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Qin S, Wang Y, Yao J, Liu Y, Yi T, Pan Y, Chen Z, Zhang X, Lu J, Yu J, Zhang Y, Cheng P, Mao Y, Zhang J, Fang M, Zhang Y, Lv J, Li R, Dou N, Tang Q, Ma J. Hetrombopag for the management of chemotherapy-induced thrombocytopenia in patients with advanced solid tumors: a multicenter, randomized, double-blind, placebo-controlled, phase II study. Ther Adv Med Oncol 2024; 16:17588359241260985. [PMID: 38882443 PMCID: PMC11179448 DOI: 10.1177/17588359241260985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/24/2024] [Indexed: 06/18/2024] Open
Abstract
Background Chemotherapy-induced thrombocytopenia (CIT) increases the risk of bleeding, necessitates chemotherapy dose reductions and delays, and negatively impacts prognosis. Objectives This study aimed to evaluate the efficacy and safety of hetrombopag for the management of CIT in patients with advanced solid tumors. Design A multicenter, randomized, double-blind, placebo-controlled, phase II study. Methods Patients with advanced solid tumors who experienced a chemotherapy delay of ⩾7 days due to thrombocytopenia (platelet count <75 × 109/L) were randomly assigned (1:1) to receive oral hetrombopag at an initial dose of 7.5 mg once daily or a matching placebo. The primary endpoint was the proportion of treatment responders, defined as patients resuming chemotherapy within 14 days (platelet count ⩾100 × 109/L) and not requiring a chemotherapy dose reduction of ⩾15% or a delay of ⩾4 days or rescue therapy for two consecutive cycles. Results Between 9 October 2021 and 5 May 2022, 60 patients were randomized, with 59 receiving ⩾1 dose of assigned treatment (hetrombopag/placebo arm, n = 28/31). The proportion of treatment responders was significantly higher in the hetrombopag arm than in the placebo arm [60.7% (17/28) versus 12.9% (4/31); difference of proportion: 47.6% (95% confidence interval (CI): 26.0-69.3); odds ratio = 10.44 (95% CI: 2.82-38.65); p value (nominal) based on the Cochran-Mantel-Haenszel: <0.001)]. During the double-blind treatment period, grade 3 or higher adverse events (AEs) occurred in 35.7% (10/28) of patients with hetrombopag and 38.7% (12/31) of patients on placebo. The most common grade 3 or higher AEs were decreased neutrophil count [35.7% (10/28) versus 35.5% (11/31)] and decreased white blood cell count [17.9% (5/28) versus 19.4% (6/31)]. Serious AEs were reported in 3.6% (1/28) of patients with hetrombopag and 9.7% (3/31) of patients with placebo. Conclusion Hetrombopag is an effective and well-tolerated alternative for managing CIT in patients with solid tumors. Trial registration ClinicalTrials.gov identifier: NCT03976882.
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Affiliation(s)
- Shukui Qin
- GI Cancer Center, Nanjing Tianyinshan Hospital, China Pharmaceutical, Nanjing, China
| | - Yusheng Wang
- First Gastroenterology Ward, Shanxi Provincial Cancer Hospital, Taiyuan, China
| | - Jun Yao
- Department of Oncology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Yanyan Liu
- Department of Hematology, Henan Cancer Hospital, Zhengzhou, China
| | - Tienan Yi
- Department of Oncology, Xiangyang Central Hospital, Xiangyang, China
| | - Yueyin Pan
- Department of Oncology, Anhui Provincial Hospital, Hefei, China
| | - Zhendong Chen
- Department of Oncology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xizhi Zhang
- Department of Oncology, Subei People's Hospital of Jiangsu Province, Yangzhou, China
| | - Jin Lu
- Department of Oncology, Sichuan Cancer Hospital and Institute, Chengdu, China
| | - Junyan Yu
- Department of Oncology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Yanjun Zhang
- Department of Oncology, Shaanxi Provincial Cancer Hospital, Xi'an, China
| | - Peng Cheng
- Department of Oncology, The First Affiliated Hospital of Nanyang Medical College, Nanyang, China
| | - Yong Mao
- Department of Oncology, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Jian Zhang
- Department of Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Meiyu Fang
- Department of Comprehensive Medical Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Yanming Zhang
- Department of Oncology, Linfen Central Hospital, Linfen, China
| | - Jing Lv
- Department of Oncology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Runzi Li
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Ning Dou
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Qian Tang
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Jun Ma
- Department of Blood Specialty, Harbin Institute of Hematology and Oncology, 151 Diduan Street, Daoli District, Harbin, Heilongjiang 150010, China
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Zhu H, Wu M. Data mining and safety analysis of avatrombopag: a retrospective pharmacovigilance study based on the US food and drug administration's adverse event reporting system. Sci Rep 2024; 14:11262. [PMID: 38760419 PMCID: PMC11101459 DOI: 10.1038/s41598-024-62129-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/14/2024] [Indexed: 05/19/2024] Open
Abstract
With its increasing use in the treatment of thrombocytopenia, avatrombopag's associated adverse events (AEs) pose a major challenge to its clinical application. This study aims to comprehensively study AEs associated with avatrombopag by using real-world evidence. We curated AE reports for avatrombopag from the first quarter of 2018 to the fourth quarter of 2023 in the US Food and Drug Administration's Adverse Event Reporting System (FAERS) database. AEs were coded using the Medical Dictionary for Regulatory Activities of Preferred Terms and System Organ Classes. The reporting odds ratio, proportional reporting ratio, Bayesian confidence propagation neural network, and multi-item Gamma-Poisson Shrinker were used to investigate the relationship between avatrombopag and AE reports. Among 9,060,312 reported cases in the FAERS database, 1211 reports listed avatrombopag as "primary suspected" drug. Disproportionality analysis identified 44 preferred terms across 17 organ systems met the criteria for at least one of the four algorithms. The most commonly reported AEs were platelet count decreased (20.2%), headache (16.7%), platelet count increased (11.9%), platelet count abnormal (6.3%), contusion (2.7%), pulmonary embolism (2.3%), and deep vein thrombosis (2.1%). Unexpected AEs such as seasonal allergy, rhinorrhea, antiphospholipid syndrome, ear discomfort, and photopsia were also observed. Excluding the other serious outcomes, hospitalization (34.6%) was the most frequently reported serious outcome, followed by death (15.4%). Most reported AEs occurred within the first 2 days of initiating avatrombopag therapy, and the median onset time was 60 days. We identified new and unexpected AEs with clinical use of avatrombopag, and our results may provide valuable information for clinical monitoring and identifying risks associated with avatrombopag.
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Affiliation(s)
- Hong Zhu
- Department of Pharmacy, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huaian, 223300, Jiangsu, China
| | - Meng Wu
- Department of Oral and Maxillofacial Surgery, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, 1 Huanghe West Road, Huaian, 223300, Jiangsu, China.
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Al-Samkari H. Thrombopoietin Agonism to Promote Platelet Engraftment Following Hematopoietic Stem Cell Transplantation: Promising, but Not Ready for Primetime. Transplant Cell Ther 2024; 30:465-467. [PMID: 38677790 DOI: 10.1016/j.jtct.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Crawford J, Herndon D, Gmitter K, Weiss J. The impact of myelosuppression on quality of life of patients treated with chemotherapy. Future Oncol 2024:1-16. [PMID: 38587388 DOI: 10.2217/fon-2023-0513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 02/21/2024] [Indexed: 04/09/2024] Open
Abstract
Side effects from chemotherapy-induced myelosuppression can negatively affect patients' quality of life (QoL). Neutropenia increases infection risk, and anemia frequently results in debilitating fatigue. Additionally, the bleeding risk associated with thrombocytopenia can lead to fear and anxiety. However, traditional interventions for myelosuppression fall short of the ideal. Granulocyte colony-stimulating factors reduce the risk of severe neutropenia but commonly lead to bone pain. Erythropoiesis-stimulating agents are not always effective and may cause thromboembolic events, while transfusions to correct anemia/thrombocytopenia are associated with transfusion reactions and volume overload. Trilaciclib, which is approved for reducing myelosuppression in patients with extensive-stage small cell lung cancer, together with several investigational agents in development for managing myelosuppression have the potential to improve QoL for patients on chemotherapy.
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Affiliation(s)
| | - Dana Herndon
- Cone Health Cancer Center, Greensboro, NC 27403, USA
| | | | - Jared Weiss
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC 27599, USA
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Virk ZM, Leaf RK, Kuter DJ, Goodarzi K, Connell NT, Connors JM, Al-Samkari H. Avatrombopag for adults with early versus chronic immune thrombocytopenia. Am J Hematol 2024; 99:155-162. [PMID: 38063420 PMCID: PMC11101755 DOI: 10.1002/ajh.27080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 01/21/2024]
Abstract
Avatrombopag is a newer thrombopoietin receptor agonist (TPO-RA) currently approved to treat chronic ITP (duration >12 months). No studies have yet evaluated the safety and effectiveness of avatrombopag in newly diagnosed ITP (duration <3 months) or persistent ITP (duration 3-12 months), and so its use in these populations is presently off-label worldwide. We hypothesize that avatrombopag has similar safety and effectiveness irrespective of ITP disease phase. To evaluate this, we performed a multicenter observational cohort study of adults with ITP treated with avatrombopag, comparing patient outcomes by disease phase (newly diagnosed/persistent versus chronic). Seventy-five patients were included, 23 with newly diagnosed/persistent ITP (17.7 patient-years of avatrombopag treatment) and 52 with chronic ITP (65.3 patient-years of avatrombopag treatment). On avatrombopag, 91% of newly diagnosed/persistent patients versus 96% of chronic patients (p = .58) achieved a platelet response (≥50 × 109 /L) and 86% versus 81% of patients (p = .78) achieved a complete response (≥100 × 109 /L). Median platelet counts on avatrombopag were similar between the two groups (165 × 109 /L vs. 129 × 109 /L, p = .57). Response durability was high and similar in both groups. No patients in the newly diagnosed/persistent group had a major bleeding event, thromboembolic event or avatrombopag discontinuation for adverse events, compared with 4, 1, and 2, respectively, in the chronic group. Thrombocytosis (platelets ≥400 × 109 /L) incidence was similar in the two groups. No other drug-related adverse events occurred in either group. Avatrombopag was safe and effective in patients with newly diagnosed and persistent ITP, with outcomes numerically, statistically, and clinically similar to patients receiving avatrombopag for chronic ITP.
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Affiliation(s)
- Zain M. Virk
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rebecca K. Leaf
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - David J. Kuter
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Katayoon Goodarzi
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nathan T. Connell
- Harvard Medical School, Boston, Massachusetts, USA
- Hematology Division, Brigham & Women’s Hospital, Boston, Massachusetts, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jean M. Connors
- Harvard Medical School, Boston, Massachusetts, USA
- Hematology Division, Brigham & Women’s Hospital, Boston, Massachusetts, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Al-Samkari H. Optimal management of chemotherapy-induced thrombocytopenia with thrombopoietin receptor agonists. Blood Rev 2024; 63:101139. [PMID: 37914568 PMCID: PMC10872905 DOI: 10.1016/j.blre.2023.101139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 11/03/2023]
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of antineoplastic therapy, resulting in antineoplastic therapy dose reductions, treatment delays, treatment discontinuation, and morbid bleeding events. Despite several decades of research into thrombopoietic growth factors in CIT, there are presently no available U.S. FDA- or EMA-approved agents to treat CIT. However, a respectable body of evidence has been published evaluating the thrombopoietin receptor agonists (TPO-RAs) for the management and prevention of CIT in patients with solid tumors, and critical studies are ongoing with the TPO-RAs romiplostim and avatrombopag. When employed in the appropriate patient population and used properly, TPO-RAs can successfully and safely manage CIT for extended periods of time with minimal apparent risks. This comprehensive review discusses the evidence for TPO-RAs in CIT in patients with solid tumors, provides detailed guidance for their use in the clinic, and discusses ongoing essential clinical trials in management of CIT.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Soff G, Leader A, Al-Samkari H, Falanga A, Maraveyas A, Sanfilippo K, Wang TF, Zwicker J. Management of chemotherapy-induced thrombocytopenia: guidance from the ISTH Subcommittee on Hemostasis and Malignancy. J Thromb Haemost 2024; 22:53-60. [PMID: 37827380 DOI: 10.1016/j.jtha.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/08/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
Thrombocytopenia is a common adverse effect of chemotherapy. The development of chemotherapy-induced thrombocytopenia (CIT) is influenced by cancer type and therapy, occurring in approximately one-third of patients with a solid tumor diagnosis and half of all patients with a hematologic malignancy. CIT may complicate the administration of chemotherapy, leading to therapeutic delays or dose reductions. This guidance document, presented by the International Society on Thrombosis and Haemostasis (ISTH) Subcommittee on Hemostasis and Malignancy, provides a comprehensive summary of the evidence and offers direction on the use of thrombopoietin receptor agonists (TPO-RAs) in various settings of CIT, including solid tumors, acute myeloid leukemia, stem cell transplant, and lymphoma. Studies have shown that TPO-RAs can improve platelet counts in CIT, but the clinical benefits of TPO-RA in terms of reducing bleeding, limiting platelet transfusion, avoiding chemotherapy delay, or dose reduction are uncertain. Further research is needed to optimize the selection of appropriate indications and study design to manage thrombocytopenia following chemotherapy.
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Affiliation(s)
- Gerald Soff
- Department of Medicine, University of Miami Health System/Sylvester Comprehensive Cancer Center, Miami, Florida, USA.
| | - Avi Leader
- Section of Hematology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Hanny Al-Samkari
- Classical Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Anthony Maraveyas
- Faculty of Health Sciences, Joint Centre for Cancer Studies, The Hull York Medical School, Castle Hill Hospital, Hull, UK
| | - Kristen Sanfilippo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA. https://twitter.com/sanfilippomd
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. https://twitter.com/tzufeiwang
| | - Jeffrey Zwicker
- Section of Hematology, Memorial Sloan Kettering Cancer Center, New York, New York, USA. https://twitter.com/jzbos
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Gurumurthy G, Kisiel F, Gurumurthy S, Gurumurthy J. Role of thrombopoietin receptor agonists in chemotherapy-induced thrombocytopenia: A meta-analysis. J Oncol Pharm Pract 2023:10781552231219003. [PMID: 38155484 DOI: 10.1177/10781552231219003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Chemotherapy-induced thrombocytopenia (CIT) is a significant challenge in cancer treatment, often leading to dose reductions and reduced number of cycles. The limited effectiveness of platelet transfusions in managing CIT highlights the need for alternative treatments. Thrombopoietin receptor agonists (TPO-RA), including romiplostim, eltrombopag and avatrombopag, have shown potential in increasing platelet counts in CIT patients, necessitating a comprehensive analysis of their efficacy. METHODS This meta-analysis followed the Preferred Reporting Items for Systemic Reviews and Meta-analysis guidelines, searching Ovid databases up to 5 October 2023. The primary metric of interest was platelet count changes post-TPO-RA administration in CIT patients. RESULTS From the initial 867 studies obtained, 7 studies were selected based on the inclusion criteria. The analysis included 348 patients. A significant association was found between TPO-RA administration and platelet count increase, with a combined-effect increase of 69.52 ± 2.24 × 109/l. Subgroup analysis based on Romiplostim use suggested an increase of approximately 70.11 ± 39.07 × 109/l, while non-Romiplostim TPO-RAs showcased an increase of about 68.09 ± 82.58 × 109/l. CONCLUSIONS The meta-analysis demonstrates the effectiveness of TPO-RAs in managing CIT. Further research comparing platelet increases across standardised TPO-RA regimens is recommended to refine treatment strategies. This analysis provides valuable insights for clinicians in tailoring CIT treatment using TPO-RAs.
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Affiliation(s)
- Gerard Gurumurthy
- School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Filip Kisiel
- School of Chemical Engineering and Analytical Science, The University of Manchester, Manchester, UK
| | - Samantha Gurumurthy
- School of Infectious Disease and Immunity, Imperial College London, London, UK
| | - Juditha Gurumurthy
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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Chen W, Liu Y, Li L, Zeng X. Efficacy and safety of thrombopoietin receptor agonists in solid tumors with chemotherapy-induced thrombocytopenia: a meta-analysis. BMC Pharmacol Toxicol 2023; 24:71. [PMID: 38041150 PMCID: PMC10693054 DOI: 10.1186/s40360-023-00707-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 11/14/2023] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of thrombopoietin receptor agonists (TPO-RAs) in solid tumors with chemotherapy-induced thrombocytopenia (CIT). METHODS We conducted a comprehensive search of PubMed, FMRS, Cochrane Library, Web of Science, EMBASE, and ClinicalTrials.gov for randomized controlled trials (RCTs) reporting the efficacy and safety of TPO-RAs in solid tumors with CIT. The search was limited to articles published before April 30, 2022. Primary outcomes included chemotherapy dose reduction or delays, platelet transfusion, the incidence of grade 3 or 4 thrombocytopenia, and bleeding events. Secondary outcomes encompassed the incidence of platelet count > 400 × 109/L, adverse events (AEs), serious AEs, thrombosis, and mortality. RESULTS Our analysis encompassed six studies: five rigorous RCTs and one unique study comparing romiplostim to an observation group, involving a total of 489 patients. For primary outcomes, TPO-RAs significantly reduced the incidence of grade 3 or 4 thrombocytopenia (RR = 0.69, 95% CI: 0.52-0.91). After applying the Bonferroni correction for multiple comparisons, the significance of the reduction in grade 3 or 4 thrombocytopenia incidence persisted (P = 0.008). TPO-RAs showed no significant impact on chemotherapy dose reduction or delays (RR = 0.81, 95% CI: 0.65-1.01), platelet transfusion (RR = 1.04, 95% CI: 0.48-2.27), or bleeding events (RR = 0.50, 95% CI: 0.23-1.10). In terms of safety, there were no significant difference in the incidence of any AEs (RR = 0.98, 95% CI:0.92-1.04), serious AEs (RR = 0.79, 95% CI:0.45-1.40), thrombotic events (RR = 1.20, 95% CI:0.51-2.84) and mortality (RR = 1.15, 95% CI:0.55-2.41). CONCLUSIONS This meta-analysis suggests that TPO-RAs are generally well-tolerated. However, their efficacy in solid tumors with CIT appears limited, as they only demonstrate a reduction in the incidence of grade 3 or 4 thrombocytopenia.
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Affiliation(s)
- Wen Chen
- Department of Medical Oncology, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Yubingxue Liu
- Department of Health Examination and Oncology Screening Center, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Luchun Li
- Department of Medical Oncology, Chongqing University Cancer Hospital, Chongqing, 400030, China
| | - Xianghua Zeng
- Department of Medical Oncology, Chongqing University Cancer Hospital, Chongqing, 400030, China.
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Al-Samkari H. Treatment of chemotherapy-induced thrombocytopenia with monotherapy versus combination therapy: the devil is in the details. Res Pract Thromb Haemost 2023; 7:102250. [PMID: 38193065 PMCID: PMC10772883 DOI: 10.1016/j.rpth.2023.102250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Xia X, Zhou H, Zhang H, Deng W, Li R, Huang Q, Wang Y, Xiong H. Hetrombopag plus recombinant human thrombopoietin for chemotherapy-induced thrombocytopenia in patients with solid tumors. Res Pract Thromb Haemost 2023; 7:102231. [PMID: 38077816 PMCID: PMC10704501 DOI: 10.1016/j.rpth.2023.102231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/05/2023] [Accepted: 09/22/2023] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Chemotherapy-induced thrombocytopenia (CIT) is a common hematological complication in patients with cancer. Hetrombopag is a novel thrombopoietin receptor agonist that has shown an additive effect in stimulating platelet production when combined with recombinant human thrombopoietin (rhTPO). OBJECTIVES This multicenter retrospective cohort study aimed to evaluate the efficacy and safety of hetrombopag plus rhTPO compared with rhTPO alone for CIT. METHODS A total of 294 patients with solid tumors and CIT (platelet count, <50 × 109/L) who received either rhTPO plus hetrombopag (146 patients) or rhTPO alone (148 patients) at 3 centers from January to December 2022 were included in the study. The primary outcome was a platelet count at least 50 × 109/L higher than the baseline value within 14 days. Chemotherapy dose reductions/delays, bleeding, and adverse events were reported. RESULTS One hundred twenty patients (82.2%) in the rhTPO-hetrombopag group vs 100 patients (67.6%) in the rhTPO group achieved the primary outcome (P = .005). This significant difference persisted in adjusted analysis (odds ratio, 2.01; 95% CI, 1.12-3.60). A total of 115 patients (78.8%) in the rhTPO-hetrombopag group and 101 patients (68.2%) in the rhTPO group avoided chemotherapy dose reductions/delays (P = .041). There was no significant difference in bleeding rates, and adverse events were mild and similar between the 2 groups. No deaths occurred. CONCLUSION Compared to rhTPO alone, our findings suggest that the combination of hetrombopag and rhTPO is safe and more effective in patients with CIT.
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Affiliation(s)
- Xiaohui Xia
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haiting Zhou
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hao Zhang
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wanjun Deng
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Li
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiao Huang
- Department of Oncology, Yichang Central People’s Hospital, Yichang, China
| | - Yuehua Wang
- Department of Oncology, Xiangyang Central Hospital, Xiangyang, China
| | - Huihua Xiong
- Department of Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Rainone M, Kasparian S, Nguyen T, Talwar N, Yuan Y, Mei M, Mortimer JE, Waisman JR, Patel N, Pullarkat V. Thrombopoietin Receptor Agonists for Thrombocytopenia Secondary to HER2-Targeted Antibody Drug Conjugates. Oncologist 2023; 28:e843-e846. [PMID: 37335880 PMCID: PMC10485295 DOI: 10.1093/oncolo/oyad185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023] Open
Abstract
Trastuzumab emtansine and trastuzumab deruxtecan are widely used in breast cancer and other solid tumor malignancies. Thrombocytopenia is a common adverse event associated with the use of these agents that can lead to a treatment delay, reduction in dose intensity, and discontinuation. The role of thrombopoietin receptor agonists (TPO-RA) remains unknown in this setting. We report a case series of 6 individuals with breast cancer that experienced dose-reductions and therapy delays due to thrombocytopenia secondary to trastuzumab emtansine or trastuzumab deruxtecan therapy and received intervention with TPO-RA. All 6 were able to resume therapy with TPO-RA support.
