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Piekarska A, Pawelec K, Szmigielska-Kapłon A, Ussowicz M. The state of the art in the treatment of severe aplastic anemia: immunotherapy and hematopoietic cell transplantation in children and adults. Front Immunol 2024; 15:1378432. [PMID: 38646536 PMCID: PMC11026616 DOI: 10.3389/fimmu.2024.1378432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Acquired aplastic anemia (AA) is an immune-mediated bone marrow (BM) failure where marrow disruption is driven by a cytotoxic T-cell-mediated autoimmune attack against hematopoietic stem cells. The key diagnostic challenge in children, but also in adults, is to exclude the possible underlying congenital condition and myelodysplasia. The choice of treatment options, either allogeneic hematopoietic cell transplantation (alloHCT) or immunosuppressive therapy (IST), depends on the patient's age, comorbidities, and access to a suitable donor and effective therapeutic agents. Since 2022, horse antithymocyte globulin (hATG) has been available again in Europe and is recommended for IST as a more effective option than rabbit ATG. Therefore, an update on immunosuppressive strategies is warranted. Despite an improved response to the new immunosuppression protocols with hATG and eltrombopag, some patients are not cured or remain at risk of aplasia relapse or clonal evolution and require postponed alloHCT. The transplantation field has evolved, becoming safer and more accessible. Upfront alloHCT from unrelated donors is becoming a tempting option. With the use of posttransplant cyclophosphamide, haploidentical HCT offers promising outcomes also in AA. In this paper, we present the state of the art in the management of severe AA for pediatric and adult patients based on the available guidelines and recently published studies.
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Affiliation(s)
- Agnieszka Piekarska
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Katarzyna Pawelec
- Department of Oncology, Pediatric Hematology, Clinical Transplantology and Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Marek Ussowicz
- Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
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Mitani K, Lee JW, Jang JH, Tomiyama Y, Miyazaki K, Nagafuji K, Usuki K, Uoshima N, Fujisaki T, Kosugi H, Matsumura I, Sasaki K, Kizaki M, Sawa M, Hidaka M, Kobayashi N, Ichikawa S, Yonemura Y, Murotani K, Shimizu M, Matsuda A, Ozawa K, Nakao S. Long-term efficacy and safety of romiplostim in refractory aplastic anemia: follow-up of a phase 2/3 study. Blood Adv 2024; 8:1415-1419. [PMID: 38134300 PMCID: PMC10950812 DOI: 10.1182/bloodadvances.2023010959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/14/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Affiliation(s)
- Kinuko Mitani
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Jong Wook Lee
- Division of Hematology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jun Ho Jang
- Department of Hematology, Sungkyunkwan University Samsung Medical Center, Seoul, Republic of Korea
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Osaka, Japan
| | - Koji Miyazaki
- Department of Transfusion and Cell Transplantation, Kitasato University School of Medicine, Sagamihara, Japan
| | - Koji Nagafuji
- Department of Hematology, Kurume University Hospital, Kurume, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Nobuhiko Uoshima
- Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Tomoaki Fujisaki
- Department of Internal Medicine, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Hiroshi Kosugi
- Department of Hematology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Itaru Matsumura
- Department of Hematology and Rheumatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Ko Sasaki
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Masahiro Kizaki
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Masashi Sawa
- Department of Hematology and Oncology, Anjo Kosei Hospital, Anjo, Japan
| | - Michihiro Hidaka
- Department of Hematology, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Naoki Kobayashi
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Satoshi Ichikawa
- Department of Hematology, Tohoku University Hospital, Sendai, Japan
| | - Yuji Yonemura
- Department of Transfusion Medicine and Cell Therapy, Kumamoto University Hospital, Kumamoto, Japan
| | | | - Mami Shimizu
- Department of Medical Affairs, Kyowa Kirin Co, Ltd, Tokyo, Japan
| | - Akira Matsuda
- Department of Hemato-Oncology, Saitama Medical University International Medical Center, Saitama Medical University, Saitama, Japan
| | - Keiya Ozawa
- Division of Hematology, Jichi Medical University, Tochigi, Japan
| | - Shinji Nakao
- Division of Hematology/Respiratory Medicine, Faculty of Medicine, Institute of Medical Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
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Kulasekararaj A, Cavenagh J, Dokal I, Foukaneli T, Gandhi S, Garg M, Griffin M, Hillmen P, Ireland R, Killick S, Mansour S, Mufti G, Potter V, Snowden J, Stanworth S, Zuha R, Marsh J. Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline. Br J Haematol 2024; 204:784-804. [PMID: 38247114 DOI: 10.1111/bjh.19236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/26/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024]
Abstract
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.
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Affiliation(s)
- Austin Kulasekararaj
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Jamie Cavenagh
- St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Inderjeet Dokal
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London and Barts Health NHS Trust, London, UK
| | - Theodora Foukaneli
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- NHS Blood and Transplant, Bristol, UK
| | - Shreyans Gandhi
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
- British Society Haematology Task Force Representative, London, UK
| | | | | | - Robin Ireland
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Sally Killick
- University Hospitals Dorset NHS Foundation Trust, The Royal Bournemouth Hospital, Bournemouth, UK
| | - Sahar Mansour
- St George's Hospital/St George's University of London, London, UK
| | - Ghulam Mufti
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - Victoria Potter
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
| | - John Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Roslin Zuha
- James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, England
| | - Judith Marsh
- King's College Hospital NHS Foundation Trust, London and King's College London, London, UK
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4
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Scheinberg P. Progress in medical therapy in aplastic anemia: why it took so long? Int J Hematol 2024; 119:248-254. [PMID: 38403842 DOI: 10.1007/s12185-024-03713-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/27/2023] [Accepted: 01/15/2024] [Indexed: 02/27/2024]
Abstract
The treatment of aplastic anemia (AA) has significantly advanced in the last 50 years, evolving from a fatal condition to one where survival rates now exceed 80-85%. Hematopoietic stem cell transplantation (HSCT) and immunosuppressive therapy (IST) have become the primary treatments, with the latter widely adopted due to factors like the scarcity of compatible donors, patient age, comorbidities, and limited HSCT access. A therapy breakthrough was the introduction of antithymocyte globulin (ATG), with its effectiveness further boosted by cyclosporine. However, it took years to achieve another major milestone in management. Initially, treatments aimed to intensify immunosuppression following the success of the ATG-cyclosporine combination, but these methods fell short of expectations. A major turning point was combining immunosuppression with stem cell stimulation, surpassing the efficacy of IST alone. Earlier, growth factors had shown limited success in AA treatment, but thrombopoietin receptor agonists represented a significant advancement. Initially applied alone as salvage, these were later combined with IST, forming the most effective current regimen for medically managing SAA. Horse ATG is the preferred formulation combined with cyclosporine and eltrombopag. This progress in AA treatment offers improved outcomes for patients afflicted with this once-lethal disease.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Rua Martiniano de Carvalho, 951, São Paulo, SP, 01321-001, Brazil.
