Romiplostim in aplastic anaemia - another tool in the armamentarium

Romiplostim in Aplastic Anemia: A Single-Center Retrospective Study

Background Acquired aplastic anemia (AA) is an immune-mediated hematopoietic disorder. It is characterized by pancytopenia and hypocellular bone marrow. The first-line treatment approach to AA includes immunosuppressive treatment (IST) using the combination of antithymocyte globulin (ATG) and cyclosporine A. Those patients who do not respond to this first-line treatment or have refractory disease succumb to bleeding or infections within five years following their diagnosis even after IST. Romiplostim, a thrombopoietin (TPO) receptor antagonist, promotes trilineage hematopoiesis in patients with AA. A retrospective study assessed the safety and effectiveness of romiplostim, as monotherapy among patients with refractory AA in Indian settings. Methods The case record forms of patients diagnosed with refractory AA and receiving treatment with weekly doses of 250 mg romiplostim and concomitant medications were reviewed at Yashoda Hematology Clinic, India. The primary outcome was to evaluate the increase in platelet count/percentage and the safety of romiplostim in these patients. The secondary outcomes were a change in total leucocyte count (TLC) and hemoglobin (Hb) levels from baseline after romiplostim therapy. Results Data from 28 patients diagnosed with AA and having received romiplostim subcutaneously in a dose of 250 mg weekly were analyzed. There was a significant improvement in platelet count which increased by 0.064 × 109/L units (95% CI: 0.021-0.107) at a 100-day interval from the initial measurement. The TLCs also increased by 0.022 × 109/L units (95% CI: 0.002-0.042). The mean Hb levels increased from 7.61 gm/L to 13.38 gm/L (95% CI, p < 0.001). No severe adverse events were reported. Conclusion Romiplostim demonstrated clinically significant outcomes with a favorable safety profile in patients with refractory AA.

Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline

Pancytopenia with hypocellular bone marrow is the hallmark of aplastic anaemia (AA) and the diagnosis is confirmed after careful evaluation, following exclusion of alternate diagnosis including hypoplastic myelodysplastic syndromes. Emerging use of molecular cyto-genomics is helpful in delineating immune mediated AA from inherited bone marrow failures (IBMF). Camitta criteria is used to assess disease severity, which along with age and availability of human leucocyte antigen compatible donor are determinants for therapeutic decisions. Supportive care with blood and platelet transfusion support, along with anti-microbial prophylaxis and prompt management of opportunistic infections remain key throughout the disease course. The standard first-line treatment for newly diagnosed acquired severe/very severe AA patients is horse anti-thymocyte globulin and ciclosporin-based immunosuppressive therapy (IST) with eltrombopag or allogeneic haemopoietic stem cell transplant (HSCT) from a matched sibling donor. Unrelated donor HSCT in adults should be considered after lack of response to IST, and up front for young adults with severe infections and a readily available matched unrelated donor. Management of IBMF, AA in pregnancy and in elderly require special attention. In view of the rarity of AA and complexity of management, appropriate discussion in multidisciplinary meetings and involvement of expert centres is strongly recommended to improve patient outcomes.