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Affiliation(s)
- Michael Rainone
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Saro Kasparian
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Tina Nguyen
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Neel Talwar
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Yuan Yuan
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
- Department of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew Mei
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Joanne E Mortimer
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - James R Waisman
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Niki Patel
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
- Department of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
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13
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Rainone M, Behrendt CE, Kasparian S, Nguyen T, Sedrak MS, Lavasani S, Stewart DB, Yuan Y, Mortimer JE, Waisman JR, Patel N, Pullarkat V. HER2-targeted antibody-drug conjugates for breast cancer: ancestry and dose adjustment for thrombocytopenia. Breast Cancer 2023; 30:796-801. [PMID: 37326930 PMCID: PMC10404202 DOI: 10.1007/s12282-023-01473-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/28/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Thrombocytopenia is a common adverse event on HER2-targeted therapies, fam-trastuzumab deruxtecan (T-DXd) and ado-trastuzumab emtansine (T-DM1). A reported association of Asian ancestry with this event merits investigation to rule out potential confounding. METHODS Subjects in this retrospective cohort were female patients with HER2 positive breast cancer, of Asian or non-Hispanic White ancestry, who initiated T-DM1 or T-DXd from January 2017 through October 2021. Follow-up closed in January 2022. Primary endpoint was dose adjustment for thrombocytopenia. Competing endpoints were discontinuation of drug for other toxicity, disease progression, or for completion of prescribed cycles. The association between Asian ancestry and thrombocytopenia-related dose adjustment was tested at p < 0.01 in a proportional hazards model for the sub-distributions of 4 (primary and competing) endpoints. Covariates examined as potential confounders were age, metastatic disease, specific HER2-targeted drug, and prior drug switching for toxicity. RESULTS Among 181 subjects, 48 reported Asian ancestry. Incidence of dose adjustment for thrombocytopenia was higher in patients with Asian ancestry and among patients switched to T-DXd after experiencing thrombocytopenia on T-DM1. Independent of specific drug and prior drug switching, Asian ancestry was associated with dose adjustment for thrombocytopenia (hazards ratio 2.95, 95% confidence interval 1.41-6.18) but not with competing endpoints. Among participants of Asian ancestry, the ancestral origin was usually China or the Philippines (where Chinese ancestry is common). CONCLUSIONS The association between Asian ancestry and thrombocytopenia on HER2-targeted therapy is independent of age, metastatic disease, drug, and history of similar toxicity. This association may have a genetic basis linked to Chinese ancestry.
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Affiliation(s)
- Michael Rainone
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
- Hematology and Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
| | - Carolyn E Behrendt
- Biostatistics, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
| | - Saro Kasparian
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
- Hematology and Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
| | - Tina Nguyen
- Hematology and Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
| | - Mina S Sedrak
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
| | - Sayeh Lavasani
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
| | - Daphne B Stewart
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
| | - Yuan Yuan
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
- Medical Oncology, Cedars-Sinai Medical Center, 127 South San Vicente Blvd, Los Angeles, CA, 90048, USA
| | - Joanne E Mortimer
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
| | - James R Waisman
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
| | - Niki Patel
- Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA
- Medical Oncology, Cedars-Sinai Medical Center, 127 South San Vicente Blvd, Los Angeles, CA, 90048, USA
| | - Vinod Pullarkat
- Hematology and Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA, 91101, USA.
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14
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[Chinese expert consensus on the clinical application of recombinant human thrombopoiein and thrombopoiein receptor agonist (2023)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:535-542. [PMID: 37749031 PMCID: PMC10509622 DOI: 10.3760/cma.j.issn.0253-2727.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Indexed: 09/27/2023]
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15
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Shin J, Kim MJ, Quan X, Kim JW, Lee S, Park S, Jeong JY, Yea K. Thrombopoietin receptor agonist antibody for treating chemotherapy-induced thrombocytopenia. BMC Cancer 2023; 23:490. [PMID: 37259024 DOI: 10.1186/s12885-023-10975-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 05/16/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Thrombocytopenia is a common complication in cancer patients undergoing chemotherapy. Chemotherapy-induced thrombocytopenia (CIT) leads to dose reduction and treatment delays, lowering chemotherapy efficacy and survival rate. Thus, rapid recovery and continuous maintenance of platelet count during chemotherapy cycles are crucial in patients with CIT. Thrombopoietin (TPO) and its receptor, myeloid proliferative leukemia (MPL) protein, play a major role in platelet production. Although several MPL agonists have been developed to regulate thrombopoiesis, none have been approved for the management of CIT due to concerns regarding efficacy or safety. Therefore, the development of effective MPL agonists for treating CIT needs to be further expanded. METHODS Anti-MPL antibodies were selected from the human combinatorial antibody phage libraries using phage display. We identified 2R13 as the most active clone among the binding antibodies via cell proliferation assay using BaF3/MPL cells. The effect of 2R13 on megakaryocyte differentiation was evaluated in peripheral blood CD34+ cells by analyzing megakaryocyte-specific differentiation markers (CD41a+ and CD42b+) and DNA ploidy using flow cytometry. The 2R13-induced platelet production was examined in 8- to 10-week-old wild-type BALB/c female mice and a thrombocytopenia mouse model established by intraperitoneal injection of 5-fluorouracil (150 mg/kg). The platelet counts were monitored twice a week over 14 days post-initiation of treatment with a single injection of 2R13, or recombinant human TPO (rhTPO) for seven consecutive days. RESULTS We found that 2R13 specifically interacted with MPL and activated its signaling pathways. 2R13 stimulated megakaryocyte differentiation, evidenced by increasing the proportion of high-ploidy (≥ 8N) megakaryocytes in peripheral blood-CD34+ cells. The platelet count was increased by a single injection of 2R13 for up to 14 days. Injection of 5-fluorouracil considerably reduced the platelet count by day 4, which was recovered by 2R13. The platelets produced by 2R13 sustained a higher count than that achieved using seven consecutive injections of rhTPO. CONCLUSIONS Our findings suggest that 2R13 is a promising therapeutic agent for CIT treatment.
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Affiliation(s)
- Jiwon Shin
- Department of New Biology, Daegu Gyeongbuk Institute of Science and Technology (DGIST), Daegu, 42988, Republic of Korea
| | - Min-Jung Kim
- Department of Biochemistry, Kosin University College of Medicine, Busan, 49267, Republic of Korea
| | - Xingguo Quan
- Department of Microbiology and Immunology, Inje University College of Medicine, Busan, 47392, Republic of Korea
| | - Ji Woong Kim
- Department of Biochemistry, Kookmin University, Seoul, 02707, Republic of Korea
| | - Sukmook Lee
- Department of Biochemistry, Kookmin University, Seoul, 02707, Republic of Korea
| | - SaeGwang Park
- Department of Microbiology and Immunology, Inje University College of Medicine, Busan, 47392, Republic of Korea.
| | - Jee-Yeong Jeong
- Department of Biochemistry, Kosin University College of Medicine, Busan, 49267, Republic of Korea.
| | - Kyungmoo Yea
- Department of New Biology, Daegu Gyeongbuk Institute of Science and Technology (DGIST), Daegu, 42988, Republic of Korea.
- New Biology Research Center, DGIST, Daegu, 43024, Republic of Korea.
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16
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Song AB, Al-Samkari H. Emerging data on thrombopoietin receptor agonists for management of chemotherapy-induced thrombocytopenia. Expert Rev Hematol 2023; 16:365-375. [PMID: 37039010 PMCID: PMC10190112 DOI: 10.1080/17474086.2023.2201428] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/06/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION Chemotherapy-induced thrombocytopenia (CIT) is a common complication of cancer treatment, frequently leading to reduced relative dose intensity, and is associated with reduced survival. Given the lack of FDA-approved therapies for CIT, thrombopoietin receptor agonists (TPO-RAs) have received significant attention for treatment and prevention of CIT. AREAS COVERED This review will summarize the development of prior agents for treatment of CIT, discuss the existing literature investigating the use of TPO-RAs in CIT primarily in patients with solid tumor malignancies, and offer insights on the future direction of TPO-RAs and other therapeutics for CIT. EXPERT OPINION In alignment with NCCN guidelines, we recommend that patients with CIT participate in a clinical trial for consideration of TPO-RA treatment or consider off-label use of romiplostim when participation in clinical trials is not possible. The literature to date supports the use of TPO-RAs for treatment of persistent CIT. Further data is needed to describe the long-term efficacy, safety, and prescribing practices of TPO-RAs in a diverse patient population with a variety of tumor types and chemotherapy regimens in addition to exploring the underlying biology of CIT.
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Affiliation(s)
- Andrew B. Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA
- Division of Hematology, Massachusetts General Hospital, Boston, MA
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17
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Gao A, Zhang L, Zhong D. Chemotherapy-induced thrombocytopenia: literature review. Discov Oncol 2023; 14:10. [PMID: 36695938 PMCID: PMC9877263 DOI: 10.1007/s12672-023-00616-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/12/2023] [Indexed: 01/26/2023] Open
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common condition that frequently results in reduced chemotherapy dosages, postponed treatment, bleeding, and unfavorable oncological outcomes. At present, there is no clear suggestions for preventing or treating CIT. Thrombopoietin (TPO) replacement therapy has been invented and used to treat CIT to promote the production of megakaryocytes and stimulate the formation of platelets. However, this treatment is limited to the risk of immunogenicity and cancer progression. Therefore, an unmet need exists for exploring alternatives to TPO to address the clinical issue of CIT. Application of appropriate therapeutic drugs may be due to understanding the potential mechanisms of CIT. Studies have shown that chemotherapy significantly affects various cells in bone marrow (BM) microenvironment, reduces their ability to support normal hematopoiesis, and may lead to BM damage, including CIT in cancer patients. This review focuses on the epidemiology and treatment of cancer patients with CIT. We also introduce some recent progress to understand the cellular and molecular mechanisms of chemotherapy inhibiting normal hematopoiesis and causing thrombocytopenia.
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Affiliation(s)
- Ai Gao
- Department of Medical Oncology, Tianjin Medical University General Hospital, No.154, Anshandao, Heping District, Tianjin, 300052, China.
| | - Linlin Zhang
- Department of Medical Oncology, Tianjin Medical University General Hospital, No.154, Anshandao, Heping District, Tianjin, 300052, China
| | - Diansheng Zhong
- Department of Medical Oncology, Tianjin Medical University General Hospital, No.154, Anshandao, Heping District, Tianjin, 300052, China
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18
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Chi Y, Hu Q, Yang C, Chen M, Han B. Avatrombopag is effective in patients with chemoradiotherapy-induced aplastic anemia: a single-center, retrospective study. Exp Hematol 2023; 117:62-68. [PMID: 36400314 DOI: 10.1016/j.exphem.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/05/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022]
Abstract
Aplastic anemia (AA) secondary to radiotherapy presents a difficult situation in the treatment of both the malignant tumor and AA itself. We aimed to evaluate the efficacy of avatrombopag (AVA), a thrombopoietin receptor agonist, in patients with AA secondary to chemoradiotherapy. In this retrospective study, patients with malignant tumors who were diagnosed with AA after radiotherapy and chemotherapy and accepted AVA between September 2020 and October 2021 at Peking Union Medical College Hospital were selected. A total of 34 patients were enrolled, including 13 (38.2%) men, with a median age of 60 (20-71) years. At a median of 8 (6-18) months of follow-up, the overall response rates (ORRs) at 1, 3, and 6 months were 32.4%, 55.9%, and 58.8%, respectively, and the complete response rates (CRRs) were 5.9%, 14.7%, and 23.5%, respectively. The median time to respond was 3 (1-6) months. In total, 15.0% of patients relapsed during follow-up, but no clonal evolution was noticed. Mild side effects were observed in 17.6% of patients without drug withdrawal. At the end of follow-up, 17.6% of patients had tumors relapsed. Four patients died, three from tumor relapse and one from cerebral hemorrhage. The ORR and CRR did not correlate with eltrombopag before AVA (p > 0.05) but increased when the total exposure of AVA increased (p = 0.011), and the threshold for AVA response was a cumulative dose > 3,000 mg (p = 0.013). AVA yielded good response and tolerance in patients treated for AA secondary to chemoradiotherapy, and a higher dose may correlate with better response.
