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Cooper N, Scully M, Percy C, Nicolson PLR, Lowe G, Bagot CN, Thachil J, Grech H, Nokes T, Hill QA, Bradbury C, Talks K, Dutt T, Evans G, Pavord S, Wexler S, Charania A, Collington SJ, Ervin A, Ramscar N, Provan D. Real-world use of thrombopoietin receptor agonists for the management of immune thrombocytopenia in adult patients in the United Kingdom: Results from the TRAIT study. Br J Haematol 2024. [PMID: 38429869 DOI: 10.1111/bjh.19345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 03/03/2024]
Abstract
Few studies have reported the real-world use of both romiplostim and eltrombopag in immune thrombocytopenia (ITP). TRAIT was a retrospective observational study aimed to evaluate the platelet responses and adverse effects associated with the use of these thrombopoietin receptor agonists (TPO-RAs) in adult patients with ITP in the United Kingdom. Of 267 patients (median age at diagnosis, 48 years) with ITP (primary ITP [n = 218], secondary ITP [n = 49]) included in the study, 112 (42%) received eltrombopag and 155 (58%) received romiplostim as the first prescribed TPO-RA. A platelet count ≥30 × 109 /L was achieved in 89% of patients with the first TPO-RA treatments, while 68% achieved a platelet count ≥100 × 109 /L. Treatment-free response (TFR; platelet count ≥30 × 109 /L, 3 months after discontinuing treatment) was achieved by 18% of the total patients. Overall, 61 patients (23%) switched TPO-RAs, most of whom achieved platelet counts ≥30 × 109 /L with the second TPO-RA (23/25 who switched from eltrombopag to romiplostim [92%]; 28/36 who switched from romiplostim to eltrombopag [78%]). TFR was associated with secondary ITP, early TPO-RA initiation after diagnosis, the presence of comorbidity and no prior splenectomy or treatment with steroids or mycophenolate mofetil. Both TPO-RAs had similar efficacy and safety profiles to those reported in clinical studies.
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Affiliation(s)
| | - Marie Scully
- Haematology Programme, NIHR UCLH/UCL BRC, London, UK
| | - Charles Percy
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Queen Elizabeth Hospital, Birmingham, UK
| | - Phillip L R Nicolson
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- HaemSTAR, Torquay, UK
| | - Gillian Lowe
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Queen Elizabeth Hospital, Birmingham, UK
| | - Catherine N Bagot
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde NHS Board, Glasgow, UK
| | - Jecko Thachil
- Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Henri Grech
- Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
| | - Tim Nokes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | - Kate Talks
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tina Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Gillian Evans
- East Kent Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Kent, UK
| | - Sue Pavord
- Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, UK
| | - Sarah Wexler
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | | | | | | | | | - Drew Provan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Liu ZR, Zhang YM, Cui ZL, Tong W. Effects of thrombopoietin pre-treatment on peri-liver transplantation thrombocytopenia in a mouse model of cirrhosis with hypersplenism. World J Gastrointest Surg 2023; 15:2115-2122. [PMID: 37969704 PMCID: PMC10642473 DOI: 10.4240/wjgs.v15.i10.2115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/05/2023] [Accepted: 08/25/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND During cirrhosis, the liver is impaired and unable to synthesize and clear thrombopoietin properly. At the same time, the spleen assumes the function of hemofiltration and storage due to liver dysfunction, resulting in hypersplenism and excessive removal of platelets in the spleen, further reducing platelet count. When liver function is decompensated in cirrhotic patients, the decrease of thrombopoietin (TPO) synthesis is the main reason for the decrease of new platelet production. This change of TPO leads to thrombocytopenia and bleeding tendency in cirrhotic patients with hypersplenism. AIM To investigate the clinical efficacy of recombinant human TPO (rhTPO) in the treatment of perioperative thrombocytopenia during liver transplantation in cirrhotic mice with hypersplenism. METHODS C57BL/6J mice and TPO receptor-deficient mice were used to establish models of cirrhosis with hypersplenism. Subsequently, these mice underwent orthotopic liver transplantation (OLT). The mice in the experimental group were given rhTPO treatment for 3 consecutive days before surgery and 5 consecutive days after surgery, while the mice in the control group received the same dose of saline at the same frequency. Differences in liver function and platelet counts were determined between the experimental and control groups. Enzyme-linked immunosorbent assay was used to assess the expression of TPO and TPO receptor (c-Mpl) in the blood. RESULTS Preoperative administration of rhTPO significantly improved peri-OLT thrombocytopenia in mice with cirrhosis and hypersplenism. Blocking the expression of TPO receptors exacerbated peri-OLT thrombocytopenia. The concentration of TPO decreased while the concentration of c-Mpl increased in compensation in the mouse model of cirrhosis with hypersplenism. TPO pre-treatment significantly increased the postoperative TPO concentration in mice, which in turn led to a decrease in the c-Mpl concentration. TPO pre-treatment also significantly enhanced the Janus kinase (Jak)/signal transducers and activators of transcription pathway protein expressions in bone marrow stem cells of the C57BL/6J mice. Moreover, the administration of TPO, both before and after surgery, regulated the levels of biochemical indicators, such as alanine aminotransferase, alkaline phosphatase, and aspartate aminotransferase in the C57BL/6J mice. CONCLUSION Pre-treatment with TPO not only exhibited therapeutic effects on perioperative thrombocytopenia in the mice with cirrhosis and hypersplenism, who underwent liver transplantation but also significantly enhanced the perioperative liver function.
