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Witkowski M, Ryżewska W, Robak T. Thrombopoietin receptor agonist and rituximab combination therapy in patients with refractory primary immune thrombocytopenia. Blood Coagul Fibrinolysis 2024; 35:108-114. [PMID: 38358901 DOI: 10.1097/mbc.0000000000001283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
The aim of our study was to evaluate the efficacy of this therapy in patients with refractory primary immune thrombocytopenia. It is crucial to develop alternative treatment methods for this patient group in order to achieve better response. This combination therapy combines two different mechanisms of action, which is promising in terms of targeting pathophysiology of immune thrombocytopenia. We conducted a retrospective study, which included all patients who were diagnosed with refractory primary immune thrombocytopenia and received TPO-RA and rituximab at the General Hematology Department, Copernicus Memorial Hospital in Lodz, Poland. We assessed the response, time to response and treatment-free remission (TFR). After 1 month of treatment, the complete response (CR1, PLT >100 g/l) was achieved in 62.5% patients, and response (R1, PLT >30 g/l) was achieved in 62.5% patients. The median PLT was 175 × 10 9 /l. Within 1 month of treatment, 87.5% of patients achieved TFR. Adequately, after 6 months, CR6 and R6 was 62.5 and 75%. The median PLT was 182 × 10 9 /l. Treatment-free remission 6 months after completion was in 50% of patients. The study group achieved response to treatment, which suggests that combination of TPO-RA and rituximab is effective and relatively well tolerated. Prospective study on larger group of patients is needed to better evaluate the efficiency and safety of this treatment.
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Affiliation(s)
- Michał Witkowski
- Department of General Haematology, Copernicus Memorial Hospital, Lodz
| | - Wiktoria Ryżewska
- Jozef Stus Memorial Multispecialty Municipal Hospital, Poznan
- Students' Scientific Circle at the Haematology Clinic
| | - Tadeusz Robak
- Haematology Clinic, Medical University in Lodz, Lodz, Poland
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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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Gómez-Almaguer D, Rojas-Guerrero EA, Gómez-De León A, Colunga-Pedraza PR, Jaime-Pérez JC. Alternatives for managing patients with newly diagnosed immune thrombocytopenia: a narrative review. Expert Rev Hematol 2022; 15:493-501. [PMID: 35615916 DOI: 10.1080/17474086.2022.2082936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Primary immune thrombocytopenia (ITP) is an acquired bleeding disorder. Conventionally, first-line ITP therapy aims to obtain a rapid response and stop or decrease the risk of bleeding by increasing the platelet count. At this point, the duration of the response, the tolerability, and the long-term safety of pharmacologic interventions are considered less of a priority. Combination treatments that simultaneously address multiple disease mechanisms are an attractive strategy to increase efficacy in acute ITP therapy. In this review, we discuss the treatment of newly diagnosed ITP patients, emphasizing the use of new combinations to benefit from their synergy. AREAS COVERED This article summarizes conventional treatment, recent and novel combinations, and COVID-19 management recommendations of newly diagnosed ITP patients. EXPERT OPINION The key areas for improvement consider the long-term effects of conventional first-line therapy, reducing relapse rates, and extending responses to achieve long-term remission. Although corticosteroids remain first-line therapy, restricting their use to avoid toxicity and the increasing use of rituximab and TPO-RAs in the first three months after diagnosis open the landscape for future interventions in frontline therapy for ITP. First-line therapy intensification or synergistic drug combination offers a potential and realistic shift in future treatment guidelines.
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Affiliation(s)
- David Gómez-Almaguer
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Edgar A Rojas-Guerrero
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Andrés Gómez-De León
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Perla R Colunga-Pedraza
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - José C Jaime-Pérez
- Hematology Service, Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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Tarantini F, Cumbo C, Anelli L, Zagaria A, Conserva MR, Redavid I, Specchia G, Musto P, Albano F. Exploring the Potential of Eltrombopag: Room for More? Front Pharmacol 2022; 13:906036. [PMID: 35677428 PMCID: PMC9168361 DOI: 10.3389/fphar.2022.906036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/06/2022] [Indexed: 11/26/2022] Open
Abstract
Since its introduction in clinical practice, eltrombopag (ELT) has demonstrated efficacy in heterogeneous clinical contexts, encompassing both benign and malignant diseases, thus leading researchers to make a more in-depth study of its mechanism of action. As a result, a growing body of evidence demonstrates that ELT displays many effects ranging from native thrombopoietin agonism to immunomodulation, anti-inflammatory, and metabolic properties. These features collectively explain ELT effectiveness in a broad spectrum of indications; moreover, they suggest that ELT could be effective in different, challenging clinical scenarios. We reviewed the extended ELT mechanism of action in various diseases, with the aim of further exploring its full potential and hypothesize new, fascinating indications.
