesis and diagnosis. We examined whether the nonobese diabetic/severe combined immunodeficient (NOD/scid) mouse, which lacks xenoantibodies and therefore allows infused human platelets to circulate, can be used to study drug-dependent clearance of platelets by DDAbs in vivo. In this report, we show that the NOD/scid model is suitable for this purpose and describe studies to optimize its sensitivity for drug-dependent human antibody detection. We further show that the mouse can produce metabolites of acetaminophen and naproxen for which certain drug-dependent antibodies are specific in quantities sufficient to enable these antibodies to cause platelet destruction. The findings indicate that the NOD/scid mouse can provide a unique tool for studying DITP pathogenesis and may be particularly valuable for identifying metabolite-specific antibodies capable of causing immune thrombocytopenia or hemolytic anemia.

scholarly journals Pathophysiology and Diagnosis of Drug-Induced Immune Thrombocytopenia

2020 ◽  
Vol 9 (7) ◽  
pp. 2212 ◽  
Author(s):  
Caroline Vayne ◽  
Eve-Anne Guéry ◽  
Jérôme Rollin ◽  
Tatiana Baglo ◽  
Rachel Petermann ◽  
...  
Keyword(s):  
Immune Thrombocytopenia ◽  
Clinical Syndrome ◽  
Severe Thrombocytopenia ◽  
Drug Induced ◽  
Platelet Factor ◽  
Life Threatening ◽  
Thrombotic Complications ◽  
Drug Dependent

Drug-induced immune thrombocytopenia (DITP) is a life-threatening clinical syndrome that is under-recognized and difficult to diagnose. Many drugs can cause immune-mediated thrombocytopenia, but the most commonly implicated are abciximab, carbamazepine, ceftriaxone, eptifibatide, heparin, ibuprofen, mirtazapine, oxaliplatin, penicillin, quinine, quinidine, rifampicin, suramin, tirofiban, trimethoprim-sulfamethoxazole, and vancomycin. Several different mechanisms have been identified in typical DITP, which is most commonly characterized by severe thrombocytopenia due to clearance and/or destruction of platelets sensitized by a drug-dependent antibody. Patients with typical DITP usually bleed when symptomatic, and biological confirmation of the diagnosis is often difficult because detection of drug-dependent antibodies (DDabs) in the patient’s serum or plasma is frequently not possible. This is in contrast to heparin-induced thrombocytopenia (HIT), which is a particular DITP caused in most cases by heparin-dependent antibodies specific for platelet factor 4, which can strongly activate platelets in vitro and in vivo, explaining why affected patients usually have thrombotic complications but do not bleed. In addition, laboratory tests are readily available to diagnose HIT, unlike the methods used to detect DDabs associated with other DITP that are mostly reserved for laboratories specialized in platelet immunology.

scholarly journals On the mechanisms of sensitization and attachment of antibodies to RBC in drug-induced immune hemolytic anemia

Blood ◽  
1987 ◽  
Vol 69 (4) ◽  
pp. 1006-1010 ◽  
Author(s):  
A Salama ◽  
C Mueller-Eckhardt
Keyword(s):  
Specific Binding ◽  
Drug Induced ◽  
Cell Complexes ◽  
Large Panels ◽  
Plot Analysis ◽  
Number Of Patients ◽  
Immune Hemolytic Anemia ◽  
Drug Dependent ◽  
Reaction Patterns