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Affiliation(s)
- Yarong Chi
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China
| | - Qinglin Hu
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China
| | - Chen Yang
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China
| | - Miao Chen
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China
| | - Bing Han
- Department of Hematology, Chinese Academy of Medical Science and Peking Union Medical College Hospital, Beijing, China.
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Thrombopoietin receptor agonists for chemotherapy-induced thrombocytopenia: a new solution for an old problem. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:286-295. [PMID: 36485134 PMCID: PMC9821429 DOI: 10.1182/hematology.2022000374] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is common, resulting in increased bleeding risk and chemotherapy delays, dose reduction, and treatment discontinuation, which can negatively affect oncologic outcomes. The only agent approved by the US Food and Drug Administration to manage CIT (oprelvekin) was voluntarily withdrawn from the market by the manufacturer, leaving few options for patients. Therefore, patients experiencing CIT present a significant clinical challenge in daily practice. The availability of thrombopoietin receptor agonists has led to formal clinical trials describing efficacy in CIT as well as a rather extensive body of published observational data from off-label use in this setting but no formal regulatory indications for CIT to date. The accumulated data, however, have affected National Comprehensive Cancer Network guidelines, which now recommend consideration of TPO-RA clinical trials as well as off-label use of romiplostim. This review article details the evidence to date for the management of CIT with thrombopoietin receptor agonists (TPO-RAs), discussing the efficacy data, the specific circumstances when treatment is warranted (and when it is generally unnecessary), and safety considerations. Specific recommendations regarding patient selection, initiation, dosing, titration, and discontinuation for TPO-RA therapy in CIT are given, based on published data and expert opinion where evidence is lacking.
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20
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Effectiveness and Safety of Avatrombopag in Liver Cancer Patients with Severe Thrombocytopenia: Real-World Data and Challenges. JOURNAL OF ONCOLOGY 2022; 2022:9138195. [PMID: 36405248 PMCID: PMC9668468 DOI: 10.1155/2022/9138195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/28/2022] [Accepted: 10/11/2022] [Indexed: 11/10/2022]
Abstract
Background Avatrombopag has been approved in patients who have severe thrombocytopenia (<50 × 109/L) and chronic liver disease (CLD) while receiving invasive procedures. The real-world application and effectiveness of avatrombopag in the subgroup patients with liver cancer remain unknown. Methods Liver cancer patients (including primary liver cancer and colorectal cancer liver metastasis) who had severe thrombocytopenia and received avatrombopag were retrospectively enrolled. Avatrombopag dose, peak and absolute platelet count increase, combination treatment with other thrombopoietic agents, responder (peak count ≥50 × 109/L with absolute increase ≥20 × 109/L) rate, and anticancer treatment effect were analyzed. Thrombosis and bleeding events were assessed. Results In total, 93 patients were enrolled, with 72 and 21 in the CLD and non-CLD groups, respectively. Patients with CLD had hepatitis B or C, larger spleen volume, and a higher cirrhosis degree. Baseline platelet counts were similar between two groups (median, 37.0 × 109/L vs. 39.0 × 109/L; P=0.594), while patients without CLD had higher peak platelet (median, 134.0 × 109/L vs. 74.0 × 109/L; P=0.015) and absolute increase (median, 101.0 × 109/L vs. 41.0 × 109/L; P=0.020) after avatrombopag treatment. The responder rate was higher in patients without CLD (100% vs. 76.4%; P=0.010). Combined avatrombopag with other thrombopoietic agents significantly increased platelet count; repeated use of avatrombopag produced similar effects with that of initial treatment. Concerning anticancer treatment effect, patients who responded to avatrombopag had a higher disease control rate. No thrombosis or hemorrhagic events were observed, even in patients with portal vein tumor thrombosis. Conclusion Avatrombopag was safe and effective and ensured successful implementation of anticancer treatment in liver cancer patients with severe thrombocytopenia, accompanied with or without CLD.
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21
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Cui Y, He Y, Hu C, Tu C, Huang J, Zhu X, Zang C, Ding K, Zhan B, Zhao Y, Qian L. Avatrombopag for the treatment of thrombocytopenia induced by chemotherapy in patients with solid tumors: A multicenter, open-label, single-arm trial. Front Pharmacol 2022; 13:970978. [PMID: 36238568 PMCID: PMC9553127 DOI: 10.3389/fphar.2022.970978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: To explore the effect and safety of avatrombopag for chemotherapy-induced thrombocytopenia (CIT). Methods: This multicenter, open-label, single-arm trial enrolled CIT patients in eight centers from October 2020 to April 2021. The participants received avatrombopag tablets 60 mg once a day for 5–10 days. The main endpoint was the proportion of patients with platelet count ≥100×109/L or increased by ≥ 50×109/L or increased by ≥ 100% in the cycle after the start of treatment. Results: Seventy-four participants were enrolled with a mean age of 59.8 ± 11.62.2% were males. The cumulative effective rate (any criteria) was 70.3% at 4 weeks. 42 (56.8%) achieved platelet count ≥100×109/L, 44 (59.5%) increased by ≥ 50×109/L, and 27 (36.5%) increase by ≥ 100% from baseline. The duration of grade III and IV platelet reduction was 4.2 ± 5.3 days. The time of PLT recovery to ≥75×109/L was 9.4 ± 6.6 days. The time of PLT recovery to ≥100×109/L was 10.2 ± 6.4 days. The platelet count nadir was 57.9 ± 45.3×109/L. The most common adverse events were nausea (8.1%), fatigue (5.4%), and abdominal pain (1.4%). There were no cases of fever, headache, or peripheral edema. Conclusion: Although it was a single-arm trial without a control group, the application of avatrombopag in patients with CIT can increase the platelet count of the patients compared with baseline. Avatrombopag is safe and tolerable. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT04609891?term=04609891&draw=2&rank=1, identifier [NCT04609891]
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Affiliation(s)
- Yayun Cui
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Yifu He
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Changlu Hu
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Congyin Tu
- Department of Surgical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Jin Huang
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Xiaofeng Zhu
- Department of Gastroenterology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Chunbao Zang
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Kaiyang Ding
- Department of Hematology-Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Bihong Zhan
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Yufei Zhao
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
| | - Liting Qian
- Department of Medical Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei, Anhui, China
- *Correspondence: Liting Qian,
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22
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EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere 2022; 6:e750. [PMID: 35924068 PMCID: PMC9281983 DOI: 10.1097/hs9.0000000000000750] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/01/2022] [Indexed: 01/19/2023] Open
Abstract
In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.
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23
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Song AB, Al-Samkari H. An updated evaluation of avatrombopag for the treatment of chronic immune thrombocytopenia. Expert Rev Clin Immunol 2022; 18:783-791. [PMID: 35793401 DOI: 10.1080/1744666x.2022.2098119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Multiple agents are available for the management of chronic immune thrombocytopenia (ITP), including thrombopoietin-receptor agonists (TPO-RAs), rituximab, and fostamatinib. Although TPO-RAs are often selected as treatments for chronic ITP, when choosing between the TPO-RAs, clinicians must balance safety profile, dosing restrictions, and method of administration incorporating patient preference. AREAS COVERED We provide an overview of the thrombopoietin receptor agonists with a particular focus on avatrombopag, the newest agent in this class. In phase II and III clinical trials, avatrombopag was shown to offer durable improvement in platelet counts. We also include recent real-world evidence describing avatrombopag effectiveness in patients with poor response to prior treatments (including other TPO-RAs). EXPERT OPINION Compared with other TPO-RAs used to treat ITP, avatrombopag offers practical oral dosing with a single pill strength, does not require long-term dietary restrictions, and has no warning for hepatotoxicity. It is frequently effective after use of other TPO-RAs in ITP. The primary downside with avatrombopag use at present is the lack of longer-term safety data in ITP that presently exists for romiplostim and eltrombopag.
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Affiliation(s)
- Andrew B Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA.,Division of Hematology, Massachusetts General Hospital, Boston, MA
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24
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Ha H, Lim JH. Managing Side Effects of Cytotoxic Chemotherapy in Patients With High Grade Gliomas. Brain Tumor Res Treat 2022; 10:158-163. [PMID: 35929113 PMCID: PMC9353159 DOI: 10.14791/btrt.2022.0018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/20/2022] Open
Abstract
Cytotoxic chemotherapy has been a mainstay of cancer treatment since the 1940s. In the recent era of emergent targeted therapies and immunotherapies, many cytotoxic chemotherapy agents including temozolomide are still one of main weapons for the treatment of high grade gliomas. However, cytotoxic chemotherapy often causes side effects. Proper management of chemotherapy-induced toxicity can have a significant impact on a patient’s quality of life and clinical outcomes. Many supportive care advances have transformed our ability to give full doses of chemotherapy, which is important for achieving their full efficacy. Prevention and treatment strategies have been developed for many chemotherapy-related toxicities. This review focused on managing gastrointestinal toxicity, chemotherapy-induced nausea and vomiting, and hematologic toxicities such as thrombocytopenia during cytotoxic chemotherapy treatment in high-grade brain tumors.
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Affiliation(s)
- Hyerim Ha
- Department of Hematology and Oncology, Inha University Hospital, Inha University College of Medicine, Incheon, Korea
| | - Joo Han Lim
- Department of Hematology and Oncology, Inha University Hospital, Inha University College of Medicine, Incheon, Korea.
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25
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Griffiths EA, Roy V, Alwan L, Bachiashvili K, Baird J, Cool R, Dinner S, Geyer M, Glaspy J, Gojo I, Hicks A, Kallam A, Kidwai WZ, Kloth DD, Kraut EH, Landsburg D, Lyman GH, Mahajan A, Miller R, Nachar V, Patel S, Patel S, Perez LE, Poust A, Riaz F, Rosovsky R, Rugo HS, Simon S, Vasu S, Wadleigh M, Westbrook K, Westervelt P, Berardi RA, Pluchino L. NCCN Guidelines® Insights: Hematopoietic Growth Factors, Version 1.2022. J Natl Compr Canc Netw 2022; 20:436-442. [PMID: 35545171 DOI: 10.6004/jnccn.2022.0026] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Hematopoietic Growth Factors provide recommendations for the appropriate use of growth factors in the clinical management of febrile neutropenia (FN), chemotherapy-induced thrombocytopenia (CIT), and chemotherapy-induced anemia (CIA). Management and prevention of these sequelae are an integral part of supportive care for many patients undergoing cancer treatment. The purpose of these guidelines is to operationalize the evaluation, prevention, and treatment of FN, CIT, and CIA in adult patients with nonmyeloid malignancies and to enable the patient and clinician to assess management options for FN, CIT, and CIA in the context of an individual patient's condition. These NCCN Guidelines Insights provide a summary of the important recent updates to the NCCN Guidelines for Hematopoietic Growth Factors, with particular emphasis on the incorporation of a newly developed section on CIT.
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Affiliation(s)
| | | | - Laura Alwan
- 3Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | - Rita Cool
- 6The University of Texas MD Anderson Cancer Center
| | - Shira Dinner
- 7Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Ivana Gojo
- 10The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - Eric H Kraut
- 15The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Gary H Lyman
- 3Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | - Seema Patel
- 20Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Shiven Patel
- 21Huntsman Cancer Institute at the University of Utah
| | | | | | | | | | - Hope S Rugo
- 26UCSF Helen Diller Family Comprehensive Cancer Center
| | - Shayna Simon
- 27UT Southwestern Simmons Comprehensive Cancer Center
| | - Sumithira Vasu
- 15The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Peter Westervelt
- 30Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine; and
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26
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Thrombopoietin receptor agonist in chemotherapy-induced thrombocytopenia. Lancet Haematol 2022; 9:e168-e169. [DOI: 10.1016/s2352-3026(22)00030-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/17/2022] [Indexed: 12/26/2022]
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