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Spitz AZ, Zacharioudakis E, Reyna DE, Garner TP, Gavathiotis E. Eltrombopag directly inhibits BAX and prevents cell death. Nat Commun 2021; 12:1134. [PMID: 33602934 PMCID: PMC7892824 DOI: 10.1038/s41467-021-21224-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/14/2021] [Indexed: 01/08/2023] Open
Abstract
The BCL-2 family protein BAX has essential activity in mitochondrial regulation of cell death. While BAX activity ensures tissue homeostasis, when dysregulated it contributes to aberrant cell death in several diseases. During cellular stress BAX is transformed from an inactive cytosolic conformation to a toxic mitochondrial oligomer. Although the BAX transformation process is not well understood, drugs that interfere with this process are useful research tools and potential therapeutics. Here, we show that Eltrombopag, an FDA-approved drug, is a direct inhibitor of BAX. Eltrombopag binds the BAX trigger site distinctly from BAX activators, preventing them from triggering BAX conformational transformation and simultaneously promoting stabilization of the inactive BAX structure. Accordingly, Eltrombopag is capable of inhibiting BAX-mediated apoptosis induced by cytotoxic stimuli. Our data demonstrate structure-function insights into a mechanism of BAX inhibition and reveal a mechanism for Eltrombopag that may expand its use in diseases of uncontrolled cell death.
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Affiliation(s)
- Adam Z Spitz
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Emmanouil Zacharioudakis
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Denis E Reyna
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Thomas P Garner
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Evripidis Gavathiotis
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, USA.
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
- Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, USA.
- Wilf Family Cardiovascular Research Institute, Albert Einstein College of Medicine, Bronx, NY, USA.
- Institute of Aging Research, Albert Einstein College of Medicine, Bronx, NY, USA.
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Nevil G, Roth M, Gill J, Zhang W, Teicher B, Erickson SW, Gatto G, Smith M, Kolb EA, Gorlick R. Initial in vivo testing of TPO-receptor agonist eltrombopag in osteosarcoma patient-derived xenograft models by the pediatric preclinical testing consortium. Pediatr Hematol Oncol 2021; 38:8-13. [PMID: 32804009 PMCID: PMC8670012 DOI: 10.1080/08880018.2020.1802539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Eltrombopag is a small molecule, thrombopoietin receptor agonist approved for the treatment of patients with aplastic anemia and chronic immune thrombocytopenia. It is also a polyvalent cation chelator and inhibits leukemia cell proliferation via reduction of intracellular iron. The in vivo efficacy of eltrombopag was tested against a panel of six Pediatric Preclinical Testing Consortium osteosarcoma xenografts at doses of 5 mg/kg/day (moderate dose) and 50 mg/kg/day (high dose). Eltrombopag, at moderate doses, failed to significantly improve event-free survival (EFS) in 6/6 models. At high doses, eltrombopag significantly prolonged EFS in 2/2 models, though the effect size was small. All models tested demonstrated progressive disease. While eltrombopag did not meaningfully inhibit osteosarcoma growth, it also did not stimulate tumor growth, suggesting it may be safely investigated as a supportive care agent to enhance platelet recovery post chemotherapy.
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Affiliation(s)
- Grace Nevil
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Roth
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jonathan Gill
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wendong Zhang
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Gregory Gatto
- RTI International, Research Triangle Park, North Carolina, USA
| | - Malcom Smith
- National Cancer Institute, Bethesda, maryland, USA
| | - E. Anders Kolb
- Division of Pediatric Hematology/Oncology, A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Richard Gorlick
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Eltrombopag inhibits Type I interferon-mediated antiviral signaling by decreasing cellular iron. Biochem Pharmacol 2021; 186:114436. [PMID: 33539815 DOI: 10.1016/j.bcp.2021.114436] [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: 11/06/2020] [Revised: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 11/21/2022]
Abstract
Thrombocytopenia is common among patients with viral hepatitis, limiting the use of antiviral therapy. Eltrombopag (EP) is a thrombopoietin receptor (TPO-R) agonist that has been approved for treatment of immune thrombocytopenia patients with hepatitis virus infection. Interferon-α (IFN-α) plays a crucial role in the antiviral response, and is recommended as the first-line agent for chronic hepatitis B patients. Here, we investigated whether EP inhibits the production of IFN-stimulated genes (ISGs) induced by IFN-α through the TPO-R-independent pathway by mediating reactive oxygen species production by iron chelation. Our results assessed the inhibitory effect of EP on IFN-α signaling, which contributes to the downregulation of ISGs produced by monocytes and sheds light on the underlying mechanisms using iron chelation to treat patients with hepatitis-related immunological thrombocytopenia.
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Holbein BE, Ang MTC, Allan DS, Chen W, Lehmann C. Iron-withdrawing anti-infectives for new host-directed therapies based on iron dependence, the Achilles' heel of antibiotic-resistant microbes. ENVIRONMENTAL CHEMISTRY LETTERS 2021; 19:2789-2808. [PMID: 33907538 PMCID: PMC8062846 DOI: 10.1007/s10311-021-01242-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/13/2021] [Indexed: 05/02/2023]
Abstract
The iron dependence of antibiotic-resistant microbes represents an Achilles' heel that can be exploited broadly. The growing global problem of antibiotic resistance of microbial pathogens wherein microbes become resistant to the very antibiotics used against them during infection is linked not only to our health uses but also to agribusiness practices and the changing environment. Here we review mechanisms of microbial iron acquisition and host iron withdrawal defense, and the influence of iron withdrawal on the antimicrobial activity of antibiotics. Antibiotic-resistant microbes are unaltered in their iron requirements, but iron withdrawal from microbes enhances the activities of various antibiotics and importantly suppresses outgrowth of antibiotic-exposed resistant microbial survivors. Of the three therapeutic approaches available to exploit microbial iron susceptibility, including (1) use of gallium as a non-functional iron analogue, (2) Trojan horse conjugates of microbial siderophores carrying antibiotics, and (3) new generation iron chelators, purposely designed as anti-microbials, the latter offers various advantages. For instance, these novel anti-microbial chelators overcome the limitations of conventional clinically-used hematological chelators which display host toxicity and are not useful antimicrobials. 3-Hydroxypyridin-4-one-containing polymeric chelators appear to have the highest potential. DIBI (developmental code name) is a well-developed lead candidate, being a low molecular weight, water-soluble copolymer with enhanced iron binding characteristics, strong anti-microbial and anti-inflammatory activities, low toxicity for animals and demonstrated freedom from microbial resistance development. DIBI has been shown to enhance antibiotic efficacy for antibiotic-resistant microbes during infection, and it also prevents recovery growth and resistance development during microbe exposure to various antibiotics. Because DIBI bolsters innate iron withdrawal defenses of the infected host, it has potential to provide a host-directed anti-infective therapy.
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Affiliation(s)
- Bruce E. Holbein
- Chelation Partners Inc., #58, The Labs at Innovacorp, Life Sciences Research Institute, 1344 Summer Street, Halifax, NS B3H OA8 Canada
- Department of Microbiology and Immunology, Dalhousie University, 5859 College St., Halifax, NS B3H 1X5 Canada
| | - M. Trisha C. Ang
- Chelation Partners Inc., #58, The Labs at Innovacorp, Life Sciences Research Institute, 1344 Summer Street, Halifax, NS B3H OA8 Canada
| | - David S. Allan
- Chelation Partners Inc., #58, The Labs at Innovacorp, Life Sciences Research Institute, 1344 Summer Street, Halifax, NS B3H OA8 Canada
| | - Wangxue Chen
- Human Health Therapeutics Research Center, National Research Council Canada, 100 Sussex Drive, Ottawa, ON K1A 0R6 Canada
| | - Christian Lehmann
- Department of Microbiology and Immunology, Dalhousie University, 5859 College St., Halifax, NS B3H 1X5 Canada
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS Canada
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55
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Argenziano M, Di Paola A, Tortora C, Di Pinto D, Pota E, Di Martino M, Perrotta S, Rossi F, Punzo F. Effects of Iron Chelation in Osteosarcoma. Curr Cancer Drug Targets 2020; 21:443-455. [PMID: 33380300 DOI: 10.2174/1568009620666201230090531] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/19/2020] [Accepted: 10/25/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Osteosarcoma is an aggressive bone tumor. It represents the principal cause of cancer-associated death in children. Considering the recent findings on the role of iron in cancer, iron chelation has been investigated for its antineoplastic properties in many tumors. Deferasirox is the most used iron chelator compound and in previous studies showed an anticancer effect in hematologic and solid malignancies. Eltrombopag is a Thrombopoietin receptor used in thrombocytopenia that also binds and mobilize iron. It demonstrated an effect on iron overload conditions and also in contrasting cancer cell proliferation. OBJECTIVE We analyzed the effects of deferasirox and eltrombopag in human osteosarcoma cells in an attempt to identify other therapeutic approaches for this tumor. METHODS We cultured and treated with deferasirox and Eltrombopag, alone and in combination, two human osteosarcoma cell lines, MG63 and 143B. After 72h exposure, we performed RTqPCR, Western Blotting, Iron Assay and cytofluorimetric assays to evaluate the effect on viability, apoptosis, cell cycle progression and ROS production. RESULTS The iron-chelating properties of the two compounds are also confirmed in osteosarcoma, but we did not observe any direct effect on tumor progression. DISCUSSION We tested deferasirox and eltrombopag, alone and in combination, in human osteosarcoma cells for the first time and demonstrated that their iron-chelating activity does not influence biochemical pathways related to cancer progression and maintenance. CONCLUSION Although further investigations on possible effects mediated by cells of the tumor microenvironment could be of great interest, in vitro iron chelation in osteosarcoma does not impair tumor progression.
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Affiliation(s)
- Maura Argenziano
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alessandra Di Paola
- Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Chiara Tortora
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Daniela Di Pinto
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Elvira Pota
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Martina Di Martino
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Silverio Perrotta
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesca Punzo
- Department of Woman, Child and General and Specialist Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
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56
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Di Paola A, Palumbo G, Merli P, Argenziano M, Tortora C, Strocchio L, Roberti D, Santoro C, Perrotta S, Rossi F. Effects of Eltrombopag on In Vitro Macrophage Polarization in Pediatric Immune Thrombocytopenia. Int J Mol Sci 2020; 22:ijms22010097. [PMID: 33374151 PMCID: PMC7796119 DOI: 10.3390/ijms22010097] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 01/12/2023] Open
Abstract
Immune Thrombocytopenia (ITP) is an autoimmune disease characterized by autoantibodies-mediated platelet destruction, a prevalence of M1 pro-inflammatory macrophage phenotype and an elevated T helper 1 and T helper 2 lymphocytes (Th1/Th2) ratio, resulting in impairment of inflammatory profile and immune response. Macrophages are immune cells, present as pro-inflammatory classically activated macrophages (M1) or as anti-inflammatory alternatively activated macrophages (M2). They have a key role in ITP, acting both as effector cells, phagocytizing platelets, and, as antigen presenting cells, stimulating auto-antibodies against platelets production. Eltrombopag (ELT) is a thrombopoietin receptor agonist licensed for chronic ITP to stimulate platelet production. Moreover, it improves T and B regulatory cells functions, suppresses T-cells activity, and inhibits monocytes activation. We analyzed the effect of ELT on macrophage phenotype polarization, proposing a new possible mechanism of action. We suggest it as a mediator of macrophage phenotype switch from the M1 pro-inflammatory type to the M2 anti-inflammatory one in paediatric patients with ITP, in order to reduce inflammatory state and restore the immune system function. Our results provide new insights into the therapy and the management of ITP, suggesting ELT also as immune-modulating drug.
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MESH Headings
- B-Lymphocytes, Regulatory/immunology
- B-Lymphocytes, Regulatory/pathology
- Benzoates/pharmacology
- Child
- Child, Preschool
- Female
- Humans
- Hydrazines/pharmacology
- Macrophage Activation/drug effects
- Macrophages/immunology
- Macrophages/pathology
- Male
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/pathology
- Pyrazoles/pharmacology
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/pathology
- Th1 Cells/immunology
- Th1 Cells/pathology
- Th2 Cells/immunology
- Th2 Cells/pathology
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Affiliation(s)
- Alessandra Di Paola
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (A.D.P.); (M.A.)
| | - Giuseppe Palumbo
- Department of Haematology, Bambino Gesù Hospital, 00165 Rome, Italy; (G.P.); (P.M.); (L.S.)
| | - Pietro Merli
- Department of Haematology, Bambino Gesù Hospital, 00165 Rome, Italy; (G.P.); (P.M.); (L.S.)
| | - Maura Argenziano
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (A.D.P.); (M.A.)
| | - Chiara Tortora
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (C.T.); (D.R.); (S.P.)
| | - Luisa Strocchio
- Department of Haematology, Bambino Gesù Hospital, 00165 Rome, Italy; (G.P.); (P.M.); (L.S.)
| | - Domenico Roberti
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (C.T.); (D.R.); (S.P.)
| | - Claudia Santoro
- Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Silverio Perrotta
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (C.T.); (D.R.); (S.P.)
| | - Francesca Rossi
- Department of Woman, Child and General and Specialist Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (C.T.); (D.R.); (S.P.)
- Correspondence: ; Tel.: +39-081-566-5342
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57
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Waters T, Goss KL, Koppenhafer SL, Terry WW, Gordon DJ. Eltrombopag inhibits the proliferation of Ewing sarcoma cells via iron chelation and impaired DNA replication. BMC Cancer 2020; 20:1171. [PMID: 33256675 PMCID: PMC7706234 DOI: 10.1186/s12885-020-07668-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 11/20/2020] [Indexed: 12/30/2022] Open
Abstract
Background The treatment of Ewing sarcoma, an aggressive bone and soft tissue sarcoma, is associated with suboptimal outcomes and significant side-effects. Consequently, there is an urgent need to identify novel therapies that will improve outcomes for children and adults with Ewing sarcoma tumors while also decreasing treatment-related toxicities. Methods We analyzed data from the PRISM drug repurposing screen, which tested the activity of 4518 drugs across 578 cancer cell lines, to identify drugs that selectively inhibit the growth of Ewing sarcoma cell lines. We then tested the effects of a top hit from the screen on cell proliferation, cell cycle progression, and activation of the DNA damage pathway using Ewing sarcoma cell lines. We also used a CRISPR/Cas9 gene knockout approach to investigate the role of Schlafen 11 (SLFN11), a restriction factor for DNA replication stress that is overexpressed in Ewing sarcoma tumors, in mediating the sensitivity of Ewing sarcoma cells to the drug. Results We found that eltrombopag, an FDA-approved thrombopoietin-receptor agonist (TPO-RA) that is currently being evaluated as a treatment for chemotherapy-induced thrombocytopenia, inhibits the growth of Ewing sarcoma cell lines in vitro in proliferation and colony formation assays. However, from a mechanistic standpoint, the thrombopoietin receptor is not expressed in Ewing sarcoma cells and we show that eltrombopag impairs DNA replication and causes DNA damage in Ewing sarcoma cells by chelating iron, a known “off-target” effect of the drug. We also found that the sensitivity of Ewing sarcoma cells to eltrombopag is mediated, in part, by SLFN11, which regulates the cellular response to DNA replication stress. Conclusions Ewing sarcoma cell lines are sensitive to eltrombopag and this drug could improve outcomes for patients with Ewing sarcoma tumors by both targeting the tumor, via chelation of iron and inhibition of DNA replication, and reducing chemotherapy-induced thrombocytopenia, via stimulation of the thrombopoietin receptor. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12885-020-07668-6.
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Affiliation(s)
- Torin Waters
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Iowa, 25 S Grand Avenue, Iowa City, Iowa, 52242, USA
| | - Kelli L Goss
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Iowa, 25 S Grand Avenue, Iowa City, Iowa, 52242, USA
| | - Stacia L Koppenhafer
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Iowa, 25 S Grand Avenue, Iowa City, Iowa, 52242, USA
| | - William W Terry
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Iowa, 25 S Grand Avenue, Iowa City, Iowa, 52242, USA
| | - David J Gordon
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Iowa, 25 S Grand Avenue, Iowa City, Iowa, 52242, USA.
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Kulasekararaj AG, Marsh JCW. Romiplostim in aplastic anaemia - another tool in the armamentarium. Br J Haematol 2020; 192:15-16. [PMID: 33152102 DOI: 10.1111/bjh.17189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Austin G Kulasekararaj
- King's College Hospital NHS Foundation Trust, London, UK.,NIHR/Wellcome King's Clinical Research Facility, London, UK.,King's College London, London, UK
| | - Judith C W Marsh
- King's College Hospital NHS Foundation Trust, London, UK.,NIHR/Wellcome King's Clinical Research Facility, London, UK
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59
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The Effectiveness of Rapamycin Combined with Eltrombopag in Murine Models of Immune-Mediated Bone Marrow Failure. J Immunol Res 2020; 2020:1798795. [PMID: 33123600 PMCID: PMC7586163 DOI: 10.1155/2020/1798795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/14/2020] [Accepted: 09/15/2020] [Indexed: 11/18/2022] Open
Abstract
Severe aplastic anemia (SAA) is a rare disease characterized by severe pancytopenia and bone marrow failure. Most patients with AA respond to immunosuppressive therapy (IST), usually as antithymocyte globulin (ATG) and cyclosporine (CsA), but some relapse on CsA withdrawal or require long-term administration of CsA to maintain blood counts. Recent research has found that rapamycin (Rapa) was an effective therapy in mouse models of immune-mediated bone marrow failure. However, it has not achieved a satisfactory effect in clinical application. At present, many studies have confirmed that eltrombopag (ELT) combined with IST can improve the curative effect of AA patients. Then, whether Rapa combined Elt in the treatment of AA will acquire better efficacy than a single drug application remains unclear. In this study, an immune attack-mediated AA mouse model was constructed by total body irradiation (TBI) and allo-lymphocyte infusion. In our study, we tested the efficacy of Rapa combined with Elt as a new treatment in mouse models of immune-mediated bone marrow failure. It showed that treatment with Rapa in combination Elt in the AA mouse model ameliorated pancytopenia and extended animal survival in a manner comparable to the standard dose of CsA and Rapa alone. However, there was no significant improvement effect on the number and function of NK cells and their subsets, mDCs, and CD4+/CD8+ ratio in AA mice after the therapy of Rapa combined with Elt compared with Rapa alone. Furthermore, the secretion of IL-10 of Tregs in AA mice increased significantly after the therapy of Rapa combined with Elt, but there was no significant difference in the number of Treg cells. We did not observe the difference in the curative effect of the Rapa group and CsA group, but for IL-10/Tregs ratio, the Rapa group was superior to the CsA group. And the IFN-r secretion of CD8+T cells in AA mice decreased significantly after the combination therapy of Rapa and Elt than Rapa alone. Compared with the AA group, the level of plasma IFN-γ, IL-2, and TNF-α decreased significantly (P < 0.05), but IL-10, IL-4, IL-5, and IL-1β increased significantly in the Rapa group (P < 0.05). As for IL-10, IL-12p70, IL-2, IL-6, KC/GRO, and TNF-α, the therapy of Rapa combined with Elt showed a more significant effect than Rapa alone in AA mice. To some extent, this study had shown a relatively better synergistic effect in murine models of immune-mediated bone marrow failure after the combination therapy of Rapa and Elt, which was a promising clinical utility in SAA treatment.
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60
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Mishra K, Pramanik S, Jandial A, Sahu KK, Sandal R, Ahuja A, Yanamandra U, Kumar R, Kapoor R, Verma T, Sharma S, Singh J, Das S, Chatterjee T, Sharma A, Nair V. Real-world experience of eltrombopag in immune thrombocytopenia. AMERICAN JOURNAL OF BLOOD RESEARCH 2020; 10:240-251. [PMID: 33224568 PMCID: PMC7675127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/22/2020] [Indexed: 06/11/2023]
Abstract
Immune thrombocytopenia (ITP) is characterized by decreased platelet count in the peripheral circulation. The first-line therapy is corticosteroids with 53-80% overall response rate. Eltrombopag has been used as second-line therapy in ITP for over a decade now. The long-term efficacy and safety profile have been widely reported in the western world. However, the data from the resource-constraint settings of the developing world is scarce. We aim to present the real-life experience of efficacy and safety of eltrombopag from the resource-constraint settings. This was a retrospective, single-center study conducted at a tertiary care hospital in Northern India from 2012-2019. On audit of medical records, patients of ITP receiving eltrombopag were screened for inclusion. Patients whose treatment outcomes were not available were excluded. Finally, 53 patients were analyzed using statistical packages of Python v3.7. The patients' median age was 35 years (range 17-78), with 23 (43.4%) being female. The median time to response was 35 days (range 28-50 days) and the cumulative overall response rates (ORR) at day 30, day 60 and day 90 were 41.5%, 69.8%, and 81.1% respectively. A total of 10 patients on eltrombopag relapsed during follow up. The cumulative rate of relapse at one year, three years, and five years were 6.6%, 25.3%, and 47.7%, respectively. There was no significant difference in outcome (response rate or relapse) in any subgroups depending on age, sex, duration of disease, number of prior lines of treatment, splenectomy, or baseline platelet count. Six patients stopped eltrombopag after having a median sustained response for 796 days (range 658-1185), and after a median follow up of 624 days (range 92-1339), they continued to be in remission. Seventeen patients (17/53, 32%) reported one or more adverse events while on eltrombopag therapy. A total of 49 adverse events (n=4, grade ≥3 CTCAEv4) were noted. Anemia was the most frequent adverse event followed by hepatobiliary dysfunction as reflected by deranged AST/ALT or raised bilirubin. The use of eltrombopag among adult ITP patients in resource-constraint settings was well-tolerated and yielded excellent overall response. The benefit was found to be sustained on long-term follow up. However, events like anemia, hepatobiliary, and thrombotic complications merit closer follow up.
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Affiliation(s)
- Kundan Mishra
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
| | - Suman Pramanik
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
| | - Aditya Jandial
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
| | - Kamal Kant Sahu
- Department of Internal Medicine, Saint Vincent HospitalWorcester, Massachusetts, USA
| | - Rajeev Sandal
- Department of Health and Family WelfareHimachal Pradesh, India
| | - Ankur Ahuja
- Dept of Lab Sciences and Molecular Medicine, Army Hospital (Research & Referral) DelhiIndia
| | - Uday Yanamandra
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
| | - Rajiv Kumar
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
- Department of Internal MedicineINHS Asvini, Mumbai, India
| | - Rajan Kapoor
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
- Department of Internal Medicine, Command Hospital (Eastern Command)Kolkata, India
| | - Tarun Verma
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
| | - Sanjeevan Sharma
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
- Department of Internal Medicine, Command Hospital (Central Command)Lucknow, India
| | - Jasjit Singh
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
- Department of Internal Medicine, Command Hospital (Western Command)Chandimandir, India
| | - Satyaranjan Das
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
- Department of Internal Medicine, Command Hospital (Southern Command)Pune, India
| | - Tathagata Chatterjee
- Dept of Lab Sciences and Molecular Medicine, Army Hospital (Research & Referral) DelhiIndia
| | - Ajay Sharma
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
- Dept of Clinical Hematology and Stem Cell Transplant, Sir Ganga Ram HospitalDelhi, India
| | - Velu Nair
- Dept of Clinical Hematology and Stem Cell Transplant, Army Hospital (Research & Referral) DelhiIndia
- Chief Consultant-Haemato-Oncology & Bone Marrow Transplant, Medical Services & Comprehensive Blood & Cancer Center (CBCC)Ahmedabad, India
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Abstract
INTRODUCTION Iron overload, a state with excessive iron storage in the body, is a common complication in thalassemia patients which leads to multiple organ dysfunctions including the bone. Iron overload-induced bone disease is one of the most common and severe complications of thalassemia including osteoporosis. Currently, osteoporosis is still frequently found in thalassemia even with widely available iron chelation therapy. STUDY SELECTION Relevant publications published before December 2019 in PubMed database were reviewed. Both pre-clinical studies and clinical trials were obtained using iron overload, thalassemia, osteoporosis, osteoblast, and osteoclast as keywords. RESULTS Increased ROS production is a hallmark of iron overload-induced impaired bone remodeling. At the cellular level, oxidative stress affects bone remodeling by both osteoblast inhibition and osteoclast activation via many signaling pathways. In thalassemia patients, it has been shown that bone resorption was increased while bone formation was concurrently reduced. CONCLUSION In this review, reports on the cellular mechanisms of iron overload-associated bone remodeling are comprehensively summarized and presented to provide current understanding this pathological condition. Moreover, current treatments and potential interventions for attenuating bone remodeling in iron overload are also summarized to pave ways for the future discoveries of novel agents that alleviate this condition.
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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] [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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63
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Koca Yozgat A, Leblebisatan G, Akbayram S, Çınar Özel S, Karakaş Z, Erduran E, Yılmaz Ş, Koçak Ü, Ünal Ş, Özdemir GN, Albayrak M, Zengin E, Oymak Y, Bör Ö, Çakmaklı HF, Söker M, Gürlek Gökçebay D, Tokgöz H, Malbora B, Karaman S, Celkan T, Şaşmaz İ, Yaralı N, Ören H, Ünüvar A, Özbek NY. Outcomes of Eltrombopag Treatment and Development of Iron Deficiency in Children with Immune Thrombocytopenia in Turkey. Turk J Haematol 2020; 37:139-144. [PMID: 32181630 PMCID: PMC7463208 DOI: 10.4274/tjh.galenos.2020.2019.0380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective Immune thrombocytopenia (ITP) is a rare autoimmune disease and hematologic disorder characterized by reduced platelet counts that can result in significant symptoms, such as bleeding, bruising, epistaxis, or petechiae. The thrombopoietin receptor agonist eltrombopag (EPAG) is a second-line agent used to treat chronic ITP purpura in adults and children. Materials and Methods The present retrospective study evaluated the efficacy, safety, and side effects of EPAG treatment in pediatric patients with acute refractory and chronic immune thrombocytopenia, particularly focusing on iron-deficiency anemia. Results The diagnosis was chronic ITP in 89 patients and acute refractory ITP in 16 patients. The mean age of patients was 9.5±4.5 years (minimum-maximum: 1.2-18 years) at the beginning of EPAG treatment. The overall response rate was 74.3% (n=78). The mean time for platelet count of ≥50x109/L was 11.6±8 weeks (range: 1-34 weeks). The treatment was stopped for 27 patients (25.7%) at an average of 6.8±9 months (range: 1-38 months). The reason for discontinuation was lack of response in 18 patients, nonadherence in 4 patients, and hepatotoxicity in 2 patients. Response to treatment continued for an average of 4 months after cessation of EPAG in 3 patients. Conclusion Results of the current study imply that EPAG is an effective therapeutic option in pediatric patients with acute refractory and chronic ITP. However, patients must be closely monitored for response and side effects during treatment, and especially for iron deficiency.
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Affiliation(s)
- Ayça Koca Yozgat
- Ankara City Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
| | - Göksel Leblebisatan
- Çukurova University Faculty of Medicine, Department of Pediatric Hematology, Adana, Turkey
| | - Sinan Akbayram
- Gaziantep University Faculty of Medicine, Department of Pediatric Hematology, Gaziantep, Turkey
| | - Simge Çınar Özel
- İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - Zeynep Karakaş
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - Erol Erduran
- Karadeniz Technical University Faculty of Medicine, Department of Pediatric Hematology, Trabzon, Turkey
| | - Şebnem Yılmaz
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Hematology, İzmir, Turkey
| | - Ülker Koçak
- Gazi University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Şule Ünal
- Hacettepe University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Gül Nihal Özdemir
- Kanuni Sultan Süleyman Training and Research Hospital, Clinic of Pediatric Hematology, İstanbul, Turkey
| | - Meryem Albayrak
- Kırıkkale University Faculty of Medicine, Department of Pediatric Hematology, Kırıkkale, Turkey
| | - Emine Zengin
- Kocaeli University Faculty of Medicine, Department of Pediatric Hematology, Kocaeli, Turkey
| | - Yeşim Oymak
- Dr. Behçet Uz Children’s Training and Research Hospital, Clinic of Pediatric Hematology, İzmir, Turkey
| | - Özcan Bör
- Eskişehir University Faculty of Medicine, Department of Pediatric Hematology, Eskişehir, Turkey
| | - Hasan Fatih Çakmaklı
- Ankara University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Murat Söker
- Dicle University Faculty of Medicine, Department of Pediatric Hematology, Diyarbakır, Turkey
| | - Dilek Gürlek Gökçebay
- Ankara Keçiören Training and Research Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
| | - Hüseyin Tokgöz
- Necmettin Erbakan University Meram Faculty of Medicine, Department of Pediatric Hematology, Konya, Turkey
| | - Barış Malbora
- Yeni Yüzyıl University, Gaziosmanpaşa Hospital, Clinic of Pediatric Hematology, İstanbul, Turkey
| | - Serap Karaman
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - Tiraje Celkan
- İstanbul University-Cerrahpaşa Cerrahpaşa Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - İlgen Şaşmaz
- Çukurova University Faculty of Medicine, Department of Pediatric Hematology, Adana, Turkey
| | - Neşe Yaralı
- Ankara City Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
| | - Hale Ören
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Hematology, İzmir, Turkey
| | - Ayşegül Ünüvar
- İstanbul University, İstanbul Faculty of Medicine, Department of Pediatric Hematology, İstanbul, Turkey
| | - Namık Yaşar Özbek
- Ankara City Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
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Mitigative efficacy of the clinical dosage administration of granulocyte colony-stimulating factor and romiplostim in mice with severe acute radiation syndrome. Stem Cell Res Ther 2020; 11:339. [PMID: 32746943 PMCID: PMC7398212 DOI: 10.1186/s13287-020-01861-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/12/2020] [Accepted: 07/28/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND It has been reported that the high-dosage administration of domestically approved pharmaceutical drugs, especially granulocyte colony-stimulating factor (G-CSF) and romiplostim (RP), is a rapid and appropriate medical treatment for preventing severe acute radiation syndrome (ARS) of victims exposed to lethal total-body irradiation (TBI). However, it remains unclear whether or not the clinical dosage administration of these drugs can ameliorate TBI-induced ARS and related high mortality in order to find various drug treatment options and less toxic optimum protocol depending on the situation surrounding the radiological accidents. METHODS We assessed the clinical dosage administration in combination with G-CSF and RP as intraperitoneal injection in C57BL/6 J mice exposed to more than 7-Gy lethal dose of X-ray TBI for the survival study evaluated by the log-rank test. Bone marrow and splenic cells were collected on the 21st day, when 1 week has passed from last administration, to detect the level of cell apoptosis, intracellular reactive oxygen species (ROS), and nuclear factor erythroid 2-related factor 2 (Nrf2)-related anti-oxidative gene expressions, and enzyme-linked immune sorbent assay using sera was performed for cell senescence and inflammation status analyzed with one-way ANOVA and Tukey-Kramer or Bonferroni/Dunn multiple comparison tests. RESULTS The combined once-daily administration of 10 μg/kg G-CSF for 4 times and 10 μg/kg RP once a week for 3 times improve the 30-day survival rate of lethal TBI mice compared with untreated TBI mice, accompanied by a gradual increase in the body weight and hematopoietic cell numbers. The radio-mitigative effect is probably attributed to the scavenging of ROS and the reduction in cell apoptosis. These changes were associated with the upregulation of Nrf2 and its downstream anti-oxidative targets in TBI mice. Furthermore, this combination modulated TBI-induced cell senescence an d inflammation markers. CONCLUSIONS This study suggested that the clinical dosage administration in combination with G-CSF and RP may also have radio-mitigative effects on mice exposed to lethal TBI and may be a potent therapeutic agent for mitigating radiation-induced severe ARS.
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65
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Gao F, Zhou X, Shi J, Luo Y, Tan Y, Fu H, Lai X, Yu J, Huang H, Zhao Y. Eltrombopag treatment promotes platelet recovery and reduces platelet transfusion for patients with post-transplantation thrombocytopenia. Ann Hematol 2020; 99:2679-2687. [PMID: 32519094 DOI: 10.1007/s00277-020-04106-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/27/2020] [Indexed: 02/08/2023]
Abstract
Post-transplantation thrombocytopenia (PT) is a common and severe complication which usually leads to poor prognosis. Eltrombopag (EPAG), a novel oral thrombopoietin (TPO) receptor agonist, has shown promising effects in thrombocytopenia due to immune thrombocytopenic purpura (ITP) and refractory severe aplastic anemia (rSAA), while the effectiveness of EPAG for PT patients still needs to be evaluated. A total of 32 PT patients receiving EPAG were retrospectively analyzed between September 2017 and July 2019, including 15 patients with poor graft function (PGF) and 17 patients with secondary failure of platelet recovery (SFPR). To date, 21 (65.6%) patients achieved overall recovery (OR) and 14 (43.8%) patients achieved complete recovery (CR). Among responders, 18 (85.7%) patients discontinued or tapered the drug and 16 (76.2%) patients successfully maintained their best response. During the EPAG treatment, responders received much lower median platelet transfusion units than non-responders (11 vs. 95, P < 0.001). After a median follow-up time of 364 days (range, 24-842), the overall survival in these patients was 78.1% (100% for responders and 36.4% for non-responders, P < 0.001). In the univariate and multivariate analysis, PGF was identified as the independent risk factor for OR (P = 0.041, HR = 5.333). Megakaryocyte (Megk) amounts (P = 0.025, HR = 14.638) and splenomegaly (P = 0.042, HR = 11.278) were identified as independent risk factors for CR. Besides, PGF patients tended to take a longer time to achieve PR and CR than SFPR patients. In conclusion, our data suggest that EPAG can promote platelet recovery and reduce platelet transfusion in PT patients.
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Affiliation(s)
- Fei Gao
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China
| | - Xiaoyu Zhou
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China
| | - Jimin Shi
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China
| | - Yi Luo
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China
| | - Yamin Tan
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China
| | - Huarui Fu
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China
| | - Xiaoyu Lai
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China
| | - Jian Yu
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China
| | - He Huang
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China. .,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China. .,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China.
| | - Yanmin Zhao
- Bone Marrow Transplantation Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, Zhejiang, People's Republic of China. .,Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China. .,Zhejiang Engineering Laboratory for Stem Cell and Immunotherapy, Hangzhou, Zhejiang, People's Republic of China.
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Abstract
Iron deficiency or overload poses an increasingly complex issue in cardiovascular disease, especially heart failure. The potential benefits and side effects of iron supplementation are still a matter of concern, even though current guidelines suggest therapeutic management of iron deficiency. In this review, we sought to examine the iron metabolism and to identify the rationale behind iron supplementation and iron chelation. Cardiovascular disease is increasingly linked with iron dysmetabolism, with an increased proportion of heart failure patients being affected by decreased plasma iron levels and in turn, by the decreased quality of life. Multiple studies have concluded on a benefit of iron administration, even if just for symptomatic relief. However, new studies field evidence for negative effects of dysregulated non-bound iron and its reactive oxygen species production, with concern to heart diseases. The molecular targets of iron usage, such as the mitochondria, are prone to deleterious effects of the polyvalent metal, added by the scarcely described processes of iron elimination. Iron supplementation and iron chelation show promise of therapeutic benefit in heart failure, with the extent and mechanisms of both prospects not being entirely understood. It may be that a state of decreased systemic and increased mitochondrial iron levels proves to be a useful frame for future advancements in understanding the interconnection of heart failure and iron metabolism.
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67
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Controversies on the Consequences of Iron Overload and Chelation in MDS. Hemasphere 2020; 4:e357. [PMID: 32647792 PMCID: PMC7306315 DOI: 10.1097/hs9.0000000000000357] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/17/2020] [Indexed: 12/15/2022] Open
Abstract
Many patients with MDS are prone to develop systemic and tissue iron overload in part as a consequence of disease-immanent ineffective erythropoiesis. However, chronic red blood cell transfusions, which are part of the supportive care regimen to correct anemia, are the major source of iron overload in MDS. Increased systemic iron levels eventually lead to the saturation of the physiological systemic iron carrier transferrin and the occurrence of non-transferrin-bound iron (NTBI) together with its reactive fraction, the labile plasma iron (LPI). NTBI/LPI-mediated toxicity and tissue iron overload may exert multiple detrimental effects that contribute to the pathogenesis, complications and eventually evolution of MDS. Until recently, the evidence supporting the use of iron chelation in MDS was based on anecdotal reports, uncontrolled clinical trials or prospective registries. Despite not fully conclusive, these and more recent studies, including the TELESTO trial, unravel an overall adverse action of iron overload and therapeutic benefit of chelation, ranging from improved hematological outcome, reduced transfusion dependence and superior survival of iron-loaded MDS patients. The still limited and somehow controversial experimental and clinical data available from preclinical studies and randomized trials highlight the need for further investigation to fully elucidate the mechanisms underlying the pathological impact of iron overload-mediated toxicity as well as the effect of classic and novel iron restriction approaches in MDS. This review aims at providing an overview of the current clinical and translational debated landscape about the consequences of iron overload and chelation in the setting of MDS.
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68
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Al-Samkari H, Grace RF, Kuter DJ. The role of romiplostim for pediatric patients with immune thrombocytopenia. Ther Adv Hematol 2020; 11:2040620720912992. [PMID: 32523658 PMCID: PMC7236573 DOI: 10.1177/2040620720912992] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/18/2020] [Indexed: 01/19/2023] Open
Abstract
The thrombopoietin receptor agonists (TPO-RAs) are a class of platelet growth factors used to treat immune thrombocytopenia (ITP) in children and adults. Romiplostim is a peptide TPO-RA approved for over a decade to treat adults with ITP but was just recently US Food and Drug Administration approved to manage ITP in children 1 year of age and older who have had an inadequate response to corticosteroids, intravenous immunoglobulin, or splenectomy. Like the small molecule TPO-RA eltrombopag, romiplostim offers a high clinical response rate in pediatric patients with ITP, but requires use over an extended, and possibly indefinite, duration. This review is a critical appraisal of the role of romiplostim in pediatric ITP, discussing the safety and efficacy of this agent in clinical trials of children and adults and defining the patients most likely to benefit from romiplostim treatment. The treating hematologist is additionally provided guidance with treatment goals, dosing strategies, toxicity management, and indications for discontinuation.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical chool, Suite 118, Room 112, Zero Emerson Place, Boston, MA 02114, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - David J Kuter
- Division of Hematology, Harvard Medical School, Boston, MA, USA
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69
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Vasudevan Nampoothiri R, Kumar R. Eltrombopag: Role in Cytopenias Following Hematopoietic Stem Cell Transplantation. Indian J Hematol Blood Transfus 2020; 36:238-245. [PMID: 32425372 PMCID: PMC7229069 DOI: 10.1007/s12288-019-01194-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/16/2019] [Indexed: 12/22/2022] Open
Abstract
Eltrombopag is a small molecule oral agonist of the thrombopoietin receptor. Initially used for improving thrombocytopenia in chronic immune thrombocytopenia (ITP), it was later found to be efficacious in various other etiologies of thrombocytopenia as well as inherited marrow failure syndromes. Lately, it has been used for thrombocytopenia and poor graft function after allogeneic hematopoietic stem cell transplantation (HSCT) without any severe adverse events. Although prospective evidence of the efficacy is limited, there are increasing reports on the safety and efficacy with Eltrombopag in post HSCT thrombocytopenia and poor graft function. This provides an exciting opportunity for further research to evaluate both efficacy and cost-effectiveness of the use of Eltrombopag in this scenario. Here we review the current evidence on the indications for the use of Eltrombopag in the post allogeneic hematopoietic stem cell transplant setting.
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Affiliation(s)
- Ram Vasudevan Nampoothiri
- Messner Allogeneic Transplant Program, University of Toronto, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Rajat Kumar
- Messner Allogeneic Transplant Program, University of Toronto, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON M5G 2M9 Canada
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Abstract
Eltrombopag (ELT) is a thrombopoietin receptor activator that has shown efficacy in chronic immune thrombocytopenia. We report the outcome of ELT therapy in 4 children who were treated for rare hematologic disorders, including Pearson syndrome, DiGeorge syndrome, posttransplant allogeneic poor graft function (PGF), and Wiskott-Aldrich syndrome. The ELT tolerance in the analyzed group was good, with the exception of the child with Pearson syndrome, who experienced an exacerbation of cataracts and had to discontinue treatment. Thromboembolic events were observed in one child, who continued ELT therapy despite achieving normalized platelet counts. Independence from PLT transfusions was observed at the 4-week timepoint of therapy in patients with DiGeorge syndrome and PGF who responded to ELT. Discontinuation of therapy was successful in one child, who sustained the normal CBC values afterward. In 2 patients, an increase in neutrophil counts was observed during ELT therapy without additional intervention, and a positive correlation between neutrophil and platelet values during ELT therapy was observed in the child with PGF. ELT is effective in rare pediatric disorders, but response patterns are determined by the underlying disease. ELT shows promising results in patients, but constitutional hematopoiesis defects reduce the chances of a response.
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71
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Forging New Antibiotic Combinations under Iron-Limiting Conditions. Antimicrob Agents Chemother 2020; 64:AAC.01909-19. [PMID: 31907180 DOI: 10.1128/aac.01909-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/23/2019] [Indexed: 11/20/2022] Open
Abstract
Pseudomonas aeruginosa is a multidrug-resistant nosocomial pathogen. We showed previously that thiostrepton (TS), a Gram-positive thiopeptide antibiotic, is imported via pyoverdine receptors and synergizes with iron chelator deferasirox (DSX) to inhibit the growth of P. aeruginosa and Acinetobacter baumannii clinical isolates. A small number of P. aeruginosa and A. baumannii isolates were resistant to the combination, prompting us to search for other compounds that could synergize with TS against those strains. From literature surveys, we selected 14 compounds reported to have iron-chelating activity, plus one iron analogue, and tested them for synergy with TS. Doxycycline (DOXY), ciclopirox olamine (CO), tropolone (TRO), clioquinol (CLI), and gallium nitrate (GN) synergized with TS. Individual compounds were bacteriostatic, but the combinations were bactericidal. Our spectrophotometric data and chrome azurol S agar assay confirmed that the chelators potentiate TS activity through iron sequestration rather than through their innate antimicrobial activities. A triple combination of TS plus DSX plus DOXY had the most potent activity against P. aeruginosa and A. baumannii isolates. One P. aeruginosa clinical isolate was resistant to the triple combination but susceptible to a triple combination containing higher concentrations of CLI, CO, or DOXY. All A. baumannii isolates were susceptible to the triple combinations. Our data reveal a diverse set of compounds with dual activity as antibacterial agents and TS adjuvants, allowing combinations to be tailored for resistant clinical isolates.
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Cilloni D, Andreani G, Dragani M, De Gobbi M, Saglio G. Synergistic effect of eltrombopag and deferasirox in aplastic anemia: a clinical case and review of the literature. Leuk Lymphoma 2020; 61:234-236. [DOI: 10.1080/10428194.2019.1660969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Daniela Cilloni
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giacomo Andreani
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Matteo Dragani
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Marco De Gobbi
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
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73
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Vogel JU, Schmidt S, Schmidt D, Rothweiler F, Koch B, Baer P, Rabenau H, Michel D, Stamminger T, Michaelis M, Cinatl J. The Thrombopoietin Receptor Agonist Eltrombopag Inhibits Human Cytomegalovirus Replication Via Iron Chelation. Cells 2019; 9:cells9010031. [PMID: 31861948 PMCID: PMC7017049 DOI: 10.3390/cells9010031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 02/07/2023] Open
Abstract
The thrombopoietin receptor agonist eltrombopag was successfully used against human cytomegalovirus (HCMV)-associated thrombocytopenia refractory to immunomodulatory and antiviral drugs. These effects were ascribed to the effects of eltrombopag on megakaryocytes. Here, we tested whether eltrombopag may also exert direct antiviral effects. Therapeutic eltrombopag concentrations inhibited HCMV replication in human fibroblasts and adult mesenchymal stem cells infected with six different virus strains and drug-resistant clinical isolates. Eltrombopag also synergistically increased the anti-HCMV activity of the mainstay drug ganciclovir. Time-of-addition experiments suggested that eltrombopag interfered with HCMV replication after virus entry. Eltrombopag was effective in thrombopoietin receptor-negative cells, and the addition of Fe3+ prevented the anti-HCMV effects, indicating that it inhibits HCMV replication via iron chelation. This may be of particular interest for the treatment of cytopenias after hematopoietic stem cell transplantation, as HCMV reactivation is a major reason for transplantation failure. Since therapeutic eltrombopag concentrations are effective against drug-resistant viruses, and synergistically increase the effects of ganciclovir, eltrombopag is also a drug-repurposing candidate for the treatment of therapy-refractory HCMV disease.
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Affiliation(s)
- Jens-Uwe Vogel
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Sophie Schmidt
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Daniel Schmidt
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Florian Rothweiler
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Benjamin Koch
- Medizinische Klinik III, Nephrologie, Klinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (B.K.); (P.B.)
| | - Patrick Baer
- Medizinische Klinik III, Nephrologie, Klinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (B.K.); (P.B.)
| | - Holger Rabenau
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Detlef Michel
- Institut für Virologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (D.M.); (T.S.)
| | - Thomas Stamminger
- Institut für Virologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (D.M.); (T.S.)
| | - Martin Michaelis
- Industry Biotechnology Centre and School of Biosciences, University of Kent, Canterbury CT2 7NJ, UK
- Correspondence: (J.C.); (M.M.); Tel.: +49-69-678665-72 (J.C.); +44-1227-82-7804 (M.M.)
| | - Jindrich Cinatl
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
- Correspondence: (J.C.); (M.M.); Tel.: +49-69-678665-72 (J.C.); +44-1227-82-7804 (M.M.)
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Hernández-Sánchez JM, Bastida JM, Alonso-López D, Benito R, González-Porras JR, De Las Rivas J, Hernández Rivas JM, Rodríguez-Vicente AE. Transcriptomic analysis of patients with immune thrombocytopenia treated with eltrombopag. Platelets 2019; 31:993-1000. [PMID: 31838946 DOI: 10.1080/09537104.2019.1702156] [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: 02/07/2023]
Abstract
In the last years, the use of thrombopoietin receptor agonists (TPO-RA), eltrombopag and romiplostim, has improved the management of immune thrombocytopenia (ITP). Moreover, eltrombopag is also active in patients with aplastic anemia and myelodysplastic syndrome. However, their mechanisms of action and signaling pathways still remain controversial. In order to gain insight into the mechanisms underlying eltrombopag therapy, a gene expression profile (GEP) analysis in patients treated with this drug was carried out. Fourteen patients with chronic ITP were studied by means of microarrays before and during eltrombopag treatment. Median age was 78 years (range, 35-87 years); median baseline platelet count was 14 × 109/L (range, 2-68 × 109/L). Ten patients responded to the therapy, two cases relapsed after an initial response and the remaining two were refractory to the therapy. Eltrombopag induced relevant changes in the hematopoiesis, platelet activation and degranulation, as well as in megakaryocyte differentiation, with overexpression of some transcription factors and the genes PPBP, ITGB3, ITGA2B, F13A1, F13A1, MYL9 and ITGA2B. In addition, GP1BA, PF4, ITGA2B, MYL9, HIST1H4H and HIST1H2BH, genes regulated by RUNX1 were also significantly enriched after eltrombopag therapy. Furthermore, in non-responder patients, an overexpression of Bcl-X gene and genes involved in erythropoiesis, such as SLC4A1 and SLC25A39, was also observed. To conclude, overexpression in genes involved in megakaryopoiesis, platelet adhesion, degranulation and aggregation was observed in patients treated with eltrombopag. Moreover, an important role regarding heme metabolism was also present in non-responder patients.
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Affiliation(s)
- Jesús María Hernández-Sánchez
- Department of Hematology, Hospital Universitario Salamanca , Salamanca, Spain.,IBSAL,IBMCC-Cancer Research Center, University of Salamanca , Salamanca, Spain
| | - José María Bastida
- Department of Hematology, Hospital Universitario Salamanca , Salamanca, Spain.,IBSAL,IBMCC-Cancer Research Center, University of Salamanca , Salamanca, Spain
| | - Diego Alonso-López
- Bioinformatics Unit, Cancer Research Center (CSIC-USAL) , Salamanca, Spain
| | - Rocío Benito
- Department of Hematology, Hospital Universitario Salamanca , Salamanca, Spain.,IBSAL,IBMCC-Cancer Research Center, University of Salamanca , Salamanca, Spain
| | - José Ramón González-Porras
- Department of Hematology, Hospital Universitario Salamanca , Salamanca, Spain.,IBSAL,IBMCC-Cancer Research Center, University of Salamanca , Salamanca, Spain
| | | | - Jesús María Hernández Rivas
- Department of Hematology, Hospital Universitario Salamanca , Salamanca, Spain.,IBSAL,IBMCC-Cancer Research Center, University of Salamanca , Salamanca, Spain
| | - Ana Eugenia Rodríguez-Vicente
- Department of Hematology, Hospital Universitario Salamanca , Salamanca, Spain.,IBSAL,IBMCC-Cancer Research Center, University of Salamanca , Salamanca, Spain
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75
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Bussel J, Kulasekararaj A, Cooper N, Verma A, Steidl U, Semple JW, Will B. Mechanisms and therapeutic prospects of thrombopoietin receptor agonists. Semin Hematol 2019; 56:262-278. [PMID: 31836033 DOI: 10.1053/j.seminhematol.2019.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
The second-generation thrombopoietin (TPO) receptor agonists eltrombopag and romiplostim are potent activators of megakaryopoiesis and represent a growing treatment option for patients with thrombocytopenic hematological disorders. Both TPO receptor agonists have been approved worldwide for the treatment of children and adults with chronic immune thrombocytopenia. In the EU and USA, eltrombopag is approved for the treatment of patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy and in the USA for the first-line treatment of severe aplastic anemia in combination with immunosuppressive therapy. Eltrombopag has also shown efficacy in several other disease settings, for example, chemotherapy-induced thrombocytopenia, selected inherited thrombocytopenias, and myelodysplastic syndromes. While both TPO receptor agonists stimulate TPO receptor signaling and enhance megakaryopoiesis, their vastly different biochemical structures bestow upon them markedly different molecular and functional properties. Here, we review and discuss results from preclinical and clinical studies on the functional and molecular mechanisms of action of this new class of drug.
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Affiliation(s)
- James Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY.
| | | | | | - Amit Verma
- Albert Einstein College of Medicine, New York, NY
| | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Britta Will
- Albert Einstein College of Medicine, New York, NY.
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76
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Fattizzo B, Levati G, Cassin R, Barcellini W. Eltrombopag in Immune Thrombocytopenia, Aplastic Anemia, and Myelodysplastic Syndrome: From Megakaryopoiesis to Immunomodulation. Drugs 2019; 79:1305-1319. [PMID: 31292909 DOI: 10.1007/s40265-019-01159-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Eltrombopag is an orally available thrombopoietin receptor agonist indicated for the treatment of immune thrombocytopenia (ITP). Beyond the effect on megakaryopoiesis, the drug also showed a stimulating effect on the hematopoietic stem cell with consistent clinical efficacy in aplastic anemia (AA) and myelodysplastic syndromes (MDS). Eltrombopag is highly effective in ITP and less so in AA and MDS. This observation underlines the importance of residual normal hematopoiesis, which is maximal in ITP, minimal/absent in AA, and dysregulated in MDS. In ITP, the drug at 50-75 mg daily induced up to 85% responses both in clinical trials and real-life studies, with the possibility of tapering and discontinuation. In AA, eltrombopag at 150 mg daily was effective in about 40% of cases relapsed/refractory to standard immunosuppression or ineligible for bone marrow transplant. In MDS, the drug seems less effective, with responses in about a quarter of patients at various schedules. The efficacy of eltrombopag in ITP, AA, and MDS suggests the existence of common immune-pathological mechanisms in these diseases, including autoimmunity against peripheral blood cells and bone marrow precursors, as well as a possible evolution of one condition into the other. Additional mechanisms of action emerging from the clinical use of eltrombopag include modulation of T-regulatory cells, restoration of Fc-γ receptor balance in phagocytes, and an iron-mobilizing effect. In this review, we analyzed the most recent literature on eltrombopag use and efficacy in patients with ITP, AA, and MDS, exploring the basis for different dosing, combined treatments, and discontinuation in each context.
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Affiliation(s)
- Bruno Fattizzo
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giorgia Levati
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,University of Milan, Milan, Italy
| | - Ramona Cassin
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wilma Barcellini
- UO Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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77
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Activity of eltrombopag in severe aplastic anemia. Blood Adv 2019; 2:3054-3062. [PMID: 30425070 DOI: 10.1182/bloodadvances.2018020248] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/24/2018] [Indexed: 12/22/2022] Open
Abstract
Since the approval of horse antithymocyte globulin (ATG) decades ago, there was a long hiatus in therapies with activity in severe aplastic anemia (SAA). This scenario changed in 2014 when eltrombopag, a thrombopoietin receptor agonist, was approved for SAA after an insufficient response to initial immunosuppressive therapy (IST). The basis for this approval was the observation of single-agent activity of eltrombopag in this patient population, where 40% to 50% recovered blood counts at times involving >1 lineage. The achievement of transfusion independence confirmed the clinical benefit of this approach. Increase in marrow cellularity and CD34+ cells suggested a recovery to a more functioning bone marrow. Further in its development, eltrombopag was associated with standard horse ATG plus cyclosporine in first line, producing increases in overall (at about 90%) and complete response rates (at about 40%) and leading to transfusion independence and excellent survival. Interestingly, best results were observed when all drugs were started simultaneously. The cumulative incidence of clonal cytogenetic abnormalities to date has compared favorably with the vast experience with IST alone in SAA. Longer follow-up will help in define these long-term risks. In this review, the development of eltrombopag in SAA will be discussed.
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78
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Fattizzo B, Cavallaro F, Milesi G, Barcellini W. Iron mobilization in a real life cohort of aplastic anemia patients treated with eltrombopag. Am J Hematol 2019; 94:E237-E239. [PMID: 31172568 DOI: 10.1002/ajh.25550] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 05/30/2019] [Accepted: 06/03/2019] [Indexed: 02/02/2023]
Affiliation(s)
- Bruno Fattizzo
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoUnità di Ematologia Milano Italy
| | - Francesca Cavallaro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoUnità di Ematologia Milano Italy
| | - Giulia Milesi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoUnità di Ematologia Milano Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoUnità di Ematologia Milano Italy
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79
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Leitch HA, Gattermann N. Hematologic improvement with iron chelation therapy in myelodysplastic syndromes: Clinical data, potential mechanisms, and outstanding questions. Crit Rev Oncol Hematol 2019; 141:54-72. [DOI: 10.1016/j.critrevonc.2019.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/25/2018] [Accepted: 06/03/2019] [Indexed: 12/25/2022] Open
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80
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Christensen RD. Medicinal Uses of Hematopoietic Growth Factors in Neonatal Medicine. Handb Exp Pharmacol 2019; 261:257-283. [PMID: 31451971 DOI: 10.1007/164_2019_261] [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: 03/17/2023]
Abstract
This review focuses on certain hematopoietic growth factors that are used as medications in clinical neonatology. It is important to note at the chapter onset that although all of the pharmacological agents mentioned in this review have been approved by the US Food and Drug administration for use in humans, none have been granted a specific FDA indication for neonates. Thus, in a sense, all of the agents mentioned in this chapter could be considered experimental, when used in neonates. However, a great many of the pharmacological agents utilized routinely in neonatology practice do not have a specific FDA indication for this population of patients. Consequently, many of the agents reviewed in this chapter are considered by some practitioners to be nonexperimental and are used when they judge such use to be "best practice" for the disorders under treatment.The medicinal uses of the agents in this chapter vary considerably, between geographic locations, and sometimes even within an institutions. "Consistent approaches" aimed at using these agents in uniform ways in the practice of neonatology are encouraged. Indeed some healthcare systems, and some individual NICUs, have developed written guidelines for using these agents within the practice group. Some such guidelines are provided in this review. It should be noted that these guidelines, or "consistent approaches," must be viewed as dynamic and changing, requiring adjustment and refinement as additional evidence accrues.
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Affiliation(s)
- Robert D Christensen
- Divisions of Neonatology and Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA. .,Intermountain Healthcare, Salt Lake City, UT, USA.
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81
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Abstract
Introduction: Immune thrombocytopenia (ITP) is an autoimmune disease. Even though there are many treatments available, some patients remain resistant to multiple treatments. Therefore, it is very important to develop new treatment options. Areas covered: Here, the authors summarize several current and emerging treatments developed for ITP in recent years. They include a summary of their mechanisms of action and clinical trial results. Expert opinion: At present, the first-line treatment of ITP is glucocorticoid and intravenous immunoglobulin (IVIg). Other traditional therapies include splenectomy, thrombopoietin (TPO), rituximab and other immunosuppressive agents. The several emerging treatments developed recently for ITP may change the treatment pattern in the future.
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Affiliation(s)
- Xueqing Dou
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College , Tianjin , PR China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College , Tianjin , PR China
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82
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Ghanima W, Cooper N, Rodeghiero F, Godeau B, Bussel JB. Thrombopoietin receptor agonists: ten years later. Haematologica 2019; 104:1112-1123. [PMID: 31073079 PMCID: PMC6545830 DOI: 10.3324/haematol.2018.212845] [Citation(s) in RCA: 215] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/11/2019] [Indexed: 01/19/2023] Open
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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83
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Yamaguchi M, Hirouchi T, Yoshioka H, Watanabe J, Kashiwakura I. Diverse functions of the thrombopoietin receptor agonist romiplostim rescue individuals exposed to lethal radiation. Free Radic Biol Med 2019; 136:60-75. [PMID: 30926566 DOI: 10.1016/j.freeradbiomed.2019.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/22/2019] [Accepted: 03/22/2019] [Indexed: 01/03/2023]
Abstract
In cases of radiological accidents, especially victims exposed to high-dose ionizing radiation, the administration of appropriate approved pharmaceutical drugs is the most rapid medical treatment. However, currently, there are no suitable candidates. The thrombopoietin receptor (TPOR) agonist romiplostim (RP) is a therapeutic agent for immune thrombocytopenia and has potential to respond to such victims. Here, we show that RP administration in mice exposed to lethal-dose radiation leads not only to the promotion of haematopoiesis in multiple organs, including the lungs but also a reduction in damage to organs and cells. RP also causes a rapid increase in the number of mesenchymal stem cells in the spleen. In addition, RP suppresses the expression of several miRNAs involved in radiation-induced leukemogenesis, suggesting the presence of targets other than TPOR. Among the currently approved pharmaceutical drugs, RP is the most suitable candidate for victims exposed to high-dose ionizing radiation.
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Affiliation(s)
- Masaru Yamaguchi
- Department of Radiation Science, Hirosaki University Graduate School of Health Sciences, 66-1 Hon-cho, Hirosaki, Aomori, 036-8564, Japan
| | - Tokuhisa Hirouchi
- Department of Radiobiology, Institute for Environmental Sciences, 2-121 Hacchazawa, Takahoko, Rokkasho-vil. Kamikita-gun, Aomori, 039-3213, Japan
| | - Haruhiko Yoshioka
- Department of Bioscience and Laboratory Medicine, Hirosaki University Graduate School of Health Sciences, 66-1 Hon-cho, Hirosaki, Aomori, 036-8564, Japan
| | - Jun Watanabe
- Department of Bioscience and Laboratory Medicine, Hirosaki University Graduate School of Health Sciences, 66-1 Hon-cho, Hirosaki, Aomori, 036-8564, Japan
| | - Ikuo Kashiwakura
- Department of Radiation Science, Hirosaki University Graduate School of Health Sciences, 66-1 Hon-cho, Hirosaki, Aomori, 036-8564, Japan.
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84
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Caillon H, Peterlin P, Chevallier P, Guillaume T, Lebourgeois A, Garnier A, Ropert-Bouchet M, Dejoie T. Eltrombopag induces major non-toxic hypersiderraemia. Br J Haematol 2019; 186:365-366. [PMID: 30873599 DOI: 10.1111/bjh.15863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Hélène Caillon
- Department of Biochemistry, Nantes University Hospital, Nantes, France
| | - Pierre Peterlin
- Clinic of Haematology, Nantes University Hospital, Nantes, France
| | | | | | | | - Alice Garnier
- Clinic of Haematology, Nantes University Hospital, Nantes, France
| | | | - Thomas Dejoie
- Department of Biochemistry, Nantes University Hospital, Nantes, France
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85
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Eltrombopag maintains human hematopoietic stem and progenitor cells under inflammatory conditions mediated by IFN-γ. Blood 2019; 133:2043-2055. [PMID: 30803992 DOI: 10.1182/blood-2018-11-884486] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/12/2019] [Indexed: 12/15/2022] Open
Abstract
The proinflammatory cytokine interferon-γ (IFN-γ) has been implicated in human hematopoietic stem and progenitor cell (HSPC) depletion in immune-mediated bone marrow failure syndromes. We show that IFN-γ specifically prevents full engagement of thrombopoietin (TPO), a primary positive regulator of HSPC survival, to its receptor (c-MPL) via steric occlusion of the low-affinity binding site, contributing to perturbation of TPO-induced signaling pathways and decreased survival of human HSPCs. Eltrombopag, a synthetic small molecule mimetic of TPO that interacts with c-MPL at a position distinct from the extracellular binding site of TPO, bypasses this inhibition, providing an explanation for its clinical activity in bone marrow failure, despite already elevated endogenous TPO levels. Thus, IFN-γ-mediated perturbation of TPO:c-MPL complex formation and the resulting inhibition of a critical pathway of growth factor cell signaling may represent a general mechanism by which IFN-γ impairs the function of human HSPCs. This understanding could have broad therapeutic implications for various disorders of chronic inflammation.
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86
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Eltrombopag for use in children with immune thrombocytopenia. Blood Adv 2019; 2:454-461. [PMID: 29487060 DOI: 10.1182/bloodadvances.2017010660] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/22/2018] [Indexed: 01/19/2023] Open
Abstract
Eltrombopag is currently the only US Food and Drug Administration-approved thrombopoietin receptor agonist for the treatment of chronic immune thrombocytopenia (ITP) in children. This oral, once-per-day therapy has shown favorable efficacy and adverse effect profiles in children. Two multicenter, double-blind, placebo controlled clinical trials (PETIT [Efficacy and Safety Study of Eltrombopag in Pediatric Patients With Thrombocytopenia From Chronic Idiopathic Thrombocytopenic Purpura (ITP)] and PETIT2 [Study of a New Medication for Childhood Chronic Immune Thrombocytopenia (ITP), a Blood Disorder of Low Platelet Counts That Can Lead to Bruising Easily, Bleeding Gums, and/or Bleeding Inside the Body]) demonstrated efficacy in raising platelet counts, reducing bleeding, and reducing the need for concomitant ITP therapies with relatively few adverse effects. The most commonly reported drug-related adverse effects include headache, nausea, and hepatobiliary laboratory abnormalities. Long-term safety data in children are limited, and studies in adults have not revealed a clinically significant increased incidence of thrombosis, marrow fibrosis, or cataract formation. Eltrombopag has also been approved for treating refractory severe aplastic anemia (AA) and has potential for expanded use in ITP and severe AA as well as in other conditions associated with thrombocytopenia.
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87
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Decrement in Cellular Iron and Reactive Oxygen Species, and Improvement of Insulin Secretion in a Pancreatic Cell Line Using Green Tea Extract. Pancreas 2019; 48:636-643. [PMID: 31091209 PMCID: PMC6553981 DOI: 10.1097/mpa.0000000000001320] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES We have investigated the efficacy of mono- and combined therapy with green tea extract (GTE) in mobilizing redox iron, scavenging reactive oxygen species (ROS), and improving insulin production in iron-loaded pancreatic cells. METHODS Rat insulinoma pancreatic β-cells were iron-loaded using culture medium supplemented with either fetal bovine serum or ferric ammonium citrate and treated with various doses of GTE for epigallocatechin-3-gallate (EGCG) equivalence and in combination with iron chelators. Cellular iron, ROS, and secretory insulin were measured. RESULTS The rat insulinoma pancreatic cells took up iron from fetal bovine serum more rapidly than ferric ammonium citrate. After treatment with GTE (0.23-2.29 μg EGCG equivalent), cellular levels of iron and ROS were dose dependently decreased. Importantly, secretory insulin levels were increased nearly 2.5-fold with 2.29 μg of EGCG equivalent GTE, indicating a recovery in insulin production. CONCLUSIONS Green tea EGCG ameliorated oxidative damage of iron-loaded β-cells by removing redox iron and free radicals and attenuating insulin production. The impact can result in the restoration of pancreatic functions and an increase in insulin production. Green tea extract exerts iron-chelating, free-radical scavenging, and pancreato-protective effects in the restoration of β-cell functions, all of which we believe can increase insulin production in diabetic β-thalassemia patients.
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Abstract
The relationship between blood transfusion intensity, chelatable iron pools, and extrahepatic iron distribution is described in thalassemia. Risk factors for cardiosiderosis are discussed with particular reference to the balance of transfusional iron loading rate and transferrin-iron utilization rate as marked by plasma levels of soluble transferrin receptors. Low transfusion regimens increase residual erythropoiesis allowing for apotransferrin-dependent clearance of non-transferrin-bound iron species otherwise destined for myocardium. The impact of transfusion rates on chelation dosing required for iron balance is also shown.
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Affiliation(s)
- John B Porter
- Haematology Department, University College London, UCLH and Whittington Hospitals, UCL Cancer Institute, Paul O'Gorman Building, 72 Huntley Street, London WC1E 6BT, UK.
| | - Maciej W Garbowski
- Haematology Department, University College London, Cancer Institute, UCL Cancer Institute, Paul O'Gorman Building, 72 Huntley Street, London WC1E 6BT, UK
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Iron chelating properties of Eltrombopag: Investigating its role in thalassemia-induced osteoporosis. PLoS One 2018; 13:e0208102. [PMID: 30507954 PMCID: PMC6277068 DOI: 10.1371/journal.pone.0208102] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/12/2018] [Indexed: 12/18/2022] Open
Abstract
Chronic blood transfusions are responsible to cause iron overload, which leads to several complications to end organs and osteoporosis. Iron chelation is needed to remove iron excess and to contain bone-mass loss. Deferasirox is the most recent oral iron chelator that prevents transfusion related iron overload complications. Recently Eltrombopag (ELT) iron chelating properties are emerging. ELT is an agonist at Thrombopoietin receptor, used in treatment of thrombocytopenia. We tested ELT and Deferasirox in iron overloaded osteoclasts from thalassemic patients and donors measuring intracellular iron, TRAP expression and osteoclast activity. We confirmed ELT iron chelation capacity also in bone tissue and a synergic effect when used with Deferasirox. Moreover, having demonstrated its effects on osteoclast activity, we suggest for the first time that ELT could ameliorate bone tissue’s health reducing bone mass loss.
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90
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Scheinberg P. Activity of eltrombopag in severe aplastic anemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:450-456. [PMID: 30504345 PMCID: PMC6245975 DOI: 10.1182/asheducation-2018.1.450] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Since the approval of horse antithymocyte globulin (ATG) decades ago, there was a long hiatus in therapies with activity in severe aplastic anemia (SAA). This scenario changed in 2014 when eltrombopag, a thrombopoietin receptor agonist, was approved for SAA after an insufficient response to initial immunosuppressive therapy (IST). The basis for this approval was the observation of single-agent activity of eltrombopag in this patient population, where 40% to 50% recovered blood counts at times involving >1 lineage. The achievement of transfusion independence confirmed the clinical benefit of this approach. Increase in marrow cellularity and CD34+ cells suggested a recovery to a more functioning bone marrow. Further in its development, eltrombopag was associated with standard horse ATG plus cyclosporine in first line, producing increases in overall (at about 90%) and complete response rates (at about 40%) and leading to transfusion independence and excellent survival. Interestingly, best results were observed when all drugs were started simultaneously. The cumulative incidence of clonal cytogenetic abnormalities to date has compared favorably with the vast experience with IST alone in SAA. Longer follow-up will help in define these long-term risks. In this review, the development of eltrombopag in SAA will be discussed.
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Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, Sao Paulo, Brazil
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91
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Koonyosying P, Kongkarnka S, Uthaipibull C, Svasti S, Fucharoen S, Srichairatanakool S. Green tea extract modulates oxidative tissue injury in beta-thalassemic mice by chelation of redox iron and inhibition of lipid peroxidation. Biomed Pharmacother 2018; 108:1694-1702. [PMID: 30372872 DOI: 10.1016/j.biopha.2018.10.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 09/10/2018] [Accepted: 10/03/2018] [Indexed: 02/08/2023] Open
Abstract
Iron overload in patients with β-thalassemia can cause oxidative organ dysfunction. Iron chelation along with antioxidant supplementation can ameliorate such complications and prolong lives. Green tea extract (GTE) rich in epigallocatechin-3-gallate (EGCG) exhibits anti-oxidation and iron chelation properties in β-knockout thalassemic (BKO) mice diagnosed with iron overload. We investigated the effects of GTE and deferiprone (DFP) alone in combination with one another, and upon the levels of redox-active iron, lipid-peroxidation product, insulin and hepcidin in BKO mice. A state of iron overload was induced in the mice via a trimethylhexanoyl-ferrocene supplemented (Fe) diet for 3 months, and the mice were treated daily with either: DFP (50 mg/kg), DFP (50 mg/kg) plus GTE (50 mg EGCG equivalent/kg), or GTE alone for 2 months. Plasma non-transferrin bound iron (NTBI), malondialdehyde (MDA), alanine aminotransferase (ALT), aspartate aminotransferase (AST), hepcidin and insulin; tissue iron and MDA were measured. DFP, GTE and GTE + DFP effectively decreased plasma MDA (p < 0.05), NTBI and ALT, and increased plasma hepcidin and insulin. All the treatments also reduced iron accumulation and MDA production in both the pancreas and liver in the mice. However, the combination therapy demonstrated no advantages over monotherapy. The findings suggest GTE improved liver and pancreatic β-cell functions in iron-overloaded β-thalassemia mice by diminishing redox iron and free radicals, while inhibiting lipid peroxidation. Consequently, there are indications that GTE holds significant potential for clinical use.
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Affiliation(s)
- Pimpisid Koonyosying
- Department of Biochemistry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sarawut Kongkarnka
- Department of Pathology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chairat Uthaipibull
- Protein-Ligand Engineering and Molecular Biology Laboratory, National Center for Genetic Engineering and Biotechnology (BIOTEC), National Science and Technology Development Agency, Thailand Science Park, Pathum Thani, Thailand
| | - Saovaros Svasti
- Thalassemia Research Center, Institute of Molecular Bioscience, Mahidol University Salaya Campus, Nakornpathom, Thailand
| | - Suthat Fucharoen
- Thalassemia Research Center, Institute of Molecular Bioscience, Mahidol University Salaya Campus, Nakornpathom, Thailand
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Leitch HA, Buckstein R, Zhu N, Nevill TJ, Yee KWL, Leber B, Keating MM, St Hilaire E, Kumar R, Delage R, Geddes M, Storring JM, Shamy A, Elemary M, Wells RA. Iron overload in myelodysplastic syndromes: Evidence based guidelines from the Canadian consortium on MDS. Leuk Res 2018; 74:21-41. [PMID: 30286330 DOI: 10.1016/j.leukres.2018.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/08/2018] [Accepted: 09/15/2018] [Indexed: 01/19/2023]
Abstract
In 2008 the first evidence-based Canadian consensus guideline addressing the diagnosis, monitoring and management of transfusional iron overload in patients with myelodysplastic syndromes (MDS) was published. The Canadian Consortium on MDS, comprised of hematologists from across Canada with a clinical and academic interest in MDS, reconvened to update these guidelines. A literature search was updated in 2017; topics reviewed include mechanisms of iron overload induced cellular damage, evidence for clinical endpoints impacted by iron overload including organ dysfunction, infections, marrow failure, overall survival, acute myeloid leukemia progression, and endpoints around hematopoietic stem-cell transplant. Evidence for an impact of iron reduction on the same endpoints is discussed, guidelines are updated, and areas identified where evidence is suboptimal. The guidelines address common questions around the diagnosis, workup and management of iron overload in clinical practice, and take the approach of who, when, why and how to treat iron overload in MDS. Practical recommendations for treatment and monitoring are made. Evidence levels and grading of recommendations are provided for all clinical endpoints examined.
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Affiliation(s)
- Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada.
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nancy Zhu
- Hematology/Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas J Nevill
- Leukemia/BMT Program of British Columbia, Division of Hematology, Vancouver, BC, Canada
| | - Karen W L Yee
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Brian Leber
- McMaster University, Hamilton, Ontario, Canada
| | | | - Eve St Hilaire
- Centre d'Oncologie, Dr-Leon-Richard, Moncton, New Brunswick, Canada
| | - Rajat Kumar
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Delage
- Hematology Department, Centre Hospitalier Universitaire, Laval University, Quebec, QC, Canada
| | - Michelle Geddes
- Department of Medicine/Hematology, Foothills Medical Centre, Calgary, Alberta, Canada
| | | | - April Shamