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Wang Z, Wang N, Juntao O, Ma J, Dong S, Meng J, Liu J, Chen Z, Cheng X, Wu R. Long-term eltrombopag in children with chronic immune thrombocytopenia: A single-centre extended real-life observational study in China. Br J Haematol 2024; 204:1017-1023. [PMID: 38087811 DOI: 10.1111/bjh.19253] [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: 08/27/2023] [Revised: 11/17/2023] [Accepted: 11/28/2023] [Indexed: 03/14/2024]
Abstract
We have previously confirmed the efficacy and safety of eltrombopag (ELT) in children with chronic immune thrombocytopenia (cITP). However, data on both long-term exposure and early use of TPO-RAs are lacking, so further 'field-practice' evidence on treatment is required. Here, we report the long-term follow-up results (between September 2018 and June 2023) of our previous study. The main objective of this study was to retrospectively review our large institutional experience with ITP patients previously enrolled in our paediatric cITP study. We had more than 3 years of follow-up by June 2023 for treatment patterns and outcomes. A total of 65 patients (28 males) were enrolled, with a median age at ELT initiation of 6.34 (range 1.65, 14.13) years and a follow-up of 47.07 (36.00, 57.00) months, with 40.36 (10.53, 56.83) months of ELT therapy at the time of analysis. In total, 29.23% (19/65) of patients discontinued ELT due to stable response, and 18.46% (12/65) of patients switched to other ITP therapies due to loss of response (LOR) after 19.13 (14.53, 26.37) months. Of the 19 patients who discontinued ELT due to a stable response, 24.62% (16/65) achieved a 12 m sustained response off-treatment (SRoT); the last recorded platelet count ranged from 56 to 166 × 109 /L (median 107 × 109/L); and 4.62% (3/65) patients relapsed at 5, 6 and 9 months after discontinuation. Of the 12 patients who LOR to ELT after 19.13 (14.53, 26.37) months of therapy, four switched to avatrombopag, three switched to hetrombopag, two switched to traditional Chinese medicine (TCM), one underwent splenectomy and two received additional prednisolone under ELT treatment. Thirty-four patients who tapered and maintained a durable response. The patients with LOR and the patients with tapering were compared; the platelet count at the start of ELT is lower, and the time to response is longer in the patients with LOR. The platelet count at the start of ELT and the time to response may be the predictive factors for LOR during ELT treatment. We report more than 3 years of long-term clinical data on children with cITP using ELT. These data do not raise any new safety concerns regarding the long-term use of ELT in children with cITP.
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Affiliation(s)
- Zhifa Wang
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Nan Wang
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Ouyang Juntao
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jingyao Ma
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shuyue Dong
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jinxi Meng
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jingjing Liu
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Cooper N, Ghanima W, Vianelli N, Valcárcel D, Yavaşoğlu İ, Melikyan A, Ruiz EY, Haenig J, Somenzi O, Lee J, Clark J, Zhang Y, Zaja F. Sustained response off-treatment in eltrombopag-treated adult patients with ITP who are refractory or relapsed after first-line steroids: Primary, final, and ad-hoc analyses of the Phase II TAPER trial. Am J Hematol 2024; 99:57-67. [PMID: 38014779 DOI: 10.1002/ajh.27131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 11/29/2023]
Abstract
Immune thrombocytopenia (ITP) is characterized by reduced platelet count due to increased destruction and is categorized according to the time following diagnosis (newly diagnosed, persistent, chronic). First-line corticosteroid therapy is associated with transient response, high relapse rates, and considerable toxicity. TAPER (NCT03524612) is a Phase II, prospective, single-arm trial investigating whether eltrombopag can induce a sustained response off-treatment (SRoT) in adult patients with ITP after first-line corticosteroid failure. This study defines SRoT as an off-treatment period wherein platelet count remains above 30 × 109 /L in the absence of bleeding or rescue therapy. The primary endpoint was the proportion of patients who achieved SRoT until Month 12, which was 30.5% (n = 32/105; p < .0001 testing hypothesis H1: proportion >15%) following eltrombopag tapering and discontinuation, and median SRoT duration was ~8 months until Month 12. Median platelet count increased within 1 month of treatment and remained elevated until Month 12. Quality of life improved within 3 months and was maintained. Headache (21%) was the most common adverse event. None of the 4 deaths reported were considered treatment-related. In summary, ~one-third of patients achieved SRoT until Month 12 following eltrombopag tapering and discontinuation. An ad-hoc early-use analysis, stratified by ITP duration at baseline, assessed initial hematologic responses and safety. Results suggest that eltrombopag has similar efficacy in newly diagnosed and later stages of ITP. In follow-up until Month 24, a median SRoT duration of ~22 months was observed (n = 20). The safety profile was comparable across analyses and ITP duration groups and aligned with its well-established safety profile.
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Affiliation(s)
- Nichola Cooper
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK
| | - Waleed Ghanima
- Department of Haemato-Oncology, Østfold Hospital Trust, Kalnes, Grålum, Norway
- Department of Haematology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nicola Vianelli
- Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - David Valcárcel
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Barcelona, Spain
| | - İrfan Yavaşoğlu
- Department of Hematology, Adnan Menderes University, Aydın, Turkey
| | | | - Eduardo Yañez Ruiz
- Hematology-Oncology Unit, Department of Internal Medicine, School of Medicine, Universidad de La Frontera, Temuco, Chile
| | | | | | - James Lee
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Yifan Zhang
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Francesco Zaja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
- UCO Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
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Yassin MA, Al-Rasheed M, Al-Khaboori M, Marashi M, Osman H, Wali Y, Al Kindi S, Alsayegh F, Provan D. Thrombopoietin-receptor agonists for adult patients with immune thrombocytopenia: a narrative review and an approach for managing patients fasting intermittently. Front Cardiovasc Med 2023; 10:1260487. [PMID: 38162126 PMCID: PMC10755910 DOI: 10.3389/fcvm.2023.1260487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Thrombopoietin-receptor agonist (TPO-RAs) currently represent the state of art for treating immune thrombocytopenia. Their different molecular structures contribute to the difference in their pharmacodynamics and pharmacokinetics. This narrative review aims to provide an overview of the current TPO-RAs approved for primary immune thrombocytopenia (romiplostim, eltrombopag, avatrombopag) and the effect of intermittent fasting in adult patients receiving TPO-RAs. Areas covered Literature was searched with no limits on date or language, using various combinations of keywords. Data on the pharmacokinetics, pharmacodynamics, efficacy, and safety of TPO-RAs and the effect of intermittent fasting were summarized. Expert opinion Switching between TPO-RAs is a useful strategy to tackle some associated limitations. Romiplostim and avatrombopag have an advantage over eltrombopag as they do not require any dietary restrictions. In cases where romiplostim and avatrombopag are unavailable, patients should be educated on the appropriate administration, possible interactions, and dietary restrictions before initiating eltrombopag.
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Affiliation(s)
- Mohamed A. Yassin
- National Center for Cancer Care and Research, Hematology Section, Hamad Medical Corporation, Doha, Qatar
| | - Mona Al-Rasheed
- Hematology Unit, Department of Medicine, Al-Adan Hospital, Hadiya, Kuwait
| | | | - Mahmoud Marashi
- Dubai Academic Health Corporation, Dubai, United Arab Emirates
| | - Hani Osman
- Hematology-Oncology Department, Tawam Hospital, Abu Dhabi, United Arab Emirates
| | - Yasser Wali
- Department of Child Health, Sultan Qaboos University, Muscat, Oman
| | - Salam Al Kindi
- Department of Hematology, Sultan Qaboos University, Muscat, Oman
| | - Faisal Alsayegh
- Faculty of Medicine, Department of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
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Gerard Jansen AJ, McDonald V, Newland A, Morgan M, Bastiaanse M, Wilson K, Eriksson D, Geldman E, Daykin-Pont O, Prince S, Zwaginga JJ. Patient preferences and experiences regarding thrombopoietin-receptor agonists for immune thrombocytopenia in The Netherlands (TRAPeze Netherlands study). Hematology 2023; 28:2267942. [PMID: 37818773 DOI: 10.1080/16078454.2023.2267942] [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: 06/05/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023] Open
Abstract
OBJECTIVE Identify patient experience and preference towards thrombopoietin-receptor agonists (TPO-RAs) in treatment of immune thrombocytopenia (ITP) in the Netherlands. METHODS The Thrombopoietin-Receptor Agonist Patient experience (TRAPeze) survey used a discrete choice experiment (DCE) to elicit patient preferences and a patient burden survey (PBS) to evaluate the clinical and social impact of ITP. TRAPeze collected responses from 6th October to 19th November 2021. RESULTS Seventy-six respondents completed the DCE: treatment preference appeared to be driven by method of administration (odds ratio [OR] 4.33; 95% confidence interval [CI] 2.88-6.52), frequency of dosing (OR 2.33; 95% CI 1.86-2.92) and drug-food interactions (OR 1.91; 95% CI 1.54-2.37). Respondents preferred therapies delivered orally over subcutaneous injection (OR 4.22; 95% CI 2.76-6.46), dosed once weekly over once daily (OR 2.37; 95% CI 1.58-3.54) and without food restrictions over with restrictions (OR 1.90; 95% CI 1.52-2.38). Sixty-nine respondents completed the DCE and PBS (mean [range] age 53 [19-83] years, 65% female). Seven incomplete PBS responses were excluded from analysis. Respondents were currently, or most recently, receiving eltrombopag (n = 43) or romiplostim (n = 26), of which 30% (n = 21/69) had previously received another TPO-RA. Loss (29%, n = 6/21) and lack (29%, n = 6/21) of response were the most common reasons for switching TPO-RA. Only 28% (n = 18/65) of respondents felt their TPO-RA increased energy levels. CONCLUSION Patients preferred therapies delivered orally, dosed less frequently and without food restrictions. QoL of ITP patients on TPO-RAs can be improved; the burden analyses presented can inform future efforts towards this.
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Affiliation(s)
- A J Gerard Jansen
- Department of Haematology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Vickie McDonald
- Department of Clinical Haematology, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Adrian Newland
- Academic Haematology Unit, Blizzard Institute, Barts & The London School of Medicine & Dentistry, Queen Mary Institute of London, London, UK
| | | | | | | | | | | | | | | | - Jaap Jan Zwaginga
- Department of Haematology, Leiden University Medical Centre, Leiden, Netherlands
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Mingot-Castellano ME, Canaro Hirnyk M, Sánchez-González B, Álvarez-Román MT, Bárez-García A, Bernardo-Gutiérrez Á, Bernat-Pablo S, Bolaños-Calderón E, Butta-Coll N, Caballero-Navarro G, Caparrós-Miranda IS, Entrena-Ureña L, Fernández-Fuertes LF, García-Frade LJ, Gómez del Castillo MDC, González-López TJ, Grande-García C, Guinea de Castro JM, Jarque-Ramos I, Jiménez-Bárcenas R, López-Ansoar E, Martínez-Carballeira D, Martínez-Robles V, Monteagudo-Montesinos E, Páramo-Fernández JA, Perera-Álvarez MDM, Soto-Ortega I, Valcárcel-Ferreiras D, Pascual-Izquierdo C. Recommendations for the Clinical Approach to Immune Thrombocytopenia: Spanish ITP Working Group (GEPTI). J Clin Med 2023; 12:6422. [PMID: 37892566 PMCID: PMC10607106 DOI: 10.3390/jcm12206422] [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: 09/04/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is a complex autoimmune disease whose hallmark is a deregulation of cellular and humoral immunity leading to increased destruction and reduced production of platelets. The heterogeneity of presentation and clinical course hampers personalized approaches for diagnosis and management. In 2021, the Spanish ITP Group (GEPTI) of the Spanish Society of Hematology and Hemotherapy (SEHH) updated a consensus document that had been launched in 2011. The updated guidelines have been the reference for the diagnosis and management of primary ITP in Spain ever since. Nevertheless, the emergence of new tools and strategies makes it advisable to review them again. For this reason, we have updated the main recommendations appropriately. Our aim is to provide a practical tool to facilitate the integral management of all aspects of primary ITP management.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, 41013 Sevilla, Spain
| | | | | | - María Teresa Álvarez-Román
- Hematology Department, Hospital Universitario La Paz-IdiPAZ, Universidad Autónoma de Madrid, 28046 Madrid, Spain;
| | | | - Ángel Bernardo-Gutiérrez
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - Silvia Bernat-Pablo
- Hematology Department, Hospital Universitario de la Plana, 12540 Villarreal, Spain;
| | | | - Nora Butta-Coll
- Hematology Department, Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), 28046 Madrid, Spain;
| | | | | | - Laura Entrena-Ureña
- Hematology Department, Hospital Universitario Virgen de las Nieves, 18014 Granada, Spain;
| | - Luis Fernando Fernández-Fuertes
- Hematology Department, Complejo Hospitalario Universitario Insular Materno-Infantil, 35016 Las Palmas de Gran Canaria, Spain;
| | - Luis Javier García-Frade
- Hematology Department, Hospital Universitario Río Hortega, Gerencia Regional de Salud de Castilla y León, 47012 Valladolid, Spain;
| | | | | | | | | | - Isidro Jarque-Ramos
- Hematology Department, Hospital Universitario y Politécnico La Fe, 46026 Valencia, Spain;
| | | | - Elsa López-Ansoar
- Hematology Department, Complejo Hospitalario Universitario de Vigo, 36312 Vigo, Spain;
| | | | | | | | | | - María del Mar Perera-Álvarez
- Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, 35010 Las Palmas de Gran Canaria, Spain;
| | - Inmaculada Soto-Ortega
- Hematology Department, Hospital Central de Asturias, 33011 Oviedo, Spain; (Á.B.-G.); (D.M.-C.); (I.S.-O.)
| | - David Valcárcel-Ferreiras
- Hematology Department, Vall d’Hebron Instituto de Oncología (VHIO), Universitat Autònoma de Barcelona, 08035 Barcelona, Spain;
| | - Cristina Pascual-Izquierdo
- Hematology Department, Hospital General Universitario Gregorio Marañón (HGUGM) Madrid, Instituto de Investigación Gregorio Marañón, 28007 Madrid, Spain;
- Spanish Immune Thrombocytopenia Group, 28040 Madrid, Spain
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Schifferli A, Rüfer A, Rovo A, Nimmerjahn F, Cantoni N, Holbro A, Favre G, Dirks J, Wieland A, Faeth H, Pereira R, Kühne T. Immunomodulation with romiplostim as a second-line strategy in primary immune thrombocytopenia: The iROM study. Br J Haematol 2023; 203:119-130. [PMID: 37735543 DOI: 10.1111/bjh.19074] [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: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 09/23/2023]
Abstract
Thrombopoietin receptor agonists (TPO-RAs) stimulate platelet production, which might restore immunological tolerance in primary immune thrombocytopenia (ITP). The iROM study investigated romiplostim's immunomodulatory effects. Thirteen patients (median age, 31 years) who previously received first-line treatment received romiplostim for 22 weeks, followed by monitoring until week 52. In addition to immunological data, secondary end-points included the sustained remission off-treatment (SROT) rate at 1 year, romiplostim dose, platelet count and bleedings. Scheduled discontinuation of romiplostim and SROT were achieved in six patients with newly diagnosed ITP, whereas the remaining seven patients relapsed. Romiplostim dose titration was lower and platelet count response was stronger in patients with SROT than in relapsed patients. In all patients, regulatory T lymphocyte (Treg) counts increased until study completion and the counts were higher in patients with SROT. Interleukin (IL)-4, IL-9 and IL-17F levels decreased significantly in all patients. FOXP3 (Treg), GATA3 (Th2) mRNA expression and transforming growth factor-β levels increased in patients with SROT. Treatment with romiplostim modulates the immune system and possibly influences ITP prognosis. A rapid increase in platelet counts is likely important for inducing immune tolerance. Better outcomes might be achieved at an early stage of autoimmunity, but clinical studies are needed for confirmation.
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Affiliation(s)
- Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Axel Rüfer
- Department of Hematology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Alicia Rovo
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Falk Nimmerjahn
- Department of Biology, Institute of Genetics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Nathan Cantoni
- Department of Hematology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Andreas Holbro
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Geneviève Favre
- Department of Hematology, Cantonal Hospital Liestal, Switzerland
| | - Jan Dirks
- Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Anna Wieland
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heike Faeth
- Medical University of Basel, Basel, Switzerland
| | | | - Thomas Kühne
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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7
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González-López TJ, Schifferli A. Early immunomodulation in immune thrombocytopenia-A report of the ICIS meeting in Lenzerheide, Switzerland 2022. Br J Haematol 2023; 203:101-111. [PMID: 37735547 DOI: 10.1111/bjh.19082] [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: 05/28/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
The only way to prevent immune thrombocytopenia (ITP) from becoming refractory would be to restore tolerance to platelets at an early phase of the disease. Numerous immune alterations probably accumulate in chronic ITP; thus, the chances of cure decrease significantly with time. Currently, sustained remission off treatment (SROT) is a clinical definition describing patients who can discontinue their ITP treatment without risk and maintain a state of remission. Different treatment strategies are presently being evaluated with the goal of attaining SROT, mostly combining drugs targeting the innate and/or the adaptive immune system, the inflammation state, so as increasing the platelet load. In this sense, thrombopoietin receptor agonists (TPO-RAs) have shown promising results if used as upfront treatment. TPO-RAs seem to exhibit immunomodulation and immune tolerance properties, increasing not only the platelet antigen mass but also increasing the transforming growth factor-β concentration, and stimulating regulatory T and B lymphocytes. However, more immunological studies are needed to establish accurate molecular alterations in ITP that are potentially reversed with treatments.
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Affiliation(s)
| | - Alexandra Schifferli
- Department of Haematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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8
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Moulis G, Garabet L. Markers of refractory primary immune thrombocytopenia. Br J Haematol 2023; 203:112-118. [PMID: 38019080 DOI: 10.1111/bjh.19076] [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: 06/09/2023] [Accepted: 07/31/2023] [Indexed: 11/30/2023]
Abstract
Refractory immune thrombocytopenia (ITP) is a challenging disease that can be defined by refractoriness to second-line treatments. In this review, we list and comment available evidence about clinical and biological factors associated with refractoriness to splenectomy, thrombopoietin receptor agonists (TPO-RAs), rituximab and fostamatinib, as well as those associated with multirefractory ITP (active disease with failure of rituximab, TPO-RAs and splenectomy).
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Affiliation(s)
- Guillaume Moulis
- Department of Internal Medicine, Referral Center for Autoimmune Cytopenia, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Team PEPSS, Toulouse University Hospital, Toulouse, France
| | - Lamya Garabet
- Center for Laboratory Medicine, Østfold Hospital Trust, Grålum, Norway
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9
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Wang Z, Wang L, Liu Y, Meng J, Dong S, Ma J, Hu Y, Chen Z, Cheng X, Wu R. Sustained response off treatment in eltrombopag for children with persistent/chronic primary immune thrombocytopenia: A multicentre observational retrospective study in China. Br J Haematol 2023. [PMID: 37128832 DOI: 10.1111/bjh.18842] [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: 01/04/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 05/03/2023]
Abstract
Eltrombopag (ELT) is effective and safe in adult persistent/chronic immune thrombocytopenia (p/cITP); a proportion could achieve a sustained response off treatment (SRoT); however, data on children are lacking. We attempted to analyse SRoT of ELT in children with p/cITP in this study. A multicentre retrospective observational study was performed in November 2022 for children with p/cITP who used ELT alone for >2 months between January 2017 and November 2021. Clinical data of pre-, during and post-ELT were collected. SRoT was defined as maintaining a platelet count of ≥30 × 109 /L without rescue therapy for at least 6 months off ELT. There were 143 patients enrolled; 69.2% (99/143) achieved an overall response of 43.3% and 25.9% achieved complete response (CR) and response (R). Among the 35 patients analysed from whom ELT was withdrawn, 71.4% (25/35) showed SRoT after discontinuing ELT without additional ITP therapy, with a median follow-up of 0.94 (range, 0.53-3.8) years, equal to 17.5% (25/143) in all patients treated with ELT. Compared with the patients with relapse (n = 10), the SRoT patients (n = 25) had a higher rate of CR (80% [20/25] vs. 40% [4/10]), shorter interval time from initiation to taper (6.4 months vs. 9.4 months), longer time from taper to withdrawal (1.1 years vs. 0.3 years) and a longer duration of ELT treatment (1.6 years vs. 0.5 years) with p < 0.05. Patients who achieved CR could attain SRoT more easily (p = 0.02). ELT had a response in 69.2% of children with p/cITP and 17.5% of them attained SRoT with good tolerance. The patients who achieved CR and began ELT treatment as early as possible, with a longer treatment duration and slower tapering, had a higher probability of SRoT.
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Affiliation(s)
- Zhifa Wang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Lijuan Wang
- Department of Hematology, Henan Province Children's Hospital, Zhengzhou, Henan, China
| | - Yan Liu
- Department of Hematology, Baoding Children's Hospital, Baoding, Hebei, China
| | - Jinxi Meng
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Shuyue Dong
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Jingyao Ma
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yu Hu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Department of Hematology Research, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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10
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González-López TJ, Newland A, Provan D. Current Concepts in the Diagnosis and Management of Adult Primary Immune Thrombocytopenia: Our Personal View. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:815. [PMID: 37109773 PMCID: PMC10143742 DOI: 10.3390/medicina59040815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an acquired blood disorder that causes a reduction in circulating platelets with the potential for bleeding. The incidence of ITP is slightly higher in adults and affects more women than men until 60 years, when males are more affected. Despite advances in basic science, primary ITP remains a diagnosis of exclusion. The disease is heterogeneous in its clinical behavior and response to treatment. This reflects the complex underlying pathophysiology, which remains ill-understood. Platelet destruction plays a role in thrombocytopenia, but underproduction is also a major contributing factor. Active ITP is a proinflammatory autoimmune disease involving abnormalities within the T and B regulatory cell compartments, along with several other immunological abnormalities. Over the last several years, there has been a shift from using immunosuppressive therapies for ITP towards approved treatments, such as thrombopoietin receptor agonists. The recent COVID-19 pandemic has hastened this management shift, with thrombopoietin receptor agonists becoming the predominant second-line treatment. A greater understanding of the underlying mechanisms has led to the development of several targeted therapies, some of which have been approved, with others still undergoing clinical development. Here we outline our view of the disease, including our opinion about the major diagnostic and therapeutic challenges. We also discuss our management of adult ITP and our placement of the various available therapies.
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Affiliation(s)
| | - Adrian Newland
- Academic Haematology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 2BB, UK
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 2BB, UK
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11
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González-López TJ, Provan D. Sustained Remission Off-Treatment (SROT) of TPO-RAs: The Burgos Ten-Step Eltrombopag Tapering Scheme. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:659. [PMID: 37109617 PMCID: PMC10145072 DOI: 10.3390/medicina59040659] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/15/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
Background and Objectives: TPO-RAs (romiplostim/eltrombopag/avatrombopag) have broadly demonstrated high efficacy rates (59-88%), durable responses (up to three years) and a satisfactory safety profile in clinical trials. The effect of TPO-RAs is classically considered to be transient because platelet numbers usually dropped rapidly to baseline unless therapy was maintained. However, several groups have reported the possibility of successfully discontinuing TPO-RAs in some patients without further need for concomitant treatments. This concept is usually referred as sustained remission off-treatment (SROT). Materials and Methods: Unfortunately, we still lack predictors of the response to discontinuation even after the numerous biological, clinical and in vitro studies performed to study this phenomenon. The frequency of successful discontinuation is matter of controversy, although a percentage in the range of 25-40% may probably be considered a consensus. Here, we describe all major routine clinical practice studies and reviews that report the current position on this topic and compare them with our own results in Burgos. Results: We report our Burgos ten-step eltrombopag tapering scheme with which we have achieved an elevated percentage rate of success (70.3%) in discontinuing treatment. Conclusions: We hope this protocol may help successfully taper and discontinue TPO-RAs in daily clinical practice.
