English Polski

Wyszuk. zaawans.

  • Journal of Transfusion Medicine
  • Tom 17, Nr 2 (2024) Polskie zalecenia postępowania w pierwotnej małopłytkowości immunologicznej u dorosłych opracowane przez Grupę ds. Hemostazy Polskiego Towarzystwa Hematologów i Transfuzjologów — aktualizacja 2024
Tom 17, Nr 2 (2024)
Wytyczne / stanowisko ekspertów
Opublikowany online: 2024-09-05

dostęp otwarty

Pokaż PDF Pobierz plik PDF
Wyświetlenia strony 281
Wyświetlenia/pobrania artykułu 481
Pobierz cytowanie

Eksport do Mediów Społecznościowych

Eksport do Mediów Społecznościowych

Polskie zalecenia postępowania w pierwotnej małopłytkowości immunologicznej u dorosłych opracowane przez Grupę ds. Hemostazy Polskiego Towarzystwa Hematologów i Transfuzjologów — aktualizacja 2024

Krzysztof Chojnowski1, Anna Klukowska2, Magdalena Łętowska3, Paweł Łaguna4, Wojciech Młynarski5, Andrzej Mital6, Jacek Musiał7, Jacek Treliński8, Anetta Undas9, Tomasz Urasiński10, Jerzy Windyga11, Joanna Zdziarska12, Maria Podolak‑Dawidziak13
DOI: 10.5603/jtm.101503
Journal of Transfusion Medicine 2024;17(2):76-101.

Streszczenie

Pierwotna małopłytkowość immunologiczna (ITP) jest rzadko występującą chorobą, którą się rozpoznaje po wykluczeniu innych przyczyn małopłytkowości. Od opublikowania pierwszego wydania Wytycznych upłynęło prawie 14 lat [1], w ciągu których nastąpił istotny postęp w leczeniu ITP. Głównym celem obecnej pracy jest aktualizacja obowiązujących zasad postępowania w ITP. Niniejsze zalecenia ograniczają się tylko do leczenia dorosłych chorych na ITP, postępowanie u dzieci w tej chorobie zostanie opublikowane oddzielnie. W wytycznych pominięto również wtórną małopłytkowość immunologiczną. Chociaż można w niej uzyskać odpowiedź płytkową, stosując te same leki co w postaci pierwotnej, to podstawą leczenia postaci wtórnej jest usunięcie przyczyny immunizacji. Zalecenia zostały przygotowane na podstawie opublikowanych wyników badań i wytycznych przygotowanych przez ekspertów z innych krajów [2, 3]. Ostateczny kształt nadano dokumentowi podczas konferencji uzgodnieniowych z udziałem członków Grupy ds. Hemostazy Polskiego Towarzystwa Hematologów i Transfuzjologów, które się odbyły w 2023 i 2024 r. Adresatami zaleceń są przede wszystkim lekarze sprawujący bezpośrednią opiekę nad chorymi na ITP, a także lekarze pierwszego kontaktu.

Artykuł dostępny w formacie PDF

Pokaż PDF Pobierz plik PDF

Referencje

  1. Zawilska K, et al. Podolak‑Dawidziak M. Chojnowski K. : skie zalecenia postępowania w pierwotnej małopłytkowości immunologicznej opracowane przez Grupę ds. Hemostazy skiego Towarzystwa Transfuzjologów i Hematologów. Pol Arch Med Wewn. 2010; 120(supl.): 5–28.
  2. Provan D, Arnold DM, Bussel JB, et al. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv. 2019; 3(22): 3780–3817.
    CrossRefPubMed
  3. Neunert CE, Arnold DM, Grace RF, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019; 3(23): 3829–3866.
    CrossRefPubMed
  4. Matzdorff A, et al. Meyer O. Ostermann H. : Immune thrombocytopenia – current diagnostics and therapy: recommendations of a Joint Working Group of DGHO ÖGHO SGH GPOH and DGTI. Oncol Res Treat. 2018; 41(supl. 5): 1–30.
    CrossRefPubMed
  5. Kühne T, Berchtold W, Michaels LA, et al. Intercontinental Cooperative ITP Study Group. Newly diagnosed immune thrombocytopenia in children and adults: a comparative prospective observational registry of the Intercontinental Cooperative Immune Thrombocytopenia Study Group. Haematologica. 2011; 96(12): 1831–1837.
    CrossRefPubMed
  6. Frederiksen H, Maegbaek ML, Nørgaard M. Twenty-year mortality of adult patients with primary immune thrombocytopenia: a Danish population-based cohort study. Br J Haematol. 2014; 166(2): 260–267.
    CrossRefPubMed
  7. Schuff-Werner P, Steiner M, Fenger S, et al. Effective estimation of correct platelet counts in pseudothrombocytopenia using an alternative anticoagulant based on magnesium salt. Br J Haematol. 2013; 162(5): 684–692.
    CrossRefPubMed
  8. Brighton TA, Evans S, Castaldi PA, et al. Prospective evaluation of the clinical usefulness of an antigen-specific assay (MAIPA) in idiopathic thrombocytopenic purpura and other immune thrombocytopenias. Blood. 1996; 88(1): 194–201.
    PubMed
  9. Kim KJ, Baek IW, Yoon CH, et al. Thrombotic risk in patients with immune thrombocytopenia and its association with antiphospholipid antibodies. Br J Haematol. 2013; 161(5): 706–714.
    CrossRefPubMed
  10. Pierrot-Deseilligny Despujol C, Michel M, Khellaf M, et al. Antiphospholipid antibodies in adults with immune thrombocytopenic purpura. Br J Haematol. 2008; 142(4): 638–643.
    CrossRefPubMed
  11. Liebman H. Other immune thrombocytopenias. Semin Hematol. 2007; 44(4 Suppl 5): S24–S34.
    CrossRefPubMed
  12. Altintas A, Ozel A, Okur N, et al. Prevalence and clinical significance of elevated antinuclear antibody test in children and adult patients with idiopathic thrombocytopenic purpura. J Thromb Thrombolysis. 2007; 24(2): 163–168.
    CrossRefPubMed
  13. Khellaf M, Chabrol A, Mahevas M, et al. Hydroxychloroquine is a good second-line treatment for adults with immune thrombocytopenia and positive antinuclear antibodies. Am J Hematol. 2014; 89(2): 194–198.
    CrossRefPubMed
  14. Makar RS, Zhukov OS, Sahud MA, et al. Thrombopoietin levels in patients with disorders of platelet production: diagnostic potential and utility in predicting response to TPO receptor agonists. Am J Hematol. 2013; 88(12): 1041–1044.
    CrossRefPubMed
  15. Al-Samkari H, Kuter DJ. Thrombopoietin level predicts response to treatment with eltrombopag and romiplostim in immune thrombocytopenia. Am J Hematol. 2018; 93(12): 1501–1508.
    CrossRefPubMed
  16. Al-Samkari H, Kuter DJ. Immune thrombocytopenia in adults: modern approaches to diagnosis and treatment. Semin Thromb Hemost. 2020; 46(3): 275–288.
    CrossRefPubMed
  17. Portielje JE, Westendorp RG, Kluin-Nelemans HC, et al. Morbidity and mortality in adults with idiopathic thrombocytopenic purpura. Blood. 2001; 97(9): 2549–2554.
    CrossRefPubMed
  18. Rodeghiero F, Stasi R, Gernsheimer T, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009; 113(11): 2386–2393.
    CrossRefPubMed
  19. Butros LJ, Bussel JB. Intracranial hemorrhage in immune thrombocytopenic purpura: a retrospective analysis. J Pediatr Hematol Oncol. 2003; 25(8): 660–664.
    CrossRefPubMed
  20. Cohen YC, Djulbegovic B, Shamai-Lubovitz O, et al. The bleeding risk and natural history of idiopathic thrombocytopenic purpura in patients with persistent low platelet counts. Arch Intern Med. 2000; 160(11): 1630–1638.
    CrossRefPubMed
  21. Provan D, Stasi R, Newland AC, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010; 115(2): 168–186.
    CrossRefPubMed
  22. Neunert C, Lim W, Crowther M, et al. American Society of Hematology. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011; 117(16): 4190–4207.
    CrossRefPubMed
  23. Wei Yu, Ji Xb, Wang Yw, et al. High-dose dexamethasone vs prednisone for treatment of adult immune thrombocytopenia: a prospective multicenter randomized trial. Blood. 2016; 127(3): 296–302; quiz 370.
    CrossRefPubMed
  24. Matschke J, Müller-Beissenhirtz H, Novotny J, et al. A randomized trial of daily prednisone versus pulsed dexamethasone in treatment-naïve adult patients with immune thrombocytopenia: EIS 2002 study. Acta Haematol. 2016; 136(2): 101–107.
    CrossRefPubMed
  25. Wong R, Saleh M, Khelif A, et al. Safety and efficacy of long-term treatment of chronic/persistent ITP with eltrombopag: final results of the EXTEND study. Blood. 2017; 130(23): 2527–2536.
    CrossRefPubMed
  26. Kuter DJ, Bussel JB, Lyons RM, et al. Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet. 2008; 371(9610): 395–403.
    CrossRefPubMed
  27. Jurczak W, Chojnowski K, Mayer J, et al. Phase 3 randomised study of avatrombopag, a novel thrombopoietin receptor agonist for the treatment of chronic immune thrombocytopenia. Br J Haematol. 2018; 183(3): 479–490.
    CrossRefPubMed
  28. Ghanima W, Cooper N, Rodeghiero F, et al. Thrombopoietin receptor agonists: ten years later. Haematologica. 2019; 104(6): 1112–1123.
    CrossRefPubMed
  29. González-Porras JR, Godeau B, Carpenedo M. Switching thrombopoietin receptor agonist treatments in patients with primary immune thrombocytopenia. Ther Adv Hematol. 2019; 10: 2040620719837906.
    CrossRefPubMed
  30. Zhang J, Liang Yi, Ai Y, et al. Eltrombopag versus romiplostim in treatment of adult patients with immune thrombocytopenia: A systematic review incorporating an indirect-comparison meta-analysis. PLoS One. 2018; 13(6): e0198504.
    CrossRefPubMed
  31. Al-Samkari H, Jiang D, Gernsheimer T, et al. Adults with immune thrombocytopenia who switched to avatrombopag following prior treatment with eltrombopag or romiplostim: A multicentre US study. Br J Haematol. 2022; 197(3): 359–366.
    CrossRefPubMed
  32. Guillet S, Crickx E, Azzaoui I, et al. Prolonged response after TPO-RA discontinuation in primary ITP: results of a prospective multicenter study. Blood. 2023; 141(23): 2867–2877.
    CrossRefPubMed
  33. Podda GM, Fiorelli EM, Birocchi S, et al. Thrombopoietin receptor agonists for the treatment of primary immune thrombocytopenia: a meta-analysis and systematic review. Platelets. 2021; 32(2): 216–226.
    CrossRefPubMed
  34. Cooper N, Hill QA, Grainger J, et al. Tapering and discontinuation of thrombopoietin receptor agonist therapy in patients with immune thrombocytopenia: results from a modified Delphi Panel. Acta Haematol. 2021; 144(4): 418–426.
    CrossRefPubMed
  35. Chugh S, Darvish-Kazem S, Lim W, et al. Rituximab plus standard of care for treatment of primary immune thrombocytopenia: a systematic review and meta-analysis. Lancet Haematol. 2015; 2(2): e75–e81.
    CrossRefPubMed
  36. Chapin J, Lee CS, Zhang H, et al. Gender and duration of disease differentiate responses to rituximab-dexamethasone therapy in adults with immune thrombocytopenia. Am J Hematol. 2016; 91(9): 907–911.
    CrossRefPubMed
  37. Bussel J, Arnold DM, Grossbard E, et al. Fostamatinib for the treatment of adult persistent and chronic immune thrombocytopenia: Results of two phase 3, randomized, placebo-controlled trials. Am J Hematol. 2018; 93(7): 921–930.
    CrossRefPubMed
  38. Bussel JB, Arnold DM, Boxer MA, et al. Long-term fostamatinib treatment of adults with immune thrombocytopenia during the phase 3 clinical trial program. Am J Hematol. 2019; 94(5): 546–553.
    CrossRefPubMed
  39. Strich J, Tian X, Samour M, et al. Fostamatinib for the Treatment of Hospitalized Adults With Coronavirus Disease 2019: A Randomized Trial. Clinical Infectious Diseases. 2021; 75(1): e491–e498.
    CrossRefPubMed
  40. Lucchesi A, Fattizzo B, De Stefano V, et al. Use and positioning of fostamatinib in the management of primary chronic immune thrombocytopenia: an Italian expert opinion. Ther Adv Hematol. 2023; 14: 20406207221147777.
    CrossRefPubMed
  41. Mishra K, Pramanik S, Sandal R, et al. Safety and efficacy of azathioprine in immune thrombocytopenia. Am J Blood Res. 2021; 11(3): 217–226.
    PubMed
  42. Choudhary DR, Naithani R, Mahapatra M, et al. Efficacy of cyclosporine as a single agent therapy in chronic idiopathic thrombocytopenic purpura. Haematologica. 2008; 93(10): e61–2; discussion e63.
    CrossRefPubMed
  43. Kappers-Klunne MC, van't Veer MB. Cyclosporin A for the treatment of patients with chronic idiopathic thrombocytopenic purpura refractory to corticosteroids or splenectomy. Br J Haematol. 2001; 114(1): 121–125.
    CrossRefPubMed
  44. Taylor A, Neave L, Solanki S, et al. Mycophenolate mofetil therapy for severe immune thrombocytopenia. Br J Haematol. 2015; 171(4): 625–630.
    CrossRefPubMed
  45. Zhang Wg, Ji L, Cao Xm, et al. Mycophenolate mofetil as a treatment for refractory idiopathic thrombocytopenic purpura. Acta Pharmacol Sin. 2005; 26(5): 598–602.
    CrossRefPubMed
  46. Verlin M. Laros R.K. Penner .A.: Treatment of refractory thrombocytopenic purpura with cyclophosphamine. Am J Hematol. 1976; 1: 97–104.
    CrossRefPubMed
  47. Pizzuto J, Ambriz R. Therapeutic experience on 934 adults with idiopathic thrombocytopenic purpura: Multicentric Trial of the Cooperative Latin American group on Hemostasis and Thrombosis. Blood. 1984; 64(6): 1179–1183.
    CrossRef
  48. Liu W, Gu X, Fu R, et al. The effect of danazol in primary immune thrombocytopenia: an analysis of a large cohort from a single center in China. Clin Appl Thromb Hemost. 2016; 22(8): 727–733.
    CrossRefPubMed
  49. Godeau B, Durand JM, Roudot-Thoraval F, et al. Dapsone for chronic autoimmune thrombocytopenic purpura: a report of 66 cases. Br J Haematol. 1997; 97(2): 336–339.
    CrossRefPubMed
  50. Estève C, Samson M, Guilhem A, et al. Efficacy and safety of dapsone as second line therapy for adult immune thrombocytopenia: A retrospective study of 42 patients. PLoS One. 2017; 12(10): e0187296.
    CrossRefPubMed
  51. Stasi R, Newland A, Thornton P, et al. Should medical treatment options be exhausted before splenectomy is performed in adult ITP patients? A debate. Ann Hematol. 2010; 89(12): 1185–1195.
    CrossRefPubMed
  52. Mikhael J, Northridge K, Lindquist K, et al. Short-term and long-term failure of laparoscopic splenectomy in adult immune thrombocytopenic purpura patients: a systematic review. Am J Hematol. 2009; 84(11): 743–748.
    CrossRefPubMed
  53. Kojouri K, Vesely SK, Terrell DR, et al. Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications. Blood. 2004; 104(9): 2623–2634.
    CrossRefPubMed
  54. Kühne T, Blanchette V, Buchanan GR, et al. Intercontinental Childhood ITP Study Group. Splenectomy in children with idiopathic thrombocytopenic purpura: A prospective study of 134 children from the Intercontinental Childhood ITP Study Group. Pediatr Blood Cancer. 2007; 49(6): 829–834.
    CrossRefPubMed
  55. Vianelli N, Palandri F, Polverelli N, et al. Splenectomy as a curative treatment for immune thrombocytopenia: a retrospective analysis of 233 patients with a minimum follow up of 10 years. Haematologica. 2013; 98(6): 875–880.
    CrossRefPubMed
  56. Mageau A, Terriou L, Ebbo M, et al. Splenectomy for primary immune thrombocytopenia revisited in the era of thrombopoietin receptor agonists: New insights for an old treatment. Am J Hematol. 2022; 97(1): 10–17.
    CrossRefPubMed
  57. Liu EH, Dilip CK, Yeh TS, et al. Long-term relapse-free rurvival rate and predictive factors of idiopathic thrombocytopenic purpura in adults undergoing splenectomy. Biomed J. 2013; 36(1): 23–27.
    CrossRefPubMed
  58. Duperier T, Brody F, Felsher J, et al. Predictive factors for successful laparoscopic splenectomy in patients with immune thrombocytopenic purpura. Arch Surg. 2004; 139(1): 61–6; discussion 66.
    CrossRefPubMed
  59. Aleem A. Durability and factors associated with long term response after splenectomy for primary immune thrombocytopenia (ITP) and outcome of relapsed or refractory patients. Platelets. 2011; 22(1): 1–7.
    CrossRefPubMed
  60. Juliá A, Araguás C, Rosselló J, et al. Lack of useful clinical predictors of response to splenectomy in patients with chronic idiopathic thrombocytopenic purpura. Br J Haematol. 1990; 76(2): 250–255.
    CrossRefPubMed
  61. Sarpatwari A, Provan D, Erqou S, et al. Autologous 111 In-labelled platelet sequestration studies in patients with primary immune thrombocytopenia (ITP) prior to splenectomy: a report from the United Kingdom ITP Registry. Br J Haematol. 2010; 151(5): 477–487.
    CrossRefPubMed
  62. Ejstrud P, Kristensen B, Hansen JB, et al. Risk and patterns of bacteraemia after splenectomy: a population-based study. Scand J Infect Dis. 2000; 32(5): 521–525.
    CrossRefPubMed
  63. Bisharat N, Omari H, Lavi I, et al. Risk of infection and death among post-splenectomy patients. J Infect. 2001; 43(3): 182–186.
    CrossRefPubMed
  64. Boyle S, White RH, Brunson A, et al. Splenectomy and the incidence of venous thromboembolism and sepsis in patients with immune thrombocytopenia. Blood. 2013; 121(23): 4782–4790.
    CrossRefPubMed
  65. Thomsen RW, Schoonen WM, Farkas DK, et al. Risk for hospital contact with infection in patients with splenectomy: a population-based cohort study. Ann Intern Med. 2009; 151(8): 546–555.
    CrossRefPubMed
  66. Vianelli N, Galli M, de Vivo A, et al. Gruppo Italiano per lo Studio delle Malattie Ematologiche dell'Adulto. Efficacy and safety of splenectomy in immune thrombocytopenic purpura: long-term results of 402 cases. Haematologica. 2005; 90(1): 72–77.
    PubMed
  67. Crary SE, Buchanan GR. Vascular complications after splenectomy for hematologic disorders. Blood. 2009; 114(14): 2861–2868.
    CrossRefPubMed
  68. Rodeghiero F, Ruggeri M. Short- and long-term risks of splenectomy for benign haematological disorders: should we revisit the indications? Br J Haematol. 2012; 158(1): 16–29.
    CrossRefPubMed
  69. Arnold DM, Clerici B, Ilicheva E, et al. Refractory immune thrombocytopenia in adults: Towards a new definition. Br J Haematol. 2023; 203(1): 23–27.
    CrossRefPubMed
  70. Miltiadous O, Hou M, Bussel JB. Identifying and treating refractory ITP: difficulty in diagnosis and role of combination treatment. Blood. 2020; 135(7): 472–490.
    CrossRefPubMed
  71. Arnold DM, Nazi I, Santos A, et al. Combination immunosuppressant therapy for patients with chronic refractory immune thrombocytopenic purpura. Blood. 2010; 115(1): 29–31.
    CrossRefPubMed
  72. Lv Y, Shi H, Liu H, et al. Current therapeutic strategies and perspectives in refractory ITP: What have we learned recently? Front Immunol. 2022; 13: 953716.
    CrossRefPubMed
  73. Carr JM, Kruskall MS, Kaye JA, et al. Efficacy of platelet transfusions in immune thrombocytopenia. Am J Med. 1986; 80(6): 1051–1054.
    CrossRefPubMed
  74. Salama A, Kiesewetter H, Kalus U, et al. Massive platelet transfusion is a rapidly effective emergency treatment in patients with refractory autoimmune thrombocytopenia. Thromb Haemost. 2008; 100(5): 762–765.
    PubMed
  75. Spahr JE, Rodgers GM. Treatment of immune-mediated thrombocytopenia purpura with concurrent intravenous immunoglobulin and platelet transfusion: a retrospective review of 40 patients. Am J Hematol. 2008; 83(2): 122–125.
    CrossRefPubMed
  76. Care A, Pavord S, Knight M, et al. Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study. BJOG. 2018; 125(5): 604–612.
    CrossRefPubMed
  77. Cines DB, Levine LD. Thrombocytopenia in pregnancy. Blood. 2017; 130(21): 2271–2277.
    CrossRefPubMed
  78. Loustau V, Debouverie O, Canoui-Poitrine F, et al. Effect of pregnancy on the course of immune thrombocytopenia: a retrospective study of 118 pregnancies in 82 women. Br J Haematol. 2014; 166(6): 929–935.
    CrossRefPubMed
  79. Guillet S, Loustau V, Boutin E, et al. Immune thrombocytopenia and pregnancy: an exposed/nonexposed cohort study. Blood. 2023; 141(1): 11–21.
    CrossRefPubMed
  80. Wang X, Xu Y, Luo W, et al. Thrombocytopenia in pregnancy with different diagnoses: Differential clinical features, treatments, and outcomes. Medicine (Baltimore). 2017; 96(29): e7561.
    CrossRefPubMed
  81. Rottenstreich A, Bussel JB. Treatment of immune thrombocytopenia during pregnancy with thrombopoietin receptor agonists. Br J Haematol. 2023; 203(5): 872–885.
    CrossRefPubMed
  82. Bussel JB, Cooper N, Lawrence T, et al. Romiplostim use in pregnant women with immune thrombocytopenia. Am J Hematol. 2023; 98(1): 31–40.
    CrossRefPubMed
  83. Crickx E, Mahévas M, Michel M, et al. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging. 2023; 18: 115–130.
    CrossRefPubMed
  84. Waisbren J, Dinner S, Altman J, et al. Disease characteristics and prognosis of myelodysplastic syndrome presenting with isolated thrombocytopenia. Int J Hematol. 2017; 105(1): 44–51.
    CrossRefPubMed
  85. Piel‐Julian M, Mahévas M, Germain J, et al. Risk factors for bleeding, including platelet count threshold, in newly diagnosed immune thrombocytopenia adults. J Thromb Haemost. 2018; 16(9): 1830–1842.
    CrossRefPubMed
  86. Palandri F, Catani L, Auteri G, et al. Understanding how older age drives decision-making and outcome in Immune Thrombocytopenia. A single centre study on 465 adult patients. Br J Haematol. 2019; 184(3): 424–430.
    CrossRefPubMed

Informacje o plikach cookie

Niezbędne pliki cookie

Zawsze aktywne

Te pliki cookie są niezbędne do prawidłowego wyświetlania i działania strony internetowej. Zablokowanie ich może spowodować nieprawidłowe działanie strony.

Analityczne pliki cookie

W ramach naszej strony internetowej korzystamy z narzędzi analitycznych, takich jak Google Analytics, które umożliwiają nam weryfikację ruchu na stronie internetowej. Narzędzia te mogą wymagać użycia plików cookie.

Społecznościowe pliki cookie

Są to pliki cookie powiązane z portalami społecznościowymi, z których korzystamy. Zaakceptowanie ich pozwoli na powiązanie Twojej wizyty na stronie z naszymi profilami w mediach społecznościowych.

Marketingowe pliki cookie

Są to pliki cookie odpowiedzialne za prowadzenie działań reklamowych i marketingowych - zgoda na ich wykorzystanie pozwoli nam kierować do Ciebie reklamy, bazujące na podstawie Twoich wcześniejszych aktywności w ramach naszej stronie internetowej.

Copyright © 2023-2024 Via Medica Regulamin Polityka cookies Polityka prywatności Nota prawna