Abstract The mechanisms of sensitization and attachment of drug-dependent antibodies to RBC in drug-induced immune hemolytic anemias are largely speculative. Nomifensine has been incriminated in causing immune hemolysis in a large number of patients. The hemolysis was usually of the so-called immune complex type, less commonly of the autoimmune type, and more surprisingly, few patients had developed both types of hemolysis. To determine whether nomifensine (metabolite)-dependent antibodies (ndab) exhibit specificity for antigenic structures of RBC membranes, 30 ndab were tested against large panels of RBC with common and rare antigens. We found that only 14 out of 30 ndab were invariably reactive with all cells tested. Nine antibodies were, similar to the majority of idiopathic or drug-induced autoantibodies, not or only weakly reactive with Rhnull RBC. Three antibodies did not react with cord RBC and could be inhibited by soluble I antigen. The remaining four antibodies gave inhomogeneous reaction patterns or were even negative with selected RBC; their specificity could not be identified. On a Scatchard plot analysis of one ndab, a maximum of 173,000 drug- dependent antibodies of the IgG class can specifically bind per RBC in the presence of the drug. Although nomifensine and its metabolites do not attach tightly onto RBC, our results clearly indicate that RBC do not act as “innocent bystanders,” but rather serve as a surface for a loose attachment of drugs that possibly cause a subtle structural change in the cell antigens and, by this means, allow in vivo sensitization; and a specific binding of the resultant antibodies. This concept would explain why these antibodies can be directed against drug- cell complexes, against cell antigens alone (autoantibodies), or against both in the same patient.

scholarly journals Patients with quinine-induced immune thrombocytopenia have both “drug-dependent” and “drug-specific” antibodies

Blood ◽  
2006 ◽  
Vol 108 (3) ◽  
pp. 922-927 ◽  
Author(s):  
Daniel W. Bougie ◽  
Peter R. Wilker ◽  
Richard H. Aster
Keyword(s):  
Immune Thrombocytopenia ◽  
Drug Sensitivity ◽  
Soluble Form ◽  
Severe Thrombocytopenia ◽  
Membrane Glycoproteins ◽  
Drug Induced ◽  
Specific Antibodies ◽  
Cellular Targets ◽  
Surrogate Measure ◽  
Drug Dependent

AbstractImmune thrombocytopenia induced by quinine and many other drugs is caused by antibodies that bind to platelet membrane glycoproteins (GPs) only when the sensitizing drug is present in soluble form. In this disorder, drug promotes antibody binding to its target without linking covalently to either of the reacting macro-molecules by a mechanism that has not yet been defined. How drug provides the stimulus for production of such antibodies is also unknown. We studied 7 patients who experienced severe thrombocytopenia after ingestion of quinine. As expected, drug-dependent, platelet-reactive antibodies specific for GPIIb/IIIa or GPIb/IX were identified in each case. Unexpectedly, each of 6 patients with GPIIb/IIIa-specific antibodies was found to have a second antibody specific for drug alone that was not platelet reactive. Despite recognizing different targets, the 2 types of antibody were identical in requiring quinine or desmethoxy-quinine (cinchonidine) for reactivity and in failing to react with other structural analogues of quinine. On the basis of these findings and previous observations, a model is proposed to explain drug-dependent binding of antibodies to cellular targets. In addition to having implications for pathogenesis, drug-specific antibodies may provide a surrogate measure of drug sensitivity in patients with drug-induced immune cytopenia.

scholarly journals Quinine-dependent, platelet-reactive monoclonals mimic antibodies found in patients with quinine-induced immune thrombocytopenia

Blood ◽  
2009 ◽  
Vol 113 (5) ◽  
pp. 1105-1111 ◽  
Author(s):  
Daniel W. Bougie ◽  
Jessica Birenbaum ◽  
Mark Rasmussen ◽  
Mortimer Poncz ◽  
Richard H. Aster
Keyword(s):  
Molecular Basis ◽  
Immune Thrombocytopenia ◽  
Antibody Binding ◽  
Membrane Glycoproteins ◽  
Binding Studies ◽  
Platelet Destruction ◽  
Drug Induced ◽  
N Terminus ◽  
Sequencing Studies ◽  
Drug Dependent

Abstract Drug-induced immune thrombocytopenia (DITP) is caused by drug-dependent antibodies (DDAbs) that are nonreactive in themselves but bind tightly to specific platelet membrane glycoproteins (GP) when soluble drug is present at pharmacologic concentrations. This reaction takes place without covalent linkage of drug to the target, indicating that drug does not function as a classical hapten to promote antibody binding. Studies to define other mechanism(s) responsible for this interaction have been frustrated by the polyclonal nature of human DDAbs and limited quantities of antibody usually available. We produced 2 monoclonal antibodies (mAbs), 314.1 and 314.3, from a mouse immunized with purified human GPIIb/IIIa and quinine that recognize the N terminus of the GPIIb β propeller domain only when soluble quinine is present. Both monoclonals closely mimic the behavior of antibodies from patients with quinine-induced immune thrombo-cytopenia in their reactions at various concentrations of quinine and quinine congeners. Sequencing studies showed that the 2 mAbs are closely related structurally and that mAb 314.3 probably evolved from mAb 314.1 in the course of the immune response. These monoclonal reagents are the first of their kind and should facilitate studies to define the molecular basis for drug-dependent antibody binding and platelet destruction in DITP.

scholarly journals Binding of Quinine-Dependent Monoclonal Antibodies to Gpiib/Iiia Appears to Involve Drug-Induced Modulation of Antibody Affinity

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 2246-2246
Author(s):  
Daniel W. Bougie ◽  
Julie A. Peterson ◽  
Mark Rasmussen ◽  
Richard H. Aster
Keyword(s):  
Monoclonal Antibodies ◽  
Immune Thrombocytopenia ◽  
Patent Application ◽  
Soluble Form ◽  
Docking Site ◽  
Fab Fragment ◽  
Drug Induced ◽  
Short Supply ◽  
Unique Type ◽  
Drug Dependent

Abstract A major type of drug-induced immune thrombocytopenia (DITP), characterized by an acute, sometimes life-threatening drop in platelets following drug exposure, is caused by a unique type of antibody that recognizes its target on a platelet membrane glycoprotein, usually αIIb/β3 integrin [glycoprotein (GP) IIb/IIIa], only when the sensitizing drug is present in soluble form. Quinine (Qn) is the prototypic drug that causes this complication, but many other drugs have been implicated. It is widely thought that drug-dependent, platelet-reactive antibodies (DDAbs) characteristic of DITP recognize drug-induced structural modifications of platelet glycoproteins (GP), but this has not been confirmed experimentally. The mechanism responsible for DDAb binding is difficult to study with human DDAbs, which are often poly-specific and in short supply. We used newly-developed, Qn-dependent monoclonal antibodies (IgG1 mAbs 314.1, 314.3) that recognize the N-terminus of GPIIb and closely mimic the serologic behavior of antibodies from patients with Qn-induced immune thrombocytopenia (Blood 2009; 113;1105-11) as an alternative tool for studying the molecular basis of drug-dependent antibody binding. Previous studies failed to demonstrate a docking site for Qn in domains of GPIIb/IIIa that are known targets for the "314" mAbs and for human Qn-dependent antibodies. Therefore we examined an alternative possibility - that binding of drug to antibody might be the first step in DDAb binding. For this purpose, Qn was perfused over the "314" mAbs immobilized on Biacore chips and surface plasmon resonance (SPR) signals were recorded. Findings showed that Qn binds specifically to both mAbs with high affinity (Kd about 30 nM) and with 2:1 stoichiometry (Qn to mAb), consistent with recognition of Qn by complementarity determining regions (CDR) of the mAbs. To characterize monovalent binding of mAb to GPIIb/IIIa, purified integrin in 0.1% triton X-100 was perfused over immobilized mAb 314.1 and SPR signals recorded. Weak, but specific binding was observed in the absence of Qn (Kd 11 uM) that was enhanced 5-fold (Kd 2.2 uM) when Qn was present. Kds for Qn-dependent binding of mAb 314.1 (bivalent interaction) and its Fab fragment (monovalent interaction) to GPIIb/IIIa were determined by flow cytometry using labeled antibody and Fab under conditions that did not require washing prior to direct measurement of platelet bound IgG and Fab. Weak Fab binding was observed in the presence of Qn (≈19 uM) but with intact IgG the effective Kd was reduced to 0.15 nM, reflecting a 100,000-fold increase in avidity. Together with studies that have failed to demonstrate any docking site for Qn on GPIIb/IIIa, the findings support a model in which DDAb-GPIIb/IIIa interaction starts with binding of drug to the antibody CDR, leading to a structural change that markedly increases the avidity of antibody for a weak autoantigen. A requirement for bivalent antibody-target interaction to achieve tight binding could explain why DDAbs almost invariably recognize GPIIb/IIIa or GPIb/IX, the most highly expressed platelet glycoproteins. How this type of DDAb is induced by drug remains uncertain but the findings are consistent with a model in which sensitization starts with drug-induced modification of a B cell receptor that increases its affinity for a weak autoantigen. Disclosures Aster: BLOODCENTER OF WISCONSIN: Patents & Royalties: A patent application has been filed based partly on these findings (Method of detecting platelet activating antibodies that cause heparin-induced thrombocytopenia/thrombosis; PCT/US14/62591).