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Sarson-Lawrence KTG, Hardy JM, Iaria J, Stockwell D, Behrens K, Saiyed T, Tan C, Jebeli L, Scott NE, Dite TA, Nicola NA, Leis AP, Babon JJ, Kershaw NJ. Cryo-EM structure of the extracellular domain of murine Thrombopoietin Receptor in complex with Thrombopoietin. Nat Commun 2024; 15:1135. [PMID: 38326297 PMCID: PMC10850085 DOI: 10.1038/s41467-024-45356-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/19/2024] [Indexed: 02/09/2024] Open
Abstract
Thrombopoietin (Tpo) is the primary regulator of megakaryocyte and platelet numbers and is required for haematopoetic stem cell maintenance. Tpo functions by binding its receptor (TpoR, a homodimeric Class I cytokine receptor) and initiating cell proliferation or differentiation. Here we characterise the murine Tpo:TpoR signalling complex biochemically and structurally, using cryo-electron microscopy. Tpo uses opposing surfaces to recruit two copies of receptor, forming a 1:2 complex. Although it binds to the same, membrane-distal site on both receptor chains, it does so with significantly different affinities and its highly glycosylated C-terminal domain is not required. In one receptor chain, a large insertion, unique to TpoR, forms a partially structured loop that contacts cytokine. Tpo binding induces the juxtaposition of the two receptor chains adjacent to the cell membrane. The therapeutic agent romiplostim also targets the cytokine-binding site and the characterisation presented here supports the future development of improved TpoR agonists.
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Affiliation(s)
- Kaiseal T G Sarson-Lawrence
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
| | - Joshua M Hardy
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
- ARC Centre for Cryo-electron Microscopy of Membrane Proteins, Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
| | - Josephine Iaria
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
| | - Dina Stockwell
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
| | - Kira Behrens
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
| | - Tamanna Saiyed
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
| | - Cyrus Tan
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
| | - Leila Jebeli
- Department of Microbiology and Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, 3000, Victoria, Australia
| | - Nichollas E Scott
- Department of Microbiology and Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, 3000, Victoria, Australia
| | - Toby A Dite
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
| | - Nicos A Nicola
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
| | - Andrew P Leis
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia
- ARC Centre for Cryo-electron Microscopy of Membrane Proteins, Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia
| | - Jeffrey J Babon
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia.
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia.
| | - Nadia J Kershaw
- Walter and Eliza Hall Institute of Medical Research, 1G Royal Parade, Parkville, 3052, Victoria, Australia.
- Department of Medical Biology, The University of Melbourne, Royal Parade, Parkville, 3052, Victoria, Australia.
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Yim J, Park SS, Lee JM, Yoon JH, Kim HJ, Min CK. Successful recovery of poor graft function by administration of romiplostim in a multiple myeloma case with poor graft function following autologous stem cell transplantation. Blood Res 2023; 58:237-240. [PMID: 38031472 PMCID: PMC10758637 DOI: 10.5045/br.2023.2023185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/12/2023] [Accepted: 11/24/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Jeongmin Yim
- Departments of Hematology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Soo Park
- Departments of Hematology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Mi Lee
- Departments of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Ho Yoon
- Departments of Hematology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- Departments of Hematology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang-Ki Min
- Departments of Hematology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Li A, Feng R. [CAR-T cell therapy-related long-term cytopenias]. Zhonghua Xue Ye Xue Za Zhi 2023; 44:870-875. [PMID: 38049346 PMCID: PMC10694071 DOI: 10.3760/cma.j.issn.0253-2727.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Indexed: 12/06/2023]
Affiliation(s)
- A Li
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - R Feng
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Kurita N, Nishikii H, Maruyama Y, Suehara Y, Hattori K, Sakamoto T, Kato T, Yokoyama Y, Obara N, Maruo K, Ohigashi T, Yamaguchi H, Iwamoto T, Minohara H, Matsuoka R, Hashimoto K, Sakata-Yanagimoto M, Chiba S. Safety of romiplostim administered immediately after cord-blood transplantation: a phase 1 trial. Ann Hematol 2023; 102:2895-2902. [PMID: 37589942 DOI: 10.1007/s00277-023-05410-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/08/2023] [Indexed: 08/18/2023]
Abstract
Graft failure and delayed hematopoietic recovery are the major limitations of cord-blood transplantation (CBT). Romiplostim, a thrombopoietin-receptor agonist, promotes megakaryopoiesis and multilineage hematopoiesis in aplastic anemia. The decreased number of hematopoietic stem cells in the early phase after CBT and aplastic anemia share certain characteristics. Therefore, we hypothesized that romiplostim administration immediately after CBT may promote multilineage hematopoietic recovery. We investigated the safety and preliminary efficacy of administering romiplostim a day after CBT. This phase 1 dose-escalation study included six adults with hematologic malignancies in remission. Romiplostim was administered subcutaneously within 7 days after single-unit CBT, initially at doses of 5 µg/kg or 10 µg/kg in three patients, then once a week for 14 weeks or until platelet recovery. The maximum dose was 20 µg/kg. The median number of romiplostim administrations was 6 (range, 3-15). Romiplostim-related adverse events included bone pain (3/6) and injection site reaction (1/6). Non-hematological grade ≥ 3 toxicities were observed in four patients; febrile neutropenia was the most common (4/6). All patients achieved neutrophil engraftment and the median time was 14 days (range, 12-32). Platelet counts ≥ 50 × 109 /L were recorded in all patients except for one who died on day 48; the median time was 34 days (range, 29-98). No relapse, thrombosis, or bone marrow fibrosis was observed during a median follow-up of 34 months. Romiplostim may be safely administered in the early phase of CBT. Further phase 2 trial is warranted for its efficacy evaluation. Trial registration number: UMIN000033799, August 18, 2018.
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Affiliation(s)
- Naoki Kurita
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan.
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan.
| | - Hidekazu Nishikii
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yumiko Maruyama
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yasuhito Suehara
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Keiichiro Hattori
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Tatsuhiro Sakamoto
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Takayasu Kato
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Yasuhisa Yokoyama
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Naoshi Obara
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Kazushi Maruo
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Tomohiro Ohigashi
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Hitomi Yamaguchi
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Toshiro Iwamoto
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Hideto Minohara
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Ryota Matsuoka
- Department of Diagnostic Pathology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Koichi Hashimoto
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, Tsukuba, Japan
| | - Mamiko Sakata-Yanagimoto
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Shigeru Chiba
- Department of Hematology, Institute of Medicine, University of Tsukuba, Tennodai 1-1-1, Tsukuba, Ibaraki, 305-8575, Japan
- Department of Hematology, University of Tsukuba Hospital, Tsukuba, Japan
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9
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Zhang Z, Hu Q, Yang C, Chen M, Han B. Comparison of eltrombopag and avatrombopag in the treatment of refractory/relapsed aplastic anemia: a single-center retrospective study in China. Ther Adv Hematol 2023; 14:20406207231191310. [PMID: 37719987 PMCID: PMC10503291 DOI: 10.1177/20406207231191310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/14/2023] [Indexed: 09/19/2023] Open
Abstract
Background Eltrombopag (ELT), a thrombopoietin receptor agonist (TPO-RA), has been approved for relapsed/refractory aplastic anemia (AA). However, data on avatrombopag (AVA), another TPO-RA, are limited, and the comparisons between the two TPO-RAs are lacking. Objectives We aimed to compare the efficacy and safety between ELT and AVA in relapsed/refractory AA patients. Design In this retrospective study, patients with relapsed/refractory AA who had been treated with ELT (N = 45) or AVA (N = 30) alone and had compatible baseline hematological parameters were compared. Methods Data from patients diagnosed with acquired AA were retrospectively collected. All patients were refractory/relapsed to standard immunosuppressive therapy (IST) for at least 6 months before ELT or AVA. Patients had to be treated with ELT or AVA alone for at least 6 months before evaluation if they did not respond. Baseline characteristics, overall response (OR), complete response (CR), relapse, adverse events, and factors that may affect efficacy were analyzed. Results Of the 75 patients enrolled, 45 received ELT and 30 received AVA. Patients with AVA had a higher percentage of abnormal liver or renal function than those with ELT (p = 0.036). No significant difference was found in the OR/CR rate in the first/second/third/sixth month between the two cohorts (p > 0.05). Patients treated with AVA had a shorter median time to response than those treated with ELT (p = 0.012) and had a higher platelet level in the second month (p = 0.041). AVA had fewer adverse events than ELT (p = 0.046). Under compatible follow-up time (p = 0.463), no difference was found between the ELT and AVA cohorts in relapse (p = 1.000) or clone evolution (p = 0.637). No predictive factors for OR and CR in the sixth month were found for either ELT or AVA. Conclusion With worse liver or renal function, AVA had a similar OR/CR rate but a shorter median time to response and fewer adverse events for patients with relapsed/refractory AA.