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Affiliation(s)
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2BB, UK;
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12
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Auteri G, Biondo M, Mazzoni C, Venturi M, Romagnoli AD, Paglia S, Cavo M, Vianelli N, Palandri F. Sustained response off therapy after fostamatinib: A chronic refractory ITP case report. Heliyon 2023; 9:e13462. [PMID: 36846652 PMCID: PMC9946849 DOI: 10.1016/j.heliyon.2023.e13462] [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: 10/31/2022] [Revised: 12/16/2022] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Fostamatinib is a SYK-inhibitor drug recently approved by the FDA and EMA for treating chronic immune thrombocytopenia. This drug induces a response in about 40% of patients and has a good toxicity profile. It is known that discontinuing thrombopoietin receptor agonists (TRAs) with the maintenance of sustained response off therapy is possible. On fostamatinib, we do not yet have such information. In this case report, we describe the story of a woman with a multirefractory immune thrombocytopenia (steroids, splenectomy, rituximab, both available TRAs). After 16 years from diagnosis, she started fostamatinib therapy within a clinical trial and achieved a complete response. Grade 1-2 headache and diarrhea occurred during the first months of therapy. These adverse events were resolved with dose reduction of fostamatinib. Despite the dose reduction, the platelet count remained steadily above 80 × 109/L. After 4 years, fostamatinib was gradually reduced and finally discontinued with no drop in platelet count. This is the first case in which fostamatinib discontinuation resulted in a sustained response off therapy.
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Affiliation(s)
- Giuseppe Auteri
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli, Bologna, Italy,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy,Corresponding author. Via Giuseppe Massarenti, 9, Bologna 40138, Italy.
| | - Mattia Biondo
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli, Bologna, Italy,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Camilla Mazzoni
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli, Bologna, Italy,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Marta Venturi
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli, Bologna, Italy,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Andrea Davide Romagnoli
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli, Bologna, Italy,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Simona Paglia
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli, Bologna, Italy
| | - Michele Cavo
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli, Bologna, Italy,Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Nicola Vianelli
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli, Bologna, Italy
| | - Francesca Palandri
- IRCCS – Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli, Bologna, Italy
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13
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Liu XG, Hou Y, Hou M. How we treat primary immune thrombocytopenia in adults. J Hematol Oncol 2023; 16:4. [PMID: 36658588 PMCID: PMC9850343 DOI: 10.1186/s13045-023-01401-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an immune-mediated bleeding disorder characterized by decreased platelet counts and an increased risk of bleeding. Multiple humoral and cellular immune abnormalities result in accelerated platelet destruction and suppressed platelet production in ITP. The diagnosis remains a clinical exclusion of other causes of thrombocytopenia. Treatment is not required except for patients with active bleeding, severe thrombocytopenia, or cases in need of invasive procedures. Corticosteroids, intravenous immunoglobulin, and anti-RhD immunoglobulin are the classical initial treatments for newly diagnosed ITP in adults, but these agents generally cannot induce a long-term response in most patients. Subsequent treatments for patients who fail the initial therapy include thrombopoietic agents, rituximab, fostamatinib, splenectomy, and several older immunosuppressive agents. Other potential therapeutic agents, such as inhibitors of Bruton's tyrosine kinase and neonatal Fc receptor, are currently under clinical evaluation. An optimized treatment strategy should aim at elevating the platelet counts to a safety level with minimal toxicity and improving patient health-related quality of life, and always needs to be tailored to the patients and disease phases. In this review, we address the concepts of adult ITP diagnosis and management and provide a comprehensive overview of current therapeutic strategies under general and specific situations.
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Affiliation(s)
- Xin-Guang Liu
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.
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14
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Nationwide Survey on the Use of Thrombopoietin Receptor Agonists (TPO-RA) for the Management of Immune Thrombocytopenia in Current Clinical Practice in Italy. Mediterr J Hematol Infect Dis 2023; 15:e2023019. [PMID: 36908864 PMCID: PMC10000838 DOI: 10.4084/mjhid.2023.019] [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: 12/22/2022] [Accepted: 02/19/2023] [Indexed: 03/05/2023] Open
Abstract
Background Two thrombopoietin receptor agonists (TPO-RA), romiplostim and eltrombopag, are currently widely adopted as second-line ITP therapy even in the absence of robust evidence on their comparative advantages over rituximab or splenectomy or their preferential use in some specific clinical contexts. Methods An online survey was distributed between May 2021 and June 2021 to collect standardized information on TPO-RA use in Italy. Results Eighty-eight hematologists from 79 centers completed the survey. Eighty-four percent would use TPO-RA earlier than formally indicated, without a preference for young or elderly in 82% of respondents. No clear preference for either romiplostim or eltrombopag was indicated. Seventy-two percent would use TPO-RA in young patients aiming at a complete response followed by tapering, a strategy considered by only 16% in the elderly. Switching between the two agents was considered appropriate in case of insufficient response or intolerance. Tapering schedule by reducing the dosage and prolonging the intervals between administrations was preferred by 73% of respondents. TPO-RA was considered a risk factor for thrombosis by only 35%, and 94% would administer TPO-RA in elderly patients also in the presence of other thrombotic risk factors. Thirty-three percent of respondents would withdraw TPO-RA in case of thrombosis. The TPORA administration has been reported to be preferred over anti-CD20 or splenectomy by about half of the participants due to the ongoing COVID-19 pandemic. Conclusions Significant discrepancies in TPO-RA use emerged from the survey, and participants would appreciate consensus-based specific guidance on the practical use of TPO-RA.