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Affiliation(s)
- Zi-Rong Liu
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, Tianjin 300070, China
| | - Ya-Min Zhang
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, Tianjin 300070, China
| | - Zi-Lin Cui
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, Tianjin 300070, China
| | - Wen Tong
- Department of Hepatobiliary Surgery, Tianjin First Central Hospital, Tianjin 300070, China
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Thrombosis and Hemostasis Group, Chinese Society of Hematology, Chinese Medical Association. [Chinese expert consensus on the clinical application of recombinant human thrombopoiein and thrombopoiein receptor agonist (2023)]. Zhonghua Xue Ye Xue Za Zhi 2023; 44:535-42. [PMID: 37749031 DOI: 10.3760/cma.j.issn.0253-2727.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Indexed: 09/27/2023]
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Cheng X, Wang Z, Dong S, Ma J, Meng J, Wang X, Wu R. Outcomes of switching to avatrombopag following treatment failure with eltrombopag in paediatric immune thrombocytopenia: A real-world study in China. Br J Haematol 2023. [PMID: 37188335 DOI: 10.1111/bjh.18864] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/17/2023]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder characterized by isolated thrombocytopenia and a haemorrhagic risk. Thrombopoietin receptor agonists (TPO-RAs) are highly effective for ITP and are widely used to treat patients with steroid treatment failure or dependency. However, although treatment response to TPO-RAs may differ according to the type, the potential impact of switching from eltrombopag (ELT) to avatrombopag (AVA) with respect to efficacy or tolerance in children remains unknown. This study aimed to evaluate the outcomes of switching from ELT to AVA in paediatric patients with ITP. We retrospectively evaluated children with chronic immune thrombocytopenia (cITP) switched from ELT to AVA owing to treatment failure at the Hematology-Oncology Center of Beijing Children's Hospital between July 2021 and May 2022. Overall, 11 children (seven and four boys and girls respectively) with a median age of 8.3 (range: 3.8-15.3) years were included. The overall response and complete response (platelet [PLT] count ≥100 × 109 /L) rates during AVA treatment were 81.8% (9/11) and 54.6% (6/11) respectively. The median PLT count was significantly increased from ELT to AVA (7 [range: 2-33] × 109 /L vs. 74 [15-387] × 109 /L; p = 0.007). The median time to PLT count ≥30 × 109 /L was 18 (range: 3-120) days. Overall, 7/11 patients (63.6%) used concomitant medications, and concomitant medication use was gradually discontinued within 3-6 months after AVA initiation. In conclusion, AVA after ELT is effective in the heavily pretreated paediatric cITP population, with high response rates even in those with an inadequate response to a prior TPO-RA.
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Affiliation(s)
- Xiaoling Cheng
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhifa Wang
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Shuyue Dong
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jingyao Ma
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jinxi Meng
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Wang
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
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Pulanić D, Bátorová A, Bodó I, Červinek L, Ionita I, Lissitchkov T, Melikyan A, Podolak-Dawidziak M. Use of thrombopoietin receptor agonists in adults with immune thrombocytopenia: a systematic review and Central European expert consensus. Ann Hematol 2023; 102:715-27. [PMID: 36826482 DOI: 10.1007/s00277-023-05114-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/26/2023] [Indexed: 02/25/2023]
Abstract
There are currently three thrombopoietin receptor agonists (TPO-RAs) approved in Europe for treating patients with immune thrombocytopenia (ITP): romiplostim (Nplate®), eltrombopag (Revolade®), and avatrombopag (Doptelet®). However, comparative clinical data between these TPO-RAs are limited. Therefore, the purpose of this study was to perform a literature review and seek expert opinion on the relevance and strength of the evidence concerning the use of TPO-RAs in adults with ITP. A systematic search was conducted in PubMed and Embase within the last 10 years and until June 20, 2022. A total of 478 unique articles were retrieved and reviewed for relevance. The expert consensus panel comprised ITP senior hematologists from eight countries across Central Europe. The modified Delphi method, consisting of two survey rounds, a teleconference and email correspondence, was used to reach consensus. Forty articles met the relevancy criteria and are included as supporting evidence, including five meta-analyses analyzing all three European-licensed TPO-RAs and comprising a total of 31 unique randomized controlled trials (RCTs). Consensus was reached on seven statements for the second-line use of TPO-RAs in the management of adult ITP patients. In addition, the expert panel discussed TPO-RA treatment in chronic ITP patients with mild/moderate COVID-19 and ITP patients in the first-line setting but failed to reach consensus. This work will facilitate informed decision-making for healthcare providers treating adult ITP patients with TPO-RAs. However, further studies are needed on the use of TPO-RAs in the first-line setting and specific patient populations.
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Napolitano M, Vianelli N, Ghiotto L, Cantoni S, Carli G, Carpenedo M, Carrai V, Consoli U, Giuffrida G, Lucchini E, Rossi E, Santoro C, Rodeghiero F. 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 DOI: 10.4084/MJHID.2023.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Cai X, Fu H, Zhao X, Lu J, Jiang Q, Chang Y, Huang X, Zhang X. Switching between eltrombopag and recombinant human thrombopoietin in patients with immune thrombocytopenia: an observational study. Chin Med J (Engl) 2022; 135:2344-2350. [PMID: 36535011 PMCID: PMC9771238 DOI: 10.1097/cm9.0000000000002346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Recombinant human thrombopoietin (rh-TPO) and eltrombopag are two distinct TPO receptor agonists (TPO-RAs) with different mechanisms. During the pandemic, when immunosuppressive medications are controversial, switching to another TPO-RA may be worth exploring in patients who do not benefit from their first TPO-RA. We investigated the outcomes of switching from rh-TPO to eltrombopag or vice versa in immune thrombocytopenia (ITP) patients. METHODS This prospective, open-label, observational investigation included 96 adult ITP patients who needed to switch between rh-TPO and eltrombopag between January 2020 and January 2021 at Peking University People's Hospital in China. The study evaluated response rates and platelet counts at different time points after the switch, bleeding events, time to response, duration of response, and adverse events. RESULTS At 6 weeks after switching, response was observed in 21/49 patients (43%) who switched for inefficacy and 34/47 patients (72%) who switched for non-efficacy-related issues. In the inefficacy group, 9/27 patients (33%) responded to eltrombopag, and 12/22 patients (55%) responded to rh-TPO. In the non-efficacy-related group, 21/26 (81%) and 13/21 (62%) patients in the eltrombopag and rh-TPO groups maintained their response rates at 6 weeks after switching, respectively. Response at 6 months was achieved in 24/49 patients (49%) switching for inefficacy and 37/47 patients (79%) switching for non-efficacy issues. In the inefficacy group, 13/27 patients (48%) responded to eltrombopag, and 11/22 patients (50%) responded to rh-TPO. In the non-efficacy-related group, 22/26 patients (85%) and 15/21 patients (71%) in the eltrombopag and rh-TPO groups maintained their response rates at 6 months after switching, respectively. Both eltrombopag and rh-TPO were well tolerated. CONCLUSIONS Our study confirmed the safety and effectiveness of switching between rh-TPO and eltrombopag for ITP patients who had no response to or experienced adverse events with their first TPO-RA. When the switch was motivated by other reasons, including patient preference and platelet count fluctuations, the probability of response was high. REGISTRATION ClinicalTrials.gov, NCT04214951.
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Affiliation(s)
- Xuan Cai
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Haixia Fu
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiangyu Zhao
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Jin Lu
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Qian Jiang
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yingjun Chang
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiaojun Huang
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Beijing 100044, China
- Peking University Institute of Hematology, Beijing 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing 100044, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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Kanda RG, Niero-Melo L, Domingues MAC, Oliveira CC. Impact of reticulin stain in clinical outcome of Immune Thrombocytopenic Purpura (ITP): a pathologist perspective. Surg Exp Pathol 2022. [DOI: 10.1186/s42047-022-00108-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
This study evaluated histopathological characteristics of bone marrow (BM) of patients with immune thrombocytopenic purpura (ITP) and sought to find possible associations among them and clinical aspects.
Method
A retrospective study was carried out with 120 patients using BM clot and BM biopsy samples, including morphological (cytological and histological) re-evaluation, reticulin and hemosiderin analysis, and clinical outcome review of medical records. Immunohistochemistry (CD34 and CD117) was applied in a group of patients with increased reticulin, with the objective of exclusion Myelodysplastic syndrome cases
Results
Megakaryocytic hyperplasia was observed in 109 (90.8%) patients and increased reticulin was diagnosed in nine patients, five of them with a clinically unfavorable outcome (p = 0.042). The increase in reticulin graduation was associated with a higher risk of an unfavorable outcome.
Conclusion
Increased reticulin degree in BM of patients with ITP is associated with an unfavorable outcome in this study. It is rarely explored in the literature and may provide information that contributes to understanding the patient's outcomes.
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Lee JY, Lee JH, Kim SA, Suh KJ, Kim JW, Kim SH, Lee JO, Kim JW, Kim YJ, Lee KW, Kim JH, Lee JS, Bang SM. Treatment patterns of thrombopoietin receptor agonists among adults with primary immune thrombocytopenia: A Korean nationwide population-based study. Thromb Res 2022; 213:114-118. [DOI: 10.1016/j.thromres.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/23/2022] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
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Vianelli N, Auteri G, Buccisano F, Carrai V, Baldacci E, Clissa C, Bartoletti D, Giuffrida G, Magro D, Rivolti E, Esposito D, Podda GM, Palandri F. Refractory primary immune thrombocytopenia (ITP): current clinical challenges and therapeutic perspectives. Ann Hematol 2022; 101:963-978. [PMID: 35201417 PMCID: PMC8867457 DOI: 10.1007/s00277-022-04786-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/01/2022] [Indexed: 01/19/2023]
Abstract
Chronic primary immune thrombocytopenia (ITP) can today benefit from multiple therapeutic approaches with proven clinical efficacy, including rituximab, thrombopoietin receptor agonists (TPO-RA), and splenectomy. However, some ITP patients are unresponsive to multiple lines of therapy with prolonged and severe thrombocytopenia. The diagnosis of refractory ITP is mainly performed by exclusion of other disorders and is based on the clinician's expertise. However, it significantly increases the risk of drug-related toxicity and of bleedings, including life-threatening events. The management of refractory ITP remains a major clinical challenge. Here, we provide an overview of the currently available treatment options, and we discuss the emerging rationale of new therapeutic approaches and their strategic combination. Particularly, combination strategies may target multiple pathogenetic mechanisms and trigger additive or synergistic effects. A series of best practices arising both from published studies and from real-life clinical experience is also included, aiming to optimize the management of refractory ITP.
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Affiliation(s)
- Nicola Vianelli
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy
| | - 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
| | - Francesco Buccisano
- Dipartimento Di Biomedicina E Prevenzione, Università Tor Vergata, Rome, Italy
| | | | | | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | | | | | - Elena Rivolti
- Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniela Esposito
- Presidio Ospedaliero San G. Moscati Di Aversa - ASL Caserta, Caserta, Italy
| | - Gian Marco Podda
- Medicina III, Ospedale San Paolo, ASST Santi Paolo E Carlo, Dipartimento Di Scienze Della Salute, Università Degli Studi Di Milano, Milano, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.