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Affiliation(s)
- Zhuxin Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Qinglin Hu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Chen Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Miao Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Shuaifuyuan No. 1, Dongcheng District, Beijing 100730, China
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10
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Al-Hakim A, Cull A, Topping J, Nadat F, Milek J, Alhefzi R, McDermott MF, Owen R, Cargo C, Poulter J, Kent DG, Savic S. Recovery of Bone Marrow Function in VEXAS Syndrome-potential Role for Romiplostim. Hemasphere 2023; 7:e934. [PMID: 37520777 PMCID: PMC10374182 DOI: 10.1097/hs9.0000000000000934] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/20/2023] [Indexed: 08/01/2023] Open
Affiliation(s)
- Adam Al-Hakim
- Department of Clinical Immunology and Allergy, St James’s University Hospital, Leeds, United Kingdom
| | - Alyssa Cull
- Department of Biology, York Biomedical Research Institute, University of York, United Kingdom
| | - Joanna Topping
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, St. James’s University Hospital, Leeds, United Kingdom
| | - Fatima Nadat
- Department of Clinical Immunology and Allergy, St James’s University Hospital, Leeds, United Kingdom
| | - Joanna Milek
- Department of Biology, York Biomedical Research Institute, University of York, United Kingdom
| | - Razan Alhefzi
- Department of Biology, York Biomedical Research Institute, University of York, United Kingdom
| | - Michael F. McDermott
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, St. James’s University Hospital, Leeds, United Kingdom
| | - Roger Owen
- Haematological Malignancy Diagnostic Service, St James’s University Hospital, Leeds, United Kingdom
| | - Catherine Cargo
- Haematological Malignancy Diagnostic Service, St James’s University Hospital, Leeds, United Kingdom
| | - James Poulter
- Leeds Institute of Medical Research, St. James’s University Hospital, Leeds, United Kingdom
| | - David G. Kent
- Department of Biology, York Biomedical Research Institute, University of York, United Kingdom
| | - Sinisa Savic
- Department of Clinical Immunology and Allergy, St James’s University Hospital, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, St. James’s University Hospital, Leeds, United Kingdom
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11
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Zhang S, Wang Q, Cui K, Cheng B, Fan J, Hu S. Efficacy of Eltrombopag with Immunosuppressive Therapy Versus Immunosuppressive Therapy Alone on Severe Aplastic Anaemia: A Systematic Review and Meta-analysis. Clin Drug Investig 2023; 43:315-324. [PMID: 37165250 DOI: 10.1007/s40261-023-01266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Severe aplastic anaemia (SAA) is a syndrome of bone marrow failure caused by T cell-mediated destruction of haematopoietic stem cells and progenitor cells. Whether patients with SAA should be treated with eltrombopag (EPAG) and immunosuppressive therapy (IST) or IST alone remains debatable. Therefore, we conducted this meta-analysis to compare the efficacy of eltrombopag + IST with that of IST alone in patients with SAA and to assess the difference in the efficacy of eltrombopag in adults and children. METHODS We performed this meta-analysis by retrieving studies that met the inclusion and exclusion criteria from PubMed, EMBASE, and the Cochrane Library up to 1 January 2023. We used a random-effects model to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for primary and secondary outcomes. I2 statistics were used to evaluate the heterogeneity of the included studies. RESULTS Six studies involving a total of 699 patients were included. In terms of the primary outcomes, our pooled results indicated that patients treated with EPAG + IST had a higher 6-month overall response rate (OR = 2.25; 95% CI, 1.60-3.16; p < 0.00001), a higher 6-month complete response rate (OR = 2.61; 95% CI, 1.82-3.74; p < 0.00001), and a lower 6-month nonresponse rate (OR = 0.32; 95% CI, 0.19-0.52; p < 0.00001). However, there was no significant difference in the rate of 6-month partial response (OR = 0.94; 95% CI, 0.49-1.81; p = 0.85). CONCLUSION This meta-analysis indicated that patients treated with additional eltrombopag for IST may have a higher rate of haematological response.
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Affiliation(s)
- Senlin Zhang
- Department of Haematology and Oncology, Center of Jiangsu Pediatric Haematology and Oncology, Children's Hospital of Soochow University, No. 92, Zhongnan Street, Suzhou, 215000, China
| | - Qingwei Wang
- Department of Haematology and Oncology, Center of Jiangsu Pediatric Haematology and Oncology, Children's Hospital of Soochow University, No. 92, Zhongnan Street, Suzhou, 215000, China
| | - Kai Cui
- Department of Haematology and Oncology, Center of Jiangsu Pediatric Haematology and Oncology, Children's Hospital of Soochow University, No. 92, Zhongnan Street, Suzhou, 215000, China
| | - Bingjie Cheng
- Department of Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430000, China
| | - Junjie Fan
- Department of Haematology and Oncology, Center of Jiangsu Pediatric Haematology and Oncology, Children's Hospital of Soochow University, No. 92, Zhongnan Street, Suzhou, 215000, China.
| | - Shaoyan Hu
- Department of Haematology and Oncology, Center of Jiangsu Pediatric Haematology and Oncology, Children's Hospital of Soochow University, No. 92, Zhongnan Street, Suzhou, 215000, China.
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12
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Dhingra G, Rajoreya A. A Single-Centre Experience of First-Line Romiplostim and Immunosuppressive Therapy in Patients With Aplastic Anemia. Cureus 2023; 15:e37682. [PMID: 37206485 PMCID: PMC10190113 DOI: 10.7759/cureus.37682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 05/21/2023] Open
Abstract
Background Romiplostim, a thrombopoietin (TPO) receptor antagonist, promotes tri-lineage hematopoiesis in patients with acquired aplastic anemia (AA). However, its efficacy as a first-line treatment in combination with an immunosuppressant, i.e., anti-thymocyte globulin (ATG) and cyclosporine (CSA), remains unexplored. Objective To assess the efficacy and safety of romiplostim in combination with ATG and CSA as first-line treatment in patients with AA. Method A single-center, retrospective study of AA patients, where data of patients administered with ATG + CSA + romiplostim as a first-line treatment was included. Romiplostim 5 µg/kg weekly for one month; post that, the dose was increased to 10 µg/kg weekly for the next five months. The primary outcome involves the overall response rate and hematological response at baseline, three months, and six months. Result Data from 12 patients with a median age of 18 years was evaluated. At a median follow-up of six months, 25% achieved a complete response, 41.6% achieved a partial response, and 16.7% had no response. Improvement in tri-lineage hematopoietic response had been seen at six months from baseline, with improvement in absolute neutrophil count (ANC) and platelet count (PC) being the most significant, with an increase of >100% from baseline, followed by total leukocyte count (TLC) (75.13%) and hemoglobin (Hb) (66.07%) from baseline. Two deaths were reported during the treatment. Conclusion Romiplostim, in combination with ATG plus CSA, demonstrated clinically significant outcomes as a first-line treatment in patients with AA. Further studies are required to confirm these findings in larger populations to assess long-term outcomes.