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15
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Yang F, Zong H, Li F, Luo S, Zhang X, Xu Y, Zhang X. Eltrombopag modulates the phenotypic evolution and potential immunomodulatory roles of monocytes/macrophages in immune thrombocytopenia. Platelets 2022; 34:2135694. [DOI: 10.1080/09537104.2022.2135694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Feifei Yang
- Nanjing First Hospital, Nanjing Medical University, Nanjing, Chinaand
| | - Hui Zong
- Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Feng Li
- Nanjing First Hospital, Nanjing Medical University, Nanjing, Chinaand
| | - Shulin Luo
- Nanjing First Hospital, Nanjing Medical University, Nanjing, Chinaand
| | - Xiuqun Zhang
- Nanjing First Hospital, Nanjing Medical University, Nanjing, Chinaand
| | - Yanli Xu
- Nanjing First Hospital, Nanjing Medical University, Nanjing, Chinaand
| | - Xuezhong Zhang
- Nanjing First Hospital, Nanjing Medical University, Nanjing, Chinaand
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16
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Cuker A, Lal L, Roy A, Elliott C, Carlyle M, Martin C, Haenig J, Viana R. Thrombopoietin receptor agonist discontinuation rates and reasons among patients with immune thrombocytopenia: a study of administrative claims linked with medical chart review. Ann Hematol 2022; 101:1915-1924. [PMID: 35849155 DOI: 10.1007/s00277-022-04888-7] [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: 12/07/2021] [Accepted: 06/04/2022] [Indexed: 11/01/2022]
Abstract
Administrative claims provide a rich data source for retrospective studies of real-world clinical practice, yet some important data may be inconsistent or unavailable. This study explored factors influencing discontinuation of thrombopoietin receptor agonists (TPO-RAs) among patients with immune thrombocytopenia (ITP), by adding medical chart abstraction for additional details. Adult (≥ 18 years) patients with continuous commercial or Medicare Advantage with Part D health insurance coverage were included. Inclusion criteria were ≥ 1 claim for eltrombopag or romiplostim and ≥ 2 diagnoses of ITP between December 31, 2017, and January 1, 2020. Providers were asked to provide access to medical charts for abstraction. The analyses included only patients who discontinued TPO-RA and described patient characteristics, treatment patterns, platelet values, and reasons for discontinuation. Among 207 ITP patients treated with a TPO-RA, 137 (66%) discontinued treatment during the observation period. The mean TPO-RA treatment duration was 185 days. Mean platelet count at the time of discontinuation was 197 × 109/L. The most common reason for discontinuation was improvement of the patient's condition (42%). Other reasons included worsening of ITP/lack of response (12%), adverse events (12%), and cost-related or social reasons (23%). No reason was reported for 10%. Notably 26% of patients who discontinued remained off all ITP therapy for the remainder of the study, with a mean treatment-free period of 262 days. These results emphasize that some patients with ITP are able to discontinue TPO-RA therapy and achieve durable treatment-free periods.
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Affiliation(s)
- Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Anuja Roy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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17
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Mei H, Liu X, Li Y, Zhou H, Feng Y, Gao G, Cheng P, Huang R, Yang L, Hu J, Hou M, Yao Y, Liu L, Wang Y, Wu D, Zhang L, Zheng C, Shen X, Hu Q, Liu J, Jin J, Luo J, Zeng Y, Gao S, Zhang X, Zhou X, Shi Q, Xia R, Xie X, Jiang Z, Gao L, Bai Y, Li Y, Xiong J, Li R, Zou J, Niu T, Yang R, Hu Y. Dose tapering to withdrawal stage and long-term efficacy and safety of hetrombopag for the treatment of immune thrombocytopenia: Results from an open-label extension study. J Thromb Haemost 2022; 20:716-728. [PMID: 34821020 DOI: 10.1111/jth.15602] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/18/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The efficacy of hetrombopag in Chinese patients with immune thrombocytopenia (ITP) has been demonstrated in a randomized, double-blind, placebo-controlled, multicenter, phase III trial (NCT03222843). OBJECTIVE This study aimed to report comprehensive data on a ≤6-week dose tapering to withdrawal (Stage 3) and an additional 24-week long-term extension period (Stage 4) in this phase III trial. PATIENTS/METHODS Patients who fulfilled the screening criteria were eligible to enter Stage 3 or 4. During Stage 3, hetrombopag was gradually tapered to withdrawal. During Stage 4, hetrombopag treatment was initiated at 2.5, 3.75, 5, or 7.5 mg once daily. The efficacy endpoints during Stage 3 or 4 and the safety profile during the entire treatment period were reported. RESULTS Among 194 patients who entered Stage 3, 171 (88.1%) relapsed. The median time to the first relapse since the start of Stage 3 was 15.0 days (95% CI, 14.0-16.0). In Stage 4, 144 (42.5%) patients responded at ≥75% of their assessments and 254 (74.9%) patients achieved platelet count ≥30 × 109 /L at least once, which was at least twice their baseline platelet count in the hetrombopag group (n = 339). The most common adverse events were upper respiratory tract infection (53.1%), thrombocytopenia (27.1%), and urinary tract infection (21.2%) in the hetrombopag group. CONCLUSION The majority of patients who experienced dose tapering to withdrawal experienced a relapse. Long-term treatment with hetrombopag was effective in increasing and maintaining platelet count within the desired range in Chinese adults with ITP. Hetrombopag was well tolerated.