Drug-induced thrombocytopenia: development of a novel NOD/SCID mouse model to evaluate clearance of circulating platelets by drug-dependent antibodies and the efficacy of IVIG

Blood ◽  
2010 ◽  
Vol 116 (11) ◽  
pp. 1958-1960 ◽  
Author(s):  
Simon X. Liang ◽  
Mykola Pinkevych ◽  
Levon M. Khachigian ◽  
Christopher R. Parish ◽  
Miles P. Davenport ◽  
...  
Keyword(s):  
Mouse Model ◽  
Scid Mouse ◽  
Immune Thrombocytopenia ◽  
Human Platelets ◽  
Ivig Treatment ◽  
Drug Induced ◽  
Beneficial Effects ◽  
Nonobese Diabetic ◽  
Scid Mouse Model ◽  
Drug Dependent

Abstract Drug-induced immune thrombocytopenia (DITP) is an adverse drug effect mediated by drug-dependent antibodies. Intravenous immunoglobulin (IVIG) is frequently used to treat DITP and primary immune thrombocytopenia (ITP). Despite IVIG's proven beneficial effects in ITP, its efficacy in DITP is unclear. We have established a nonobese diabetic/severe combined immunodeficient (NOD/SCID) mouse model of DITP in which human platelets survive for more than 24 hours, allowing platelet clearance by DITP/ITP antibodies to be studied. Rapid human platelet clearance was uniformly observed with all quinine-induced thrombocytopenia (QITP) patient sera studied (mean platelet lifespans: QITP 1.5 ± 0.3 hours vs controls 16.5 ± 4.3 hours), consistent with the clinical presentation of DITP. In contrast, clearance rates with ITP antibodies were more variable. IVIG treatment partially prevented platelet clearance by DITP and ITP antibodies. Our results suggest that the NOD/SCID mouse model is useful for investigating the efficacy of current and future DITP therapies, an area in which there is little experimental evidence to guide treatment.

Tamoxifen-Induced Immune-Mediated Platelet Destruction. A Case Report

1993 ◽  
Vol 79 (3) ◽  
pp. 231-234 ◽  
Author(s):  
Alfonso Candido ◽  
Stefano Bussa ◽  
Raffaele Tartaglione ◽  
Rosalba Mancini ◽  
Carlo Rumi ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Severe Thrombocytopenia ◽  
Platelet Destruction ◽  
Drug Induced ◽  
New Era ◽  
Elderly Female ◽  
Immune Mediated ◽  
Drug Dependent ◽  
Reliable Methods

Drug-induced immunologic thrombocytopenia, a fairly common disorder, is characterized by drug-dependent antiplatelet antibodies that destroy circulating platelets in the presence of the provoking drug or its metabolites. The development of reliable methods for the detection of platelet-bound immunoglobulins causing in vivo platelet destruction, such as the use of monoclonal antibodies tagged with fluorescein and flow cytofluorimetric analysis, has ushered in a new era to differentiate between immune and non-immune thrombocytopenias. A severe thrombocytopenia developed in an elderly female patient treated with tamoxifen, a non-steroidal antiestrogen drug, after surgery for breast cancer. A tamoxifen-dependent platelet antibody was detected in the patient's serum and linked on the platelet membranes. This antibody reacted only in the presence of the offending drug and showed platelet specificity. Withdrawal of drug restored platelet count to normal levels.