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Affiliation(s)
- Gaurav Dhingra
- Department of Clinical Hematology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Ashok Rajoreya
- Hematology Hemato-Oncology Center, Ratan Jyoti Netralaya Apollo Spectra Hospitals, Gwalior, IND
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13
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Fattizzo B, Motta I. Rise of the planet of rare anemias: An update on emerging treatment strategies. Front Med (Lausanne) 2023; 9:1097426. [PMID: 36698833 PMCID: PMC9868867 DOI: 10.3389/fmed.2022.1097426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/14/2022] [Indexed: 01/12/2023] Open
Abstract
Therapeutic options for rare congenital (hemoglobinopathies, membrane and enzyme defects, congenital dyserythropoietic anemia) and acquired anemias [warm autoimmune hemolytic anemia (wAIHA), cold agglutinin disease CAD, paroxysmal nocturnal hemoglobinuria (PNH), and aplastic anemia (AA)] are rapidly expanding. The use of luspatercept, mitapivat and etavopivat in beta-thalassemia and pyruvate kinase deficiency (PKD) improves transfusion dependence, alleviating iron overload and long-term complications. Voxelotor, mitapivat, and etavopivat reduce vaso-occlusive crises in sickle cell disease (SCD). Gene therapy represents a fascinating approach, although patient selection, the toxicity of the conditioning regimens, and the possible long-term safety are still open issues. For acquired forms, wAIHA and CAD will soon benefit from targeted therapies beyond rituximab, including B-cell/plasma cell targeting agents (parsaclisib, rilzabrutinib, and isatuximab for wAIHA), complement inhibitors (pegcetacoplan and sutimlimab for CAD, ANX005 for wAIHA with complement activation), and inhibitors of extravascular hemolysis in the reticuloendothelial system (fostamatinib and FcRn inhibitors in wAIHA). PNH treatment is moving from the intravenous anti-C5 eculizumab to its long-term analog ravulizumab, and to subcutaneous and oral proximal inhibitors (anti-C3 pegcetacoplan, factor D and factor B inhibitors danicopan and iptacopan). These drugs have the potential to improve patient convenience and ameliorate residual anemia, although patient compliance becomes pivotal, and long-term safety requires further investigation. Finally, the addition of eltrombopag significantly ameliorated AA outcomes, and data regarding the alternative agent romiplostim are emerging. The accelerated evolution of treatment strategies will need further effort to identify the best candidate for each treatment in the precision medicine era.
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Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, SC Ematologia, Milan, Italy,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy,*Correspondence: Bruno Fattizzo,
| | - Irene Motta
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, SC Medicina ad Indirizzo Metabolico, Milan, Italy,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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14
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Kanda Y, Mori T, Narita A, Wolter KD, Yoshimatsu H, Nishimura K. Efficacy and safety of equine anti-thymocyte immunoglobulin (eATG) in three Japanese patients with moderate to very severe aplastic anemia: a case series. Int J Hematol 2023; 117:37-43. [PMID: 36441357 PMCID: PMC9876848 DOI: 10.1007/s12185-022-03496-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022]
Abstract
Aplastic anemia results from lymphocyte-mediated destruction of hematopoietic stem cells. Immunosuppressive therapy with anti-thymocyte globulin (ATG) and cyclosporine is the standard front-line treatment for patients with severe aplastic anemia who are not suitable candidates for stem cell transplants. PF-06462700 is a potent equine ATG that targets T-lymphocytes and has been approved as a treatment for aplastic anemia outside of Japan for over 30 years. Due to the high medical need for PF-06462700, the Ministry of Health, Labor and Welfare requested its development for Japanese patients with aplastic anemia. In this case series, the efficacy and safety of PF-06462700, administered intravenously at 40 mg/kg/day for 4 days, were assessed over a 24-week period. This was as an open-label, single-arm, multicenter clinical study designed to enroll a minimum of three Japanese participants with aplastic anemia. Two participants met the primary outcome of hematologic response at week 12 and improvements in disease severity were observed. No deaths or serious adverse events were reported. The efficacy results from this case series suggest that administration of PF-06462700 is generally well-tolerated and produces a hematologic response in Japanese patients with aplastic anemia, which should be further evaluated in real-world studies.ClinicalTrials.gov identifier: NCT04350606.
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Affiliation(s)
- Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi-Ken, 329-0498, Japan.
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsushi Narita
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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15
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Corona M, Shouval R, Alarcón A, Flynn J, Devlin S, Batlevi C, Mantha S, Palomba ML, Scordo M, Shah G, Sauter C, Perales MÁ, Dahi PB. Management of prolonged cytopenia following CAR T-cell therapy. Bone Marrow Transplant 2022. [PMID: 36131002 DOI: 10.1038/s41409-022-01771-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 11/08/2022]
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16
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Wilk CM, Kovtonyuk LV, Manz MG. Romiplostim addition to conditioning prior to HSCT allows chemotherapy reduction while maintaining engraftment levels. Blood Adv 2022:bloodadvances. [PMID: 35736667 DOI: 10.1182/bloodadvances.2022007566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/20/2022] [Indexed: 11/20/2022] Open
Abstract
Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) offers are curative treatment approach for certain benign and malignant hematologic diseases. The actual HSCT is preceded by a conditioning therapy that reduces host-versus HSCT graft rejection and creates niche space for transplanted Hematopoietic Stem and Progenitor Cells (HSPCs). Conditioning consists of chemotherapy with or without irradiation and is a major cause of side-effects in HSCT. However, reduction of the intensity of cytotoxic conditioning leads to higher rates of engrafment failure and increased rates of relapse. In the present study, we investigated in how far sensitization of HSPCs to chemotherapy allows a reduction of the dose of drugs used as conditioning regimen in an HSCT mouse model. The thrombopoietin receptor agonist Romiplostim was shown to induce cell cycling activity in Hematopoietic Stem Cells (HSCs). We thus tested if the addition of Romiplostim to the clinically applied conditioning chemotherapy regimen cyclophosphamide and busulfan leads to increased efficacy of the chemotherapeutic regimen. We found that Romiplostim not only sensitizes HSCs to chemotherapy but also enables a reduction of the main chemotherapeutic component Busulfan by half, while HSC engraftment levels are maintained in long-term, serial transplantation assays.