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Al-Samkari H, Jiang D, Gernsheimer T, Liebman H, Lee S, Wojdyla M, Vredenburg M, Cuker A. Adults with immune thrombocytopenia who switched to avatrombopag following prior treatment with eltrombopag or romiplostim: A multicentre US study. Br J Haematol 2022; 197:359-366. [PMID: 35179784 PMCID: PMC9306832 DOI: 10.1111/bjh.18081] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/15/2022] [Accepted: 01/26/2022] [Indexed: 12/12/2022]
Abstract
Patients with immune thrombocytopenia (ITP) may respond to one thrombopoietin receptor agonist (TPO-RA) but not another. Limited data are available describing outcomes in patients who switched from romiplostim or eltrombopag to avatrombopag, a newer oral TPO-RA. We performed a retrospective observational study of adults with ITP who switched from eltrombopag or romiplostim to avatrombopag at four US tertiary ITP referral centres. Forty-four patients were included, with a mean ITP duration of 8.3 years and a median (range) of four prior ITP treatments. On avatrombopag, 41/44 patients (93%) achieved a platelet response (≥50 × 109 /l) and 38/44 patients (86%) achieved a complete response (≥100 × 109 /l). In all patients, the median platelet count on eltrombopag or romiplostim was 44 × 109 /l vs 113 × 109 /l on avatrombopag (p < 0.0001); in patients switched for ineffectiveness of romiplostim/eltrombopag, it was 28 × 109 /l on romiplostim/eltrombopag vs 88 × 109 /l on avatrombopag (p = 0.025). Fifty-seven percent of patients receiving concomitant ITP medications before switching discontinued them after switching, including 63% of patients receiving chronic corticosteroids. In a heavily pretreated chronic ITP population, avatrombopag was effective following therapy with romiplostim or eltrombopag, with high response rates even in patients with inadequate response to a prior TPO-RA.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Debbie Jiang
- Division of Hematology, University of Washington, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Terry Gernsheimer
- Division of Hematology, University of Washington, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Howard Liebman
- Hematology, University of Southern California-Keck School of Medicine, California, Los Angeles, USA
| | - Susie Lee
- Hematology, University of Southern California-Keck School of Medicine, California, Los Angeles, USA
| | - Matthew Wojdyla
- Dova Pharmaceuticals, a Sobi company, Durham, North Carolina, USA
| | | | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Lee E, Seshadri M, Bussel JB. Clinical outcomes in eight patients with immune thrombocytopenia each treated with the three approved thrombopoietin receptor agonists. Am J Hematol 2021; 96:E373-E376. [PMID: 34152624 DOI: 10.1002/ajh.26277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Eun‐Ju Lee
- Division of Hematology New York Presbyterian Hospital – Weill Cornell New York New York USA
| | - Madhav Seshadri
- Division of Hematology New York Presbyterian Hospital – Weill Cornell New York New York USA
| | - James B. Bussel
- Division of Pediatric Hematology/Oncology New York Presbyterian Hospital – Weill Cornell New York New York USA
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13
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Ghanima W, Gernsheimer T, Kuter DJ. How I treat primary ITP in adult patients who are unresponsive to or dependent on corticosteroid treatment. Blood 2021; 137:2736-44. [PMID: 33827138 DOI: 10.1182/blood.2021010968] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022] Open
Abstract
Approximately 80% of adult patients with immune thrombocytopenia (ITP) have treatment failure with corticosteroids or become dependent on them and require second-line therapy. Several new and effective therapies have been introduced during the past decade and our understanding of disease burden and its effect on quality of life has expanded. It is now recommended that splenectomy, the standard second-line therapy for decades, be delayed for at least 12 to 24 months, allowing for more patients to achieve remission on medical therapies before considering surgery. It is highly recommended that medical therapies be used that have abundant clinical trial evidence, such as the thrombopoietin receptor agonists (TPO-RAs) rituximab and fostamatinib. Unfortunately, there are no reliable biomarkers that help in treatment selection. These therapeutic medical options have variable efficacy, safety profiles, mechanisms of action, and modes of administration. This enables and mandates an individualized approach to treatment, where patient involvement, preferences and values have become central to the process of choosing the appropriate therapy. Both TPO-RAs and fostamatinib are maintenance therapies, whereas rituximab is given for a limited number of doses. Although the response is usually maintained while receiving a TPO-RA or fostamatinib therapy, half of rituximab responders will no longer respond 1 to 2 years after administration and require retreatment or other therapy.
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Palandri F, Rossi E, Bartoletti D, Ferretti A, Ruggeri M, Lucchini E, Carrai V, Barcellini W, Patriarca A, Rivolti E, Consoli U, Cantoni S, Oliva EN, Chiurazzi F, Caocci G, Giuffrida G, Borchiellini A, Auteri G, Baldacci E, Carli G, Nicolosi D, Sutto E, Carpenedo M, Cavo M, Mazzucconi MG, Zaja F, De Stefano V, Rodeghiero F, Vianelli N. Real-world use of thrombopoietin receptor agonists in elderly patients with primary immune thrombocytopenia. Blood 2021:blood. [PMID: 33889952 DOI: 10.1182/blood.2021010735] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/07/2021] [Indexed: 12/16/2022] Open
Abstract
The efficacy and safety of thrombopoietin-receptor agonists (TRAs) in elderly patients with primary immune thrombocytopenia (ITP) is uncertain. In 384 ITP patients treated with TRAs when aged ≥60 years, we investigated TRAs response and switch, thrombotic/hemorrhagic risk, and sustained responses off-treatment (SROT). After 3 months, 82.5% and 74.3% of eltrombopag and romiplostim-treated patients achieved a response, respectively (p=0.09); 66.7% maintained the response (median follow-up: 2.7 years). Eighty-five (22.2%) patients switched to the alternative TRA; while no cross-toxicity was observed, 83.3% of resistant patients had a response after the switch. During TRA, 34 major thromboses (3 fatal) and 14 major hemorrhages (none fatal) occurred in 18 and 10 patients, respectively, and were associated with thrombosis history (SHR: 2.04, p=0.05) and platelet count <20x109/L at TRA start (SHR: 1.69, p=0.04), respectively. A recurrent event occurred in 15.6% of patients surviving thrombosis, in all cases but one during persisting TRA treatment (incidence rate: 7.7 per 100 patient-years). All recurrences occurred in the absence of adequate antithrombotic secondary prophylaxis. Sixty-two (16.5%) responding patients discontinued TRA; 53 (13.8%) patients maintained SROT, which was associated with TRA discontinuation in complete response (p<0.001). Very old age (≥75, 41.1%) was associated with more frequent TRAs start in persistent/acute phase but not with response or thrombotic/hemorrhagic risk. TRAs are effective in elderly ITP patients, with no fatal haemorrhages and with SROT in a significant portion of patients; in patients with thrombosis history caution is warranted and a careful risk/benefit balance should be carried out.