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Affiliation(s)
- Francesco Tarantini
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Cosimo Cumbo
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Luisa Anelli
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Antonella Zagaria
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Maria Rosa Conserva
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Immacolata Redavid
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | | | - Pellegrino Musto
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesco Albano
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
- *Correspondence: Francesco Albano,
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Chen M, Fang JP, Zhou CX, Li XY, Lin SF, Xu LH. Efficacy and safety of eltrombopag in the treatment of Chinese children with chronic immune thrombocytopenia. ACTA ACUST UNITED AC 2021; 26:31-36. [PMID: 33357172 DOI: 10.1080/16078454.2020.1856511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Our aim is to evaluate initial efficacy, safety, and durable response of eltrombopag in the treatment of Chinese children with chronic immune thrombocytopenia (cITP). METHODS This was a retrospective, single-center cohort study including 30 pediatric patients with cITP administered eltrombopag between 1 July 2017 and 1 January 2019. Patients with at least 12 weeks of eltrombopag treatment and available follow-up data were included. Initial response rate, durable response rate, bleeding events, and adverse events were assessed during the follow-up period. RESULTS The median duration of eltrombopag administration was 6 months (range 3-8 months). The initial response rate was 73.3%. Patients with megakaryocyte count ≥100/slide or Treg <4.5% were more likely to achieve initial response. The median follow-up period was 10 months (range 6-20 months). A total of 53.2% of pediatric patients had a durable response of up to 20 months. Patients with megakaryocyte count ≥100/slide and Treg<4.5% had more than 60% durable response rates compared with individuals with megakaryocyte count<100/slide and Treg≥4.5%, respectively. No serious bleeding events or serious adverse events occurred during the study period. CONCLUSION Eltrombopag not only shows excellent initial response but also has continued efficacy and safety. Patients with megakaryocyte count ≥100/slide and Treg<4.5% achieve increased initial response and more frequent durable response.
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Affiliation(s)
- Mo Chen
- Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Pediatrics, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, People's Republic of China
| | - Jian-Pei Fang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Chuan-Xin Zhou
- Guangdong Provincial Key Laboratory of Biomedical Imaging, Department of Pediatrics, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, People's Republic of China
| | - Xin-Yu Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Shao-Fen Lin
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Lu-Hong Xu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China
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Jaime-Pérez JC, Ramos-Dávila EM, Meléndez-Flores JD, Gómez-De León A, Gómez-Almaguer D. Insights on chronic immune thrombocytopenia pathogenesis: A bench to bedside update. Blood Rev 2021; 49:100827. [PMID: 33771403 DOI: 10.1016/j.blre.2021.100827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 12/17/2022]
Abstract
Immune thrombocytopenia (ITP) is a heterogeneous disease with an unpredictable course. Chronicity can develop in up to two-thirds of adults and 20-25% of children, representing a significant burden on patients' quality of life. Despite acceptable responses to treatment, precise etiology and pathophysiology phenomena driving evolution to chronicity remain undefined. We analyzed reported risk factors for chronic ITP and associated them with proposed underlying mechanisms in its pathogenesis, including bone marrow (BM) microenvironment disturbances, clinical features, and immunological markers. Their understanding has diagnostic implications, such as screening for the presence of specific antibodies or BM examination employing molecular tools, which could help predict prognosis and recognize main pathogenic pathways in each patient. Identifying these underlying mechanisms could guide the use of personalized therapies such as all-trans retinoic acid, mTor inhibitors, FcRn inhibitors, oseltamivir, and others. Further research should lead to tailored treatments and chronic course prevention, improving patients' quality of life.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico.