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17
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Beyar-Katz O, Perry C, On YB, Amit O, Gutwein O, Wolach O, Kedar R, Pikovsky O, Avivi I, Gold R, Ben-Ezra J, Shasha D, Ami RB, Ram R. Thrombopoietin receptor agonist for treating bone marrow aplasia following anti-CD19 CAR-T cells-single-center experience. Ann Hematol 2022; 101:1769-1776. [PMID: 35731278 DOI: 10.1007/s00277-022-04889-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/01/2022] [Indexed: 11/28/2022]
Abstract
Anti CD-19 chimeric antigen receptor T (CAR-T) cells demonstrate effective early anti-tumor response; however, impaired hematopoietic recovery is observed in about 30% of patients with prolonged cytopenia appearing as an unmet need for optimal treatment. All adult patients given commercially available anti CD-19 CAR-T for diffuse large B cell lymphoma (DLBCL) were screened at 21-28 days after CAR-T infusion for cytopenia. In case of severe persistent cytopenia, patients were given TPO receptor agonists. Initial dose of eltrombopag was 50 mg/day and gradually increased to a maximal dose of 150 mg/day. Romiplostim was given as subcutaneous injection once a week for 2 doses (125 mcg). Response was defined as transfusion independency along with resolution of severe neutropenia (ANC > 500 /microL) and/or platelets > 20,000/microL for three consecutive values on different days. TPO receptor agonists were tapered down when response was met. From May 2019 to December 2021, 93 patients were eligible (74%, tisagenlecleucel and 26%, axicabtagene ciloleucel). The median age was 69 (range, 19-85) years. Six patients (6.5%) (tisagenlecleucel, n = 4 or axicabtagene ciloleucel, n = 2) demonstrated prolonged severe cytopenia and were treated with TPO receptor agonists (eltrombopag, n = 4; romiplastim, n = 1, both drugs, n = 1). Median time from CAR-T infusion to initiation of TPO receptor agonist was 43 (range, 21-55) days. All patients were transfusion-dependent and were given daily GCSF prior to TPO receptor agonist administration. Response to TPO receptor agonists was seen in all 6 patients. Median time from TPO receptor agonist initiation to resolution of cytopenia was 22 (range, 8-124) days for Hb, 27 (range, 6-38) days for platelets, and 29 (range, 7-61) days for neutrophils. A complete resolution of all blood counts (ANC > 500 /microL and platelets > 20,000/microL and hemoglobin > 8 gr/dL) was seen in 5/6 patients. No toxicity was observed during the therapy course. This paper supports further investigation of TPO receptor agonists in the treatment of persistent cytopenia following CAR-T cell therapy.
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Affiliation(s)
- Ofrat Beyar-Katz
- BMT Unit, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Chava Perry
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology, Tel Aviv Souraski Medical Center, 6 Weitzman Street, Tel Aviv, Israel
| | - Yael Bar On
- BMT Unit, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Odelia Amit
- BMT Unit, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Odit Gutwein
- Department of Hematology, Assaf Harofeh Medical Center, Ramla, Israel
| | - Ofir Wolach
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Rotem Kedar
- Department of Hematology, Meir Medical Center, Kfar Saba, Israel
| | - Oleg Pikovsky
- Hematology Institute, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Irit Avivi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology, Tel Aviv Souraski Medical Center, 6 Weitzman Street, Tel Aviv, Israel
| | - Ronit Gold
- BMT Unit, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv, Israel
| | - Jonathan Ben-Ezra
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pathology, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv, Israel
| | - David Shasha
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Infectious Disease, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv, Israel
| | - Ronen Ben Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Infectious Disease, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv, Israel
| | - Ron Ram
- BMT Unit, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Ding S, Fu R. New Trends of Nontransplant therapy for Acquired Aplastic Anemia. Curr Pharm Des 2022; 28:1730-1737. [PMID: 35440301 DOI: 10.2174/1381612828666220418132432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/03/2022] [Indexed: 11/22/2022]
Abstract
Aplastic anemia (AA) is a hematological disease that is characterized by pancytopenia and hypofunctional bone marrow hematopoiesis. Patients with AA are treated with either immunosuppressive therapy (IST) using anti-thymocyte globulin (ATG) and Cyclosporine (CsA) or hematopoietic stem cell transplantation (HSCT), if a matched donor is available. The standard IST regimen for AA patients which results in response rates up to 70%, and even higher overall survival. However, primary and secondary failures after IST remain frequent, and to date all attempts aiming to overcome this problem have been unfruitful. The nontransplant therapeutic options for AA have significantly expanded during the last few years. Here, we review the new trends of nontransplant therapy for AA and summarize the current therapeutic effect of AA.