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15
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Arnall JR, DiSogra KY, Downing L, Elmes JB, Tran T, Moore DC. Comparative Utilization and Efficacy of Thrombopoietin Receptor Agonists in Relapsed/Refractory Immune Thrombocytopenia. Am J Ther 2021; 28:e525-30. [PMID: 33491968 DOI: 10.1097/MJT.0000000000001335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The thrombopoietin (TPO) agonists, eltrombopag and romiplostim, stimulate the production of platelets and offer an effective treatment option in relapsed/refractory immune thrombocytopenia (ITP). Recently published 2019 ITP guidelines recommend the TPO agonists as second-line therapy following corticosteroids; however, little data offer insights into comparative efficacy and tolerability. STUDY QUESTION Is there a difference in the efficacy between romiplostim and eltrombopag in relapsed/refractory ITP? STUDY DESIGN We conducted a single-center, retrospective chart review of patients with ITP treated with romiplostim or eltrombopag. MEASURES AND OUTCOMES The primary objective was a sustained platelet response, defined as platelets greater than 50,000/μL in more than 66% of clinic visits over a 6-month period. Secondary objectives sought to evaluate response to and tolerability of TPO agonists. RESULTS The study included 107 consecutive patients, 67 (63%) on romiplostim and 40 (37%) on eltrombopag. Previous corticosteroids and rituximab were used in 95% and 50% of patients, respectively. There was no difference identified in platelet responses between the TPO-RAs, 72% romiplostim versus 65% eltrombopag (P = 0.520). In addition, no differences were identified in secondary measures of response. CONCLUSIONS In our experience with romiplostim and eltrombopag for ITP, we did not identify a difference in the efficacy of these agents. Further larger and prospective evaluations should be considered.
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Ise M, Iizuka H, Kamoda Y, Hirao M, Kida M, Usuki K. Romiplostim is effective for eltrombopag-refractory aplastic anemia: results of a retrospective study. Int J Hematol 2020; 112:787-794. [PMID: 32876852 DOI: 10.1007/s12185-020-02971-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/29/2020] [Accepted: 08/07/2020] [Indexed: 01/10/2023]
Abstract
Eltrombopag (EPAG) and romiplostim (ROM), thrombopoietin receptor-agonists with demonstrated efficacy against aplastic anemia (AA) in prospective controlled studies, were authorized in Japan for use in adults with aplastic anemia in 2017 and 2019, respectively. So far, no data are available on the potential contribution of switching from ROM to EPAG or vice versa in terms of efficacy or tolerance. Efficacies and tolerance profiles of ten patients, who failed to respond to the maximum dose of EPAG and then switched to ROM, were evaluated. All ten patients received a maximum dose of ROM (20 μg/kg/week). At a median follow-up of twelve months, seven of ten patients (70%) had achieved either neutrophil, erythroid, or platelet response, including one complete response. No patients showed platelet count fluctuations that were reported during ROM treatment for immune thrombocytopenia. In univariate analysis of the relationship between efficacy and demographics, the response had a correlation with neither factors. None of the patients stopped the ROM treatment because of adverse events. Although a larger number of patients and a longer follow-up period are needed to confirm our findings, our results show the efficacy of ROM in patients with EPAG-refractory AA.
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Affiliation(s)
- Masataka Ise
- Department of Hematology, NTT Medical Center Tokyo, 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Hiromitsu Iizuka
- Department of Hematology, NTT Medical Center Tokyo, 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Yoshimasa Kamoda
- Department of Hematology, NTT Medical Center Tokyo, 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Masako Hirao
- Department of Hematology, NTT Medical Center Tokyo, 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Michiko Kida
- Department of Hematology, NTT Medical Center Tokyo, 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo, 141-8625, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, 5-9-22 Higashigotanda, Shinagawa-ku, Tokyo, 141-8625, Japan.
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Ebbo M, Rivière E, Godeau B. [Adult immune thrombocytopenia and thrombopoietin receptor agonist: Ten years later]. Rev Med Interne 2020; 42:38-45. [PMID: 32712041 DOI: 10.1016/j.revmed.2020.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/22/2020] [Indexed: 12/24/2022]
Abstract
Ten years after their licence in France, the use of the two thrombopoietin receptor agonists (TPO-RA), eltrombopag and romiplostim, has deeply modified the landscape of immune thrombocytopenia (ITP) treatment. In this review, we summarise data on efficacy and safety of these treatments during ITP, as well as their use in clinical practice. Their place in therapeutic strategy, the recent description of persistant remission after discontinuation of TPO-RA, and future new thrombopoietic agents are also discussed. Their use has progressively increased and early use at a newly diagnosed stage of the disease is under evaluation. However physician have to keep in mind that thromboembolism rates appear to be higher with TPO-RA treatment in ITP patients at high risk of thrombosis, and that data from "real-life" studies with very long term follow up are not available. Finally, the cost of these treatments should also be evaluated in future therapeutic strategies comparisons.
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Affiliation(s)
- M Ebbo
- Département de Médecine Interne, Hôpital de la Timone, AP-HM, Marseille, France; Aix Marseille Université, CNRS, INSERM, Centre d'Immunologie de Marseille Luminy, Marseille, France
| | - E Rivière
- Université de Bordeaux, Faculté de Médecine, 232 rue Léo Saignat, 33000 Bordeaux, France; CHU de Bordeaux, Service de Médecine Interne et Maladies Infectieuses, Hôpital Haut-Lévêque, 33604 Pessac, France
| | - B Godeau
- Service de médecine interne, Centre de référence des cytopénies autoimmunes de l'adulte, CHU Henri Mondor, APHP, UPEC, 94010 Créteil, France.
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18
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Forsythe A, Schneider J, Pham T, Bhor M, Said Q, Allepuz A, Socorro O Portella MD, Kwon CS, Roy AN. Real-world evidence on clinical outcomes in immune thrombocytopenia treated with thrombopoietin receptor agonists. J Comp Eff Res 2020; 9:447-457. [PMID: 32175766 DOI: 10.2217/cer-2019-0177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Aim: Eltrombopag and romiplostim are US FDA approved for treatment of immune thrombocytopenia in patients with insufficient response to other treatments. Clinical or real-world data comparing outcomes of the two drugs are limited. Methods: This retrospective cross-sectional study sought information on bleeding-related episodes (BREs), adverse events (AEs) and other outcomes of eltrombopag or romiplostim treatment in immune thrombocytopenia. Results: Patients receiving eltrombopag experienced significantly reduced BREs, severe BREs, rescue medication use and platelet transfusions. Diarrhea and headache were significantly less frequent in patients receiving eltrombopag; other AEs occurred equally in both groups. Conclusion: There may be a potential advantage for the use of eltrombopag versus romiplostim in the practice settings studied, based on rates of BREs and AEs and rescue medication utilization.
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Affiliation(s)
- Anna Forsythe
- Evidence Generation, Purple Squirrel Economics, New York, NY 10010, USA
| | | | - Timothy Pham
- Health Economics and Outcomes Research, Novartis, East Hanover, NJ 07936, USA
| | - Menaka Bhor
- Health Economics and Outcomes Research, Novartis, East Hanover, NJ 07936, USA
| | - Qayyim Said
- Health Economics and Outcomes Research, Novartis, East Hanover, NJ 07936, USA
| | | | | | - Christina S Kwon
- Evidence Generation, Purple Squirrel Economics, New York, NY 10010, USA
| | - Anuja Nidumolu Roy
- Health Economics and Outcomes Research, Novartis, East Hanover, NJ 07936, USA
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19
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Giordano P, Lassandro G, Barone A, Cesaro S, Fotzi I, Giona F, Ladogana S, Miano M, Marzollo A, Nardi M, Notarangelo LD, Pession A, Ruggiero A, Russo G, Saracco P, Spinelli M, Tolva A, Tornesello A, Palladino V, Del Vecchio GC. Use of Eltrombopag in Children With Chronic Immune Thrombocytopenia (ITP): A Real Life Retrospective Multicenter Experience of the Italian Association of Pediatric Hematology and Oncology (AIEOP). Front Med (Lausanne) 2020; 7:66. [PMID: 32181255 PMCID: PMC7059456 DOI: 10.3389/fmed.2020.00066] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/13/2020] [Indexed: 01/19/2023] Open
Abstract
Background: The thrombopoietin receptor agonist eltrombopag has been shown to be safe and effective for children with chronic immune thrombocytopenia (ITP). The aim of the present study was to characterize eltrombopag use in current clinical practice. Material and Methods: This is a retrospective multicenter study conducted in 17 centers affiliated to the Italian Association of Pediatric Hematology and Oncology (AIEOP). The primary objective of the study was to determine the prevalence of eltrombopag use in Italian children affected by chronic ITP, after EMA authorization for pediatric age. The secondary objective was to assess efficacy in the first 6 months and safety during the whole period of eltrombopag treatment in current clinical practice. A total of 386 children with chronic ITP were retrospectively enrolled and eligible for analysis. Among these patients, 71 received eltrombopag. Results: The prevalence of eltrombopag use was 19% (95% CI 0.15–0.23). Thirty-one patients (44%) were male and 40 patients (56%) were female. The median age at the first dose of eltrombopag was 12 years (3–17 years). The median duration of eltrombopag treatment was 11 months (1–32 months) and the median starting dose was 50 mg/day (12, 5–75 mg/day). Thirty-two patients (45%) required one or more concomitant ITP medications during the first 6 months of treatment with eltrombopag. Thirty-nine patients (55%) never required concomitant medications. Median platelet counts and proportion of patients achieving the target platelet count of at least 30 × 109/L and 100 × 109/L significantly increased during the first 6 months of treatment (p < 0.0001). Additionally, eltrombopag has been proved effective in the absence of concomitant therapies. The most common Adverse Events were headache (7%) and thrombocytosis (6%). Conclusion: Our study highlighted the crucial role of eltrombopag as second line treatment in children with chronic ITP.
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Affiliation(s)
- Paola Giordano
- Pediatric Unit, Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Giuseppe Lassandro
- Pediatric Unit, Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Angelica Barone
- Department of Pediatric Onco-Hematology, University Hospital of Parma, Parma, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Ilaria Fotzi
- Department Pediatric Hematology Oncology, Azienda Ospedaliero Universitaria A. Meyer Children Hospital, Florence, Italy
| | - Fiorina Giona
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Saverio Ladogana
- Department of Hematology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Maurizio Miano
- Clinical and Experimental Hematology Unit, "G. Gaslini" Children's Hospital, Genoa, Italy
| | - Antonio Marzollo
- Pediatric Hematology-Oncology Unit, Department of Women's and Children's Health, Azienda Ospedaliera-University of Padova, Padua, Italy
| | - Margherita Nardi
- Pediatric Hematology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Andrea Pession
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanna Russo
- Pediatric Hemato-Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Paola Saracco
- Pediatric Hematology, Department of Pediatrics, University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Marco Spinelli
- Hemato-Oncology Unit, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Alessandra Tolva
- Pediatric Hematology/Oncology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Assunta Tornesello
- Pediatric Hematology Oncology, Presidio Ospedaliero Vito Fazzi, Lecce, Italy
| | - Valentina Palladino
- Pediatric Unit, Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Giovanni Carlo Del Vecchio
- Pediatric Unit, Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
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20
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Kashiwagi H, Kuwana M, Hato T, Takafuta T, Fujimura K, Kurata Y, Murata M, Tomiyama Y; Committee for the Revision of “Reference Guide for Management of adult ITP” Blood Coagulation Abnormalities Research Team, Research on Rare and Intractable Disease supported by Health, Labour and Welfare Science Research Grants. Reference guide for management of adult immune thrombocytopenia in Japan: 2019 Revision. Int J Hematol 2020; 111:329-51. [PMID: 31897887 DOI: 10.1007/s12185-019-02790-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/28/2019] [Accepted: 12/02/2019] [Indexed: 02/08/2023]
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Lozano ML, Mingot-Castellano ME, Perera MM, Jarque I, Campos-Alvarez RM, González-López TJ, Carreño-Tarragona G, Bermejo N, Lopez-Fernandez MF, de Andrés A, Valcarcel D, Casado-Montero LF, Alvarez-Roman MT, Orts MI, Novelli S, Revilla N, González-Porras JR, Bolaños E, Rodríguez-López MA, Orna-Montero E, Vicente V. Deciphering predictive factors for choice of thrombopoietin receptor agonist, treatment free responses, and thrombotic events in immune thrombocytopenia. Sci Rep 2019; 9:16680. [PMID: 31723222 PMCID: PMC6853922 DOI: 10.1038/s41598-019-53209-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023] Open
Abstract
Very few data exist on when a particular thrombopoietin-receptor agonist (TPO-RA) is favored in clinical practice for the treatment of patients with immune thrombocytopenia (ITP), about novel risk factors for vascular events (VE) with these drugs, nor about predictive factors for therapy free responses (TFR). We conducted an observational, retrospective, long-term follow-up multicenter study from November 2016 to January 2018 of 121 adult ITP patients initiating TPO-RA between January 2012 to December 2014. Data reflected that a platelet count ≤25 × 109/l at the time when the TPO-RA was initiated was associated with a 2.8 higher probability of receiving romiplostim vs. eltrombopag (P = 0.010). VE on TPO-RA was related to previous neoplasia in patients over 65 years (50% vs. 2.2%, P < 0.001), and to previous splenectomy in younger patients (100% vs. 33%, P = 0.001). Receiving romiplostim as first TPO-RA with no subsequent TPO-RA switching was associated with a 50% likelihood of TFR after 2.9 years of therapy (3.3 years in chronic ITP patients). These real-world data help deciphering some areas of uncertainty, and offer insight into some of the most relevant challenges of ITP which may help clinicians make appropriate treatment decisions in the management of adult ITP patients with TPO-RA.
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Affiliation(s)
- Maria L Lozano
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia, Spain.
| | | | - María M Perera
- Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - Isidro Jarque
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | | | | | | | - Aurora de Andrés
- Complexo Hospitalario Universitario de Santiago, A Coruña, Spain
| | - David Valcarcel
- Vall d'Hebron Institute of Oncology (VHIO), University Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | | | | | - Nuria Revilla
- Hospital Universitario Morales Meseguer, Murcia, Spain
| | - Jose R González-Porras
- Hospital Universitario de Salamanca (HUSAL/IBSAL), and IBMCC (USAL-CSIC), Salamanca, Spain
| | | | | | - Elisa Orna-Montero
- Institut Català d'Oncologia-Hospital Germans Trias i Pujol, Badalona, Spain
| | - Vicente Vicente
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia, Spain
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22
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Abstract
The two thrombopoietin receptor agonists (TPO-RA), eltrombopag and romiplostim, were licensed in the US for treatment of immune thrombocytopenia (ITP) in 2008 and, since then, their use has progressively increased around the world; they are currently used in more than 100 countries. The six largest randomized controlled trials conducted in ITP have used one of these two agents. All studies have demonstrated a platelet response rate between 50-90%, depending on the criteria used, with good safety and tolerability. TPO-RA were shown to be effective in reducing bleeding and the need for concomitant or rescue medication. Many other investigations of their mechanism of effect, prospective and retrospective trials, and studies focusing on toxicity have been performed widening our knowledge of these two agents. Initial concerns on issues such as myelofibrosis have not been confirmed. Only a small number of patients develop moderate-severe reticulin fibrosis and/or collagen fibrosis; however, these are usually reversed after discontinuation of TPO-RA. Studies indicate, however, that TPO-RA may increase the risk of venous thromboembolism. Both TPO-RA are currently approved in patients with chronic ITP aged >1-year who are refractory to at least one other treatment. Eltrombopag has acquired two additional indications: severe aplastic anemia refractory to first-line treatment and hepatitis C patients undergoing treatment with interferon-ribavirin. Despite these wide-ranging studies, important questions still need to be answered. This summary review on TPO-RA will summarize what is known regarding efficacy in ITP, evaluate safety concerns in more depth, and focus on the questions that remain.
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MESH Headings
- Animals
- Benzoates/chemistry
- Benzoates/pharmacology
- Benzoates/therapeutic use
- Biomarkers
- Blood Coagulation/drug effects
- Clinical Trials as Topic
- Disease Susceptibility
- Humans
- Hydrazines/chemistry
- Hydrazines/pharmacology
- Hydrazines/therapeutic use
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Pyrazoles/chemistry
- Pyrazoles/pharmacology
- Pyrazoles/therapeutic use
- Receptors, Fc/chemistry
- Receptors, Fc/therapeutic use
- Receptors, Thrombopoietin/agonists
- Receptors, Thrombopoietin/chemistry
- Receptors, Thrombopoietin/metabolism
- Recombinant Fusion Proteins/chemistry
- Recombinant Fusion Proteins/pharmacology
- Recombinant Fusion Proteins/therapeutic use
- Signal Transduction/drug effects
- Thrombopoietin/chemistry
- Thrombopoietin/pharmacology
- Thrombopoietin/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Waleed Ghanima
- Departments of Medicine, Hematology-Oncology and Research, Østfold Hospital Trust, Norway
- Department of Hematology, Institute of Clinical Medicine, University of Oslo, Norway
| | - Nichola Cooper
- Department of Medicine, Hammersmith Hospital, Imperial College, London, UK
| | - Francesco Rodeghiero
- Hematology Project Foundation and Department of Cell Therapy and Hematology, S. Bortolo Hospital, Vicenza, Italy
| | - Bertrand Godeau
- Department of Internal Medicine, Henri Mondor University Hospital, Assistance Publique-Hopitaux de Paris, UPEC, Créteil, France
| | - James B Bussel
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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23
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González-Porras JR, Godeau B, Carpenedo M. Switching thrombopoietin receptor agonist treatments in patients with primary immune thrombocytopenia. Ther Adv Hematol 2019; 10:2040620719837906. [PMID: 31156798 PMCID: PMC6515841 DOI: 10.1177/2040620719837906] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/05/2019] [Indexed: 12/17/2022] Open
Abstract
Primary immune thrombocytopenia (ITP) is a bleeding disorder that conventionally has been treated with steroids or other immunosuppressive treatments. The introduction of thrombopoietin receptor agonists (TPO-RAs), which increase platelet production, dramatically changed the treatment landscape for ITP by providing patients with well-tolerated, long-term treatment options. Two TPO-RAs, eltrombopag and romiplostim, have been approved in the United States and European Union for the treatment of ITP. Some patients do not benefit from the first TPO-RA they receive, so it is assumed that the alternate TPO-RA would have the same outcome. However, eltrombopag and romiplostim have distinct pharmacodynamic and pharmacokinetic properties and may have different tolerability and efficacy in individual patients with ITP. Published retrospective studies showed that >75% of patients who switched to the alternate TPO-RA maintained or achieved a response with the new treatment. Notably, most patients who switched due to lack of efficacy with the first TPO-RA responded to the alternate TPO-RA, which demonstrates an absence of cross-resistance between the two drugs. Therefore, switching to the alternate TPO-RA if the first TPO-RA fails to demonstrate a response should be considered before the use of a less-preferable option.
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Affiliation(s)
- José R González-Porras
- Department of Hematology, IBSAL-Hospital Universitario de Salamanca, 1ª Planta. Paseo de San Vicente, 58-182, 37007, Salamanca, Spain
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Abstract
Despite the improvement in understanding its pathogenesis and the introduction of novel treatment options, the management of primary immune thrombocytopenia (ITP) still remains challenging. Considering its increased incidence with aging and prolonged life-expectancy, ITP is often diagnosed in elderly patients, a subset that deserves some special precautions. Ensure the diagnosis is a crucial step, and carefully attention must be given in excluding other causes of thrombocytopenia, especially among older people that frequently suffer from many comorbidities. When it comes to treatment decision, it is worth keeping into account that the elderly have an increased risk of bleeding, thrombosis and infections, that they often require many concomitant therapies, including antiplatelet or anticoagulant agents, and that treatment-related toxicities are often increased and sometimes more dangerous that the disease itself. There are not dedicated guidelines, and only few specific studies. Steroids with or without IVIG remain the first-line treatment. Splenectomy is less effective than in youngers and burdened by an increased thrombotic and infectious risk. Rituximab is a good option in non-immunocompromised patients, but long-term remissions are few. Eltrombopag and romiplostim have a good safety and efficacy profile, and have become a prominent drug in this subset, even if they are associated with a possible increased risk of thrombosis, and long-term toxicity is unknown. Other drugs, such as dapsone and danazol, have a well-known efficacy and safety profile, and still represent a valid option among elderly patients.
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Affiliation(s)
- Elisa Lucchini
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy.
| | - Renato Fanin
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy
| | | | - Francesco Zaja
- S.C. Ematologia, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
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Lyu M, Li Y, Hao Y, Lyu C, Huang Y, Sun B, Li H, Xue F, Liu X, Yang R. CCR6 defines a subset of activated memory T cells of Th17 potential in immune thrombocytopenia. Clin Exp Immunol 2018; 195:345-357. [PMID: 30403287 DOI: 10.1111/cei.13233] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2018] [Indexed: 01/06/2023] Open
Abstract
Current researches have determined the significance of C-C chemokine receptor (CCR)6 expression as either a marker of T helper cells (Th) or an effector and regulator of T cell function. However, the roles of CCR6 in the pathogenesis of immune thrombocytopenia (ITP) are unclear. In this study, we aimed to investigate the phenotype and functional characteristics of circulating CCR6+ T cells in blood from chronic ITP patients and healthy controls. We found that the frequency of CCR6+ CD4+ cells was higher in ITP patients than in healthy controls. Anti-CD3/anti-CD28 stimulation induced rapid expansion of CCR6+ CD4+ cells in ITP patients. CCR6+ CD4+ cells had a phenotype of activated cells and predominantly expressed CD45RO. Forkhead box protein P3 (FoxP3) and CD25-positive cells were exclusively detected within the CCR6+ CD4+ cells. In ITP patients, CCR6+ regulatory T cells (Treg ) were decreased and positively correlated with platelet counts and transforming growth factor (TGF)-β plasma levels. In contrast to CCR6- counterparts, CCR6+ CD4+ cells produced higher levels of interleukin (IL)-17A. The frequency of CCR6+ Th17 was higher in ITP patients and positively correlated with IL-17A levels in supernatant. Most importantly, CCR6+ CD4+ cell subpopulations, but not CCR6- CD4+ , were closely correlated to treatment response of ITP patients. These findings suggest that circulating CCR6+ CD4+ cells in ITP patients have characteristics of activated memory Th17 phenotype and could be used to monitor disease activity and treatment response.
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Affiliation(s)
- M Lyu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China.,Department of Hematology, Affiliated Suzhou Hospital of Nanjing Medical University (Suzhou Municipal Hospital), Suzhou, China
| | - Y Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China.,Department of Hematology, China-Japan Friendship Hospital, Beijing, China
| | - Y Hao
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - C Lyu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Y Huang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - B Sun
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - H Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - F Xue
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - X Liu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - R Yang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
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Cuker A. Transitioning patients with immune thrombocytopenia to second-line therapy: Challenges and best practices. Am J Hematol 2018; 93:816-823. [PMID: 29574922 PMCID: PMC6055642 DOI: 10.1002/ajh.25092] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/11/2018] [Accepted: 03/14/2018] [Indexed: 01/19/2023]
Abstract
In patients with immune thrombocytopenia who do not adequately respond to first-line therapy, there is no clear consensus on which second-line therapy to initiate and when. This situation leads to suboptimal approaches, including prolonged exposure to treatments that are not intended for long-term use (eg, corticosteroids) and overuse of off-label therapies (eg, rituximab) while approved, more efficacious options exist. These approaches may not only fail to address symptoms and burden of disease, but may also worsen health-related quality of life. A better understanding of available second-line treatments may ensure best use of therapeutic options and thereby optimize patient outcomes.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
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Rodeghiero F. A critical appraisal of the evidence for the role of splenectomy in adults and children with ITP. Br J Haematol 2018; 181:183-195. [DOI: 10.1111/bjh.15090] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Francesco Rodeghiero
- Haematology Project Foundation; Affiliated to the Department of Cell Therapy and Haematology; S. Bortolo Hospital; Vicenza Italy
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