scholarly journals Fine specificity of drug-dependent antibodies reactive with a restricted domain of platelet GPIIIA

Blood ◽  
2008 ◽  
Vol 111 (3) ◽  
pp. 1234-1239 ◽  
Author(s):  
Julie A. Peterson ◽  
Tamara N. Nelson ◽  
Adam J. Kanack ◽  
Richard H. Aster
Keyword(s):  
Binding Sites ◽  
Immune Thrombocytopenia ◽  
Restricted Domain ◽  
Drug Induced ◽  
Structural Domains ◽  
Fine Specificity ◽  
Proposed Model ◽  
Restricted Domains ◽  
Glycoprotein Iiia ◽  
Drug Dependent

Abstract Drug-induced immune thrombocytopenia is caused by drug-dependent antibodies (DDAbs) that bind tightly to platelet glycoproteins only when drug is present. How drugs mediate this interaction is not yet resolved. Several studies indicate that sites recognized by DDAbs tend to cluster in specific structural domains, suggesting they may recognize a limited number of distinct epitopes. To address this issue, we characterized the binding sites for 16 quinine-dependent antibodies thought on the basis of preliminary studies to be possibly specific for a single epitope on glycoprotein IIIa (GPIIIa). Fourteen of the antibodies reacted with a 29-kDa GPIIIa fragment comprising only the GPIIIa hybrid and plextrin-semaphorin-integrin homology domains. However, studies with mutant GPIIIa and the blocking monoclonal antibody AP3 showed that the 14 DDAbs recognize at least 6 and possibly more distinct, but overlapping, structures involving GPIIIa residues 50 to 66. The findings suggest that even antibodies specific for restricted domains on a target glycoprotein may each have a slightly different fine specificity; ie, “unique” epitopes recognized by DDAbs may be rare or nonexistent. The observations are consistent with a recently proposed model in which drug reacts noncovalently with both target protein and antibody to promote binding of an otherwise nonreactive immunoglobulin.

Piperacillin–Tazobactam-Induced Immune Thrombocytopenia: A Case Report

2021 ◽  
pp. 089719002110481
Author(s):  
Shangwe Kiliaki
Keyword(s):  
Laboratory Testing ◽  
Immune Thrombocytopenia ◽  
Drug Discontinuation ◽  
Patient Case ◽  
Platelet Destruction ◽  
Drug Induced ◽  
Diabetic Ulcer ◽  
Heparin Induced Thrombocytopenia ◽  
Common Drug ◽  
Drug Dependent

Drug-induced immune thrombocytopenia is an isolated thrombocytopenia caused by accelerated platelet destruction from drug-dependent, platelet-reactive antibodies. Heparin-induced thrombocytopenia is the most common drug-induced immune thrombocytopenia. Common implicated antibiotics for drug-induced immune thrombocytopenia include ceftriaxone, trimethoprim–sulfamethoxazole, vancomycin, and penicillin. The platelet nadir can be less than 20 × 10 (9)/L and typically occurs within 1 to 2 weeks of exposure to the inciting drug. Although rare, drug-induced immune thrombocytopenia can be fatal. Diagnosis is made by excluding other causes of thrombocytopenia. Laboratory testing for drug-dependent antiplatelet antibodies is often helpful but not required. Thrombocytopenia typically improves within 1 to 2 days of drug discontinuation and platelet count returns to normal within a week. Identifying and discontinuing the implicated medication is key to prevention of serious complications. A patient case of drug-induced immune thrombocytopenia is described after initiation of empiric piperacillin–tazobactam for refractory right foot cellulitis in the setting of right fourth toe diabetic ulcer.

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