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Affiliation(s)
- Shaoxue Ding
- Department of Hematology, Tianjin Medical University General Hospital, No. 154, Anshan Road, Heping District, Tianjin, 300052, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, No. 154, Anshan Road, Heping District, Tianjin, 300052, China
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19
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Peng G, He G, Chang H, Gao S, Liu X, Chen T, Li P, Han B, Miao M, Ge Z, Ge X, Li F, Li Y, Wang S, Wang Y, Shen Y, Zhang T, Zou J, Zhang F. A multicenter phase II study on the efficacy and safety of hetrombopag in patients with severe aplastic anemia refractory to immunosuppressive therapy. Ther Adv Hematol 2022; 13:20406207221085197. [PMID: 35371427 PMCID: PMC8972928 DOI: 10.1177/20406207221085197] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/17/2022] [Indexed: 02/05/2023] Open
Abstract
Background: In this single-arm phase II study (NCT03557099), we evaluated the efficacy and safety of hetrombopag, a small molecule thrombopoietin (TPO) receptor agonist, in patients with severe aplastic anemia (SAA) who were refractory to standard first-line immunosuppressive therapy (IST). Methods: SAA patients who were refractory to standard first-line IST were given hetrombopag orally at an initial dose of 7.5 mg once daily to a maximum of 15 mg once daily, for a total of 52 weeks. The primary endpoint was proportion of patients achieving hematologic responses in ⩾1 lineage at week 18. Results: A total of 55 eligible patients were enrolled and received hetrombopag treatment. This study met its primary endpoint, with 23 [41.8%, 95% confidence interval (CI) = 28.7–55.9] patients achieving hematologic response in ⩾1 lineage at week 18 after initiation of hetrombopag treatment. Twenty-four (43.6%, 95% CI = 30.3–57.7) and 27 (49.1%, 95% CI = 35.4–62.9) of the 55 patients responded in ⩾1 lineage at weeks 24 and 52, respectively. Median time to initial hematologic response was 7.9 weeks (range = 2.0–32.1). The responses were durable, with a 12-month relapse-free survival rate of 82.2% (95% CI = 62.2–92.2). Adverse events occurred in 54 (98.2%) patients, and 28 (50.9%) patients had treatment-related adverse events. Seventeen (30.9%) patients had adverse events of grade ⩾3. Serious adverse events occurred in 15 (27.3%) patients and three deaths (5.5%) were reported. Conclusion: Hetrombopag showed encouraging efficacy with durable hematologic responses in patients with SAA who were refractory to IST. Hetrombopag was well tolerant and safe for long-term use. ClinicalTrials.gov identifier: NCT03557099
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Affiliation(s)
- Guangxin Peng
- Anemia Therapeutic Center, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Guangsheng He
- Department of Hematology, Jiangsu Province Hospital, Nanjing, China
| | - Hong Chang
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Sujun Gao
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Xinjian Liu
- Department of Hematology, Henan Cancer Hospital, Zhengzhou, China
| | - Tong Chen
- Department of Hematology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Pei Li
- Department of Hematology, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Beijing, China
| | - Miao Miao
- Department of Hematology, The First Affiliated Hospital of Suzhou University, Suzhou, China
| | - Zheng Ge
- Department of Hematology, Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Xiaoyan Ge
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Fei Li
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yingmei Li
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People’s Hospital, Guangzhou, China
| | - Yi Wang
- Department of Hematology, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Yaqi Shen
- Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Tao Zhang
- Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Jianjun Zou
- Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Fengkui Zhang
- Anemia Therapeutic Center, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 288 Nanjing Road, Heping District, 300020 Tianjin, China
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20
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Iino M, Jinguji A, Sato T, Nakadate A. Real-world experience of treatment with thrombopoietin receptor agonists in anti-thymocyte globulin-naïve patients with aplastic anemia: an observational retrospective analysis in a single institution. Hematology 2022; 27:360-366. [DOI: 10.1080/16078454.2022.2045725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Masaki Iino
- Department of Hematology and Hematopoietic Stem Cell Transplantation, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Atsushi Jinguji
- Department of Hematology and Hematopoietic Stem Cell Transplantation, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Tomoya Sato
- Department of Hematology and Hematopoietic Stem Cell Transplantation, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Ayato Nakadate
- Department of Hematology and Hematopoietic Stem Cell Transplantation, Yamanashi Prefectural Central Hospital, Kofu, Japan
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21
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Guan Y, Hasipek M, Jiang D, Tiwari AD, Grabowski DR, Pagliuca S, Kongkiatkamon S, Patel B, Singh S, Parker Y, LaFramboise T, Lindner D, Sekeres MA, Mian OY, Saunthararajah Y, Maciejewski JP, Jha BK. Eltrombopag inhibits TET dioxygenase to contribute to hematopoietic stem cell expansion in aplastic anemia. J Clin Invest 2022; 132:e149856. [PMID: 35085104 PMCID: PMC8843742 DOI: 10.1172/jci149856] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 01/04/2022] [Indexed: 11/18/2022] Open
Abstract
Eltrombopag, an FDA-approved non-peptidyl thrombopoietin receptor agonist, is clinically used for the treatment of aplastic anemia, a disease characterized by hematopoietic stem cell failure and pancytopenia, to improve platelet counts and stem cell function. Eltrombopag treatment results in a durable trilineage hematopoietic expansion in patients. Some of the eltrombopag hematopoietic activity has been attributed to its off-target effects, including iron chelation properties. However, the mechanism of action for its full spectrum of clinical effects is still poorly understood. Here, we report that eltrombopag bound to the TET2 catalytic domain and inhibited its dioxygenase activity, which was independent of its role as an iron chelator. The DNA demethylating enzyme TET2, essential for hematopoietic stem cell differentiation and lineage commitment, is frequently mutated in myeloid malignancies. Eltrombopag treatment expanded TET2-proficient normal hematopoietic stem and progenitor cells, in part because of its ability to mimic loss of TET2 with simultaneous thrombopoietin receptor activation. On the contrary, TET inhibition in TET2 mutant malignant myeloid cells prevented neoplastic clonal evolution in vitro and in vivo. This mechanism of action may offer a restorative therapeutic index and provide a scientific rationale to treat selected patients with TET2 mutant-associated or TET deficiency-associated myeloid malignancies.
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Affiliation(s)
- Yihong Guan
- Department of Translational Hematology and Oncology Research and
| | - Metis Hasipek
- Department of Translational Hematology and Oncology Research and
| | - Dongxu Jiang
- Department of Translational Hematology and Oncology Research and
| | - Anand D. Tiwari
- Department of Translational Hematology and Oncology Research and
| | | | - Simona Pagliuca
- Department of Translational Hematology and Oncology Research and
| | | | - Bhumika Patel
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Salendra Singh
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Yvonne Parker
- Department of Translational Hematology and Oncology Research and
| | - Thomas LaFramboise
- Department of Genetics and Genome Sciences, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Daniel Lindner
- Department of Translational Hematology and Oncology Research and
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Developmental Therapeutics, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Mikkael A. Sekeres
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Omar Y. Mian
- Department of Translational Hematology and Oncology Research and
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Developmental Therapeutics, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Yogen Saunthararajah
- Department of Translational Hematology and Oncology Research and
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Developmental Therapeutics, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Jaroslaw P. Maciejewski
- Department of Translational Hematology and Oncology Research and
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Developmental Therapeutics, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Babal K. Jha
- Department of Translational Hematology and Oncology Research and
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Developmental Therapeutics, Case Comprehensive Cancer Center, Cleveland, Ohio, USA
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22
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Park AK, Waheed A, Forst DA, Al-Samkari H. Characterization and Prognosis of Temozolomide-Induced Aplastic Anemia in Patients with Central Nervous System Malignancies. Neuro Oncol 2021; 24:964-973. [PMID: 34647594 DOI: 10.1093/neuonc/noab240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Temozolomide-induced aplastic anemia (TIAA) is a rare but highly challenging complication of temozolomide (TMZ) therapy. Evidence describing prognosis, clinical characteristics, and treatment of this entity is very limited. METHODS We performed a multicenter, 22-year observational cohort study of patients with central nervous system (CNS) malignancies treated with temozolomide who developed TIAA, retrospectively analyzing prognosis, complications, and recovery. TIAA was defined using adapted evidence-based severe aplastic anemia criteria incorporating profound cytopenias and a minimum duration (4 weeks) without hematologic recovery. RESULTS Of 3,821 patients with CNS malignancies receiving TMZ, 34 patients (0.89%) met criteria for TIAA. Onset was rapid, with 29 patients (85.3%) developing TIAA before completing a second TMZ cycle. 23 patients (67.6%) ultimately achieved a hematologic recovery. Patients without recovery were more likely to develop febrile neutropenia (72.7% vs. 30.4%, P=0.03), infectious complications (45.5% vs. 8.7%, P=0.02), require hospitalization (81.8% vs. 43.5%, P=0.04), and die (100.0% vs. 60.9%, P=0.02). Median overall survival from TIAA diagnosis was 752 days in patients achieving a partial hematologic recovery versus 28 days in those who did not (P<0.0001). 29 patients (85.3%) received one or more hematopoietic growth factors; hematologic recovery rates were higher in patients receiving thrombopoietin receptor agonists (81.8% vs. 60.9%) but were not higher in patients receiving granulocyte colony stimulating factors. CONCLUSIONS TIAA occurs in <1% of patients receiving TMZ for CNS malignancies, but is highly morbid when it occurs and frequently fatal in the one-third of patients not achieving hematologic recovery. Thrombopoietin receptor agonists may improve the likelihood of a hematologic recovery.
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Affiliation(s)
- Albert K Park
- Department of Medicine, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Anem Waheed
- Harvard Medical School, Boston, MA.,Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA
| | - Deborah A Forst
- Harvard Medical School, Boston, MA.,Division of Neuro-Oncology, Massachusetts General Hospital, Boston, MA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA.,Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA
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23
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Bussel JB, Soff G, Balduzzi A, Cooper N, Lawrence T, Semple JW. A Review of Romiplostim Mechanism of Action and Clinical Applicability. Drug Des Devel Ther 2021; 15:2243-2268. [PMID: 34079225 PMCID: PMC8165097 DOI: 10.2147/dddt.s299591] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Thrombocytopenia results from a variety of conditions, including radiation, chemotherapy, autoimmune disease, bone marrow disorders, pathologic conditions associated with surgical procedures, hematopoietic stem cell transplant (HSCT), and hematologic disorders associated with severe aplastic anemia. Immune thrombocytopenia (ITP) is caused by immune reactions that accelerate destruction and reduce production of platelets. Thrombopoietin (TPO) is a critical component of platelet production pathways, and TPO receptor agonists (TPO-RAs) are important for the management of ITP by increasing platelet production and reducing the need for other treatments. Romiplostim is a TPO-RA approved for use in patients with ITP in the United States, European Union, Australia, and several countries in Africa and Asia, as well as for use in patients with refractory aplastic anemia in Japan and Korea. Romiplostim binds to and activates the TPO receptor on megakaryocyte precursors, thus promoting cell proliferation and viability, resulting in increased platelet production. Through this mechanism, romiplostim reduces the need for other treatments and decreases bleeding events in patients with thrombocytopenia. In addition to its efficacy in ITP, studies have shown that romiplostim is effective in improving platelet counts in various settings, thereby highlighting the versatility of romiplostim. The efficacy of romiplostim in such disorders is currently under investigation. Here, we review the structure, mechanism, pharmacokinetics, and pharmacodynamics of romiplostim. We also summarize the clinical evidence supporting its use in ITP and other disorders that involve thrombocytopenia, including chemotherapy-induced thrombocytopenia, aplastic anemia, acute radiation syndrome, perisurgical thrombocytopenia, post-HSCT thrombocytopenia, and liver disease.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Gerald Soff
- Department of Medicine, Hematology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | | | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
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24
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Bastopcu M. Extensive Arterial Thrombus Following Discharge after a Covid-19 Infection. Ann Vasc Surg 2021; 72:205-208. [PMID: 33333188 PMCID: PMC7834075 DOI: 10.1016/j.avsg.2020.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/13/2020] [Accepted: 11/19/2020] [Indexed: 11/28/2022]
Abstract
The novel coronavirus pandemic is associated with coagulopathy and an increased risk of thromboembolic events. A case of an extensive arterial thrombus in the left leg of a patient that occurred after discharge from Covid-19 pneumonia is described. Some patients may be under continued risk of thromboembolism after discharge and the value of extended thromboprophylaxis should be investigated.
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Affiliation(s)
- Murat Bastopcu
- Department of Cardiovascular Surgery, Tatvan State Hospital, Bitlis, Turkey.
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