| | - Eugenia M Ramos-Dávila
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Jesús D Meléndez-Flores
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Andrés Gómez-De León
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - David Gómez-Almaguer
- Department of Hematology, Internal Medicine Division, Dr. Jose E. González University Hospital and School of Medicine, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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Virk ZM, Kuter DJ, Al-Samkari H. An evaluation of avatrombopag for the treatment of thrombocytopenia. Expert Opin Pharmacother 2020; 22:273-280. [PMID: 33095074 DOI: 10.1080/14656566.2020.1841748] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: The thrombopoietin receptor agonists (TPO-RAs) are a class of drugs that have been FDA-approved for immune thrombocytopenia (ITP), periprocedural thrombocytopenia in patients with chronic liver disease (CLD), aplastic anemia, and thrombocytopenia associated with antiviral treatment of hepatitis C. Avatrombopag is a TPO-RA that is currently FDA-approved for ITP and periprocedural thrombocytopenia in patients with CLD and is currently undergoing evaluation for chemotherapy-induced thrombocytopenia (CIT) in an international phase III clinical trial. Areas covered: This paper summarizes the chemistry, pharmacodynamics, and pharmacokinetics of avatrombopag. In addition, the authors review the efficacy and safety of avatrombopag, covering clinical trials in patients with ITP and in patients with CLD scheduled to undergo a procedure. Expert opinion: Avatrombopag has demonstrated efficacy in patients with ITP. With its low side-effect burden, absence of hepatotoxicity, ease of use as an oral medication, and lack of food-drug interactions, avatrombopag is a favorable option for ITP, though there is a lack of long-term safety data. In periprocedural thrombocytopenia in patients with CLD, avatrombopag is comparable to lusutrombopag, another TPO-RA. Finally, the results of the study of avatrombopag in CIT are eagerly awaited, as there are no currently approved medications for this indication in the USA.
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Affiliation(s)
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
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Jaime-Pérez JC, Aguilar-Calderón P, Jiménez-Castillo RA, Ramos-Dávila EM, Salazar-Cavazos L, Gómez-Almaguer D. Treatment outcomes and chronicity predictors for primary immune thrombocytopenia: 10-year data from an academic center. Ann Hematol 2020; 99:2513-2520. [DOI: 10.1007/s00277-020-04257-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/07/2020] [Indexed: 01/13/2023]
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Zhu J, Chen R, Zhao S, Zhu L, Li X, Xie M, Ye X. A megakaryocyte morphological classification-based predictive model for steroid sensitivity in primary immune thrombocytopenia. Platelets 2019; 31:939-944. [PMID: 31875757 DOI: 10.1080/09537104.2019.1708300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The first-line therapy for primary immune thrombocytopenia (ITP) is steroids, but about one-third of patients do not respond to steroids. Recent studies have shown megakaryocyte (MK) growth and development abnormalities and poorly compensated thrombopoiesis. Here, we attempted to determine the impact of MK morphological classification on steroid response. We enrolled 170 adult patients with primary ITP and divided them into steroid-sensitive ITP (109/170) and non-steroid-sensitive ITP (61/170) groups. In the univariate logistic model, female, reduced thrombocytogenic MK count (TMC), increased granular MK count to total MK count ratio (GMC/TM ratio), and elevated naked nucleus MK count to TM count ratio were significantly associated with steroid-sensitive ITP. In the multivariate logistic model, sex, reduced TMC, and increased GMC/TM ratio were independent predictors of steroid-sensitive ITP diagnosis. Based on the regression parameters, we established a predictive index with weighted risk score of 1 assigned each to sex, TMC, and GMC/TM ratio. A predictive index ≥2 points had the best area under the curve value (0.63) with 47.7% sensitivity and 78.7% specificity for predicting steroid sensitivity. These findings may help guide early treatment strategies in ITP.
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Affiliation(s)
- Jingjing Zhu
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Rongrong Chen
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Shuqi Zhao
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Lixia Zhu
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Xueying Li
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Mixue Xie
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
| | - Xiujin Ye
- Department of Haematology, The First Affiliated Hospital, College of Medicine, Zhejiang, University , Hangzhou, Zhejiang Province, China
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Al-Samkari H, Kuter DJ. Optimal use of thrombopoietin receptor agonists in immune thrombocytopenia. Ther Adv Hematol 2019; 10:2040620719841735. [PMID: 31007886 PMCID: PMC6460888 DOI: 10.1177/2040620719841735] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/11/2019] [Indexed: 12/11/2022] Open
Abstract
The thrombopoietin receptor agonists (TPO-RAs) are a class of platelet growth factors commonly used to treat immune thrombocytopenia (ITP). There are three agents that have been investigated for the treatment of chronic ITP: the peptide agent romiplostim and the small molecule agents eltrombopag and avatrombopag. These agents offer a higher clinical response rate than most other ITP therapies but may require indefinite use. This review is a critical appraisal of the TPO-RAs in adult ITP, defining the optimal patient groups to receive these agents and assisting the hematologist with agent choice, goals of treatment, dosing strategies, and toxicity management. Use of endogenous thrombopoietin levels to predict response to eltrombopag and romiplostim treatment is discussed and alternative dosing protocols suited for certain patient subgroups are described. Finally, indications for discontinuation and combination therapy with other agents are considered.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Suite 118, Room 112, Zero Emerson Place, Boston, MA 02114, USA
| | - David J. Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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