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Affiliation(s)
- Heng Mei
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Liu
- Thrombosis and Hemostasis Center, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Hematological Disorders, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yan Li
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Hu Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Feng
- Department of Hematopathology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guangxun Gao
- The Blood Internal Medicine, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Peng Cheng
- Hematology Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ruibin Huang
- Hematology Department, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linhua Yang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Jianda Hu
- Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yazhou Yao
- Hematology Department, Baoji Central Hospital, Baoji, China
| | - Li Liu
- Department of Hematopathology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Yi Wang
- Department of Hematopathology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Depei Wu
- Hematology Department, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liansheng Zhang
- Hematology Department, Lanzhou University Second Hospital, Lanzhou, China
| | - Changcheng Zheng
- Hematology Department, The First Affiliated Hospital of USTC, Hefei, China
| | - Xuliang Shen
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Qi Hu
- Department of Hematology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Jing Liu
- Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Jianmin Luo
- Department of Hematology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yun Zeng
- Department of Hematology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Sujun Gao
- Hematology, The First Hospital of Jilin University, Changchun, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Beijing, China
| | - Xin Zhou
- Hematology Department, Wuxi People's Hospital, Wuxi, China
| | - Qingzhi Shi
- Hematology Department, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ruixiang Xia
- Hematology Department, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaobao Xie
- Hematology Department, The First People's Hospital of Changzhou, Changzhou, China
| | - Zhongxing Jiang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Gao
- Department of Hematology, The Second Affiliated Hospital of Military Medical University PLA, Chongqing, China
| | - Yuansong Bai
- Hematology & Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yan Li
- Hematology Department, The First Hospital of China Medical University, Shenyang, China
| | - Junye Xiong
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Runzi Li
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Jianjun Zou
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Ting Niu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Renchi Yang
- Thrombosis and Hemostasis Center, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Hematological Disorders, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yu Hu
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Autore F, Sora’ F, Chiusolo P, Minnella G, Colangelo M, Rossi E, Sica S. Chronic Myeloid Leukemia in a Patient with Previous Idiopathic Thrombocytopenic Purpura: How to Manage Imatinib Together with Eltrombopag. Medicina (B Aires) 2021; 57:medicina57121326. [PMID: 34946271 PMCID: PMC8708281 DOI: 10.3390/medicina57121326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
The occurrence of chronic myeloid leukemia (CML), or other myeloproliferative diseases, after the development of idiopathic thrombocytopenic purpura (ITP) is very rare in the current medical literature. Considering the advances in ITP management, and the wide use of new drugs for ITP and CML, we report an unusual case with this association. Our case report focused on a 64-year-old man with long-standing ITP treated with eltrombopag, who developed hyperleukocytosis during follow-up; after specific laboratory exams, it was diagnosed as CML and he began treatment with imatinib. The treatment with eltrombopag was balanced with imatinib to stabilize his platelet count. Data on bcr-abl and JAK2 transcripts were collected and revealed an optimal response with the achievement of negativization of both molecular signatures. We could demonstrate that treatment with imatinib and eltrombopag was well tolerated and allowed complete molecular remission of CML to be achieved, as well as of ITP.
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MESH Headings
- Benzoates
- Humans
- Hydrazines/therapeutic use
- Imatinib Mesylate/therapeutic use
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Male
- Middle Aged
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Pyrazoles
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Affiliation(s)
- Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Correspondence: ; Tel.: +39-06-30155300
| | - Federica Sora’
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Gessica Minnella
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
| | - Maria Colangelo
- UOC Genetica Medica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy;
| | - Elena Rossi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
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19
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Carpenedo M, Baldacci E, Baratè C, Borchiellini A, Buccisano F, Calvaruso G, Chiurazzi F, Fattizzo B, Giuffrida G, Rossi E, Palandri F, Scalzulli PR, Siragusa SM, Vitucci A, Zaja F. Second-line administration of thrombopoietin receptor agonists in immune thrombocytopenia: Italian Delphi-based consensus recommendations. Ther Adv Hematol 2021; 12:20406207211048361. [PMID: 34646432 PMCID: PMC8504223 DOI: 10.1177/20406207211048361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction: In patients with primary immune thrombocytopenia (ITP), a short course of steroids is routinely given as first-line therapy. However, the response is often transient and additional therapy is usually needed. Thrombopoietin receptor agonists (TPO-RAs) are frequently used as second-line therapy, although there is little clinical guidance on the timing of their administration and on tapering/discontinuation of the drug. To provide clinical recommendations, we used the Delphi technique to obtain consensus for statements regarding administration and on tapering/discontinuation of second-line TPO-RAs among a group of Italian clinicians with expertise in management of ITP. Methods: The Delphi process was used to obtain agreement on five statements regarding initiation and on tapering/discontinuation of second-line TPO-RAs. Agreement was considered when 75% of participants approved the statement. Eleven experts participated in the voting. Results: Full consensus was reached for three of the five statements. The experts held that an early switch from corticosteroids to a TPO-RA has the dual advantage of sparing patients from corticosteroid abuse and improve long-term clinical outcomes. All felt that dose reduction of TPO-RAs can be considered in patients with a stable response and platelet count >100 × 109/L that is maintained for at least 6 months in the absence of concomitant treatments, although there was less agreement in patients with a platelet count >50 × 109/L. Near consensus was reached regarding the statement that early treatment with a TPO-RA is associated with an increase in clinically significant partial or complete response. The experts also agreed that optimization of tapering and discontinuation of TPO-RA therapy in selected patients can improve the quality of life. Conclusion: The present consensus can help to provide guidance on use of TPO-RAs in daily practice in patients with ITP. Plain language summary Second-line administration of thrombopoietin receptor agonists in immune thrombocytopenia
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Affiliation(s)
- Monica Carpenedo
- Hematology and Transplantation Unit, ASST San Gerardo Hospital, Via G. B. Pergolesi, 33, 20900 Monza MB, Italy
| | - Erminia Baldacci
- Department of Hematology, Policlinico Umberto I University Hospital, Rome, Italy
| | - Claudia Baratè
- Hematology and Bone Marrow Transplant Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandra Borchiellini
- Regional Reference Center of Haemostasis and Thrombosis Haematology Unit, Città della Salute e della Scienza, Turin, Italy
| | - Francesco Buccisano
- Hematology, Department of BioMedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Giuseppina Calvaruso
- Campus of Hematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo, Italy
| | - Federico Chiurazzi
- Department of Clinical Medicine, University "Federico II" of Naples, Naples, Italy
| | - Bruno Fattizzo
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gaetano Giuffrida
- Division of Haematology, A.O.U. Policlinico Vittorio Emanuele, Catania, Italy
| | - Elena Rossi
- Department of Radiological and Hematological Sciences, Universita Cattolica del Sacro Cuore and Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Potito Rosario Scalzulli
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | | | - Angelantonio Vitucci
- Haematology with Transplant Unit, Az. Universitario-Ospedaliera Consorziale Policlinico, Bari, Italy
| | - Francesco Zaja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
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Song F, Al-Samkari H. Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice. J Blood Med 2021; 12:653-664. [PMID: 34345191 PMCID: PMC8323851 DOI: 10.2147/jbm.s259101] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune process resulting in increased destruction and inadequate production of platelets that can result in bleeding, fatigue, and reduced health-related quality of life. While treatment is not required for many patients with ITP, the occurrence of bleeding manifestations, severe thrombocytopenia, and requirement for invasive procedures are among the reasons necessitating initiation of therapy. Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are typical first-line and rescue treatments, but these agents typically do not result in a durable remission in adult patients. Most patients requiring treatment therefore require subsequent line therapies, such as thrombopoietin receptor agonists (TPO-RAs), rituximab, fostamatinib, splenectomy, or a number of other immunosuppressive agents. In this focused review, we discuss management of adult ITP in the acute and chronic settings.
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Affiliation(s)
- Fei Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA.,Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
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21
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Lozano ML, Segú-Vergés C, Coma M, Álvarez-Roman MT, González-Porras JR, Gutiérrez L, Valcárcel D, Butta N. Elucidating the Mechanism of Action of the Attributed Immunomodulatory Role of Eltrombopag in Primary Immune Thrombocytopenia: An In Silico Approach. Int J Mol Sci 2021; 22:ijms22136907. [PMID: 34199099 PMCID: PMC8269123 DOI: 10.3390/ijms22136907] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/13/2022] Open
Abstract
Eltrombopag is a thrombopoietin receptor (MPL) agonist approved for the treatment of primary immune thrombocytopenia (ITP). Recent evidence shows that some patients may sustain platelet counts following eltrombopag discontinuation. The systemic immunomodulatory response that resolves ITP in some patients could result from an increase in platelet mass, caused either by the direct action of eltrombopag on megakaryocytes through MPL stimulation, or potential MPL-independent actions on other cell types. To uncover the possible mechanisms of action of eltrombopag, in silico analyses were performed, including a systems biology-based approach, a therapeutic performance mapping system, and structural analyses. Through manual curation of the available bibliography, 56 key proteins were identified and integrated into the ITP interactome analysis. Mathematical models (94.92% mean accuracy) were obtained to elucidate potential MPL-dependent pathways in non-megakaryocytic cell subtypes. In addition to the effects on megakaryocytes and platelet numbers, the results were consistent with MPL-mediated effects on other cells, which could involve interferon-gamma, transforming growth factor-beta, peroxisome proliferator-activated receptor-gamma, and forkhead box protein P3 pathways. Structural analyses indicated that effects on three apoptosis-related proteins (BCL2L1, BCL2, BAX) from the Bcl-2 family may be off-target effects of eltrombopag. In conclusion, this study proposes new hypotheses regarding the immunomodulatory functions of eltrombopag in patients with ITP.
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MESH Headings
- Benzoates/chemistry
- Benzoates/pharmacology
- Benzoates/therapeutic use
- Biomarkers
- Disease Management
- Disease Susceptibility
- Humans
- Hydrazines/chemistry
- Hydrazines/pharmacology
- Hydrazines/therapeutic use
- Immunomodulation/drug effects
- Models, Biological
- Models, Molecular
- Molecular Targeted Therapy/methods
- Protein Interaction Mapping
- Protein Interaction Maps
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Purpura, Thrombocytopenic, Idiopathic/metabolism
- Pyrazoles/chemistry
- Pyrazoles/pharmacology
- Pyrazoles/therapeutic use
- Receptors, Thrombopoietin/antagonists & inhibitors
- Receptors, Thrombopoietin/chemistry
- Receptors, Thrombopoietin/metabolism
- Signal Transduction/drug effects
- Structure-Activity Relationship
- T-Lymphocytes/drug effects
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
- Treatment Outcome
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Affiliation(s)
- Maria L. Lozano
- Hospital General Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, 30007 Murcia, Spain
- Correspondence: (M.L.L.); (N.B.)
| | - Cristina Segú-Vergés
- Anaxomics Biotech S.L., Diputació 237, 1°, 1, 08007 Barcelona, Spain; (C.S.-V.); (M.C.)
| | - Mireia Coma
- Anaxomics Biotech S.L., Diputació 237, 1°, 1, 08007 Barcelona, Spain; (C.S.-V.); (M.C.)
| | - María T. Álvarez-Roman
- Unidad de Trombosis y Hemostasia, Servicio de Hematología, Hospital Universitario La Paz, Instituto de Investigación Hospital Universitario La Paz (IdiPAZ), Paseo de la Castellana 261, 28046 Madrid, Spain;
| | - José R. González-Porras
- Unidad de Hemostasia y Trombosis, Servicio de Hematología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Paseo de San Vicente, 58-182, 37007 Salamanca, Spain;
| | - Laura Gutiérrez
- Grupo de Investigación en Plaquetas, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Departamento de Medicina, Universidad de Oviedo, 33071 Oviedo, Spain;
| | - David Valcárcel
- Servicio Hematología, Vall d´Hebron Insitute of Oncology (VHIO), Hospital Univesitario Vall d’Hebron, Universitat Autònoma de Barcelona, Centro Cellex, Natzaret, 115-117, 08035 Barcelona, Spain;
| | - Nora Butta
- Instituto de Investigación HospitaUniversitario La Paz (IdiPAZ), Paseo de la Castellana 261, 28046 Madrid, Spain
- Correspondence: (M.L.L.); (N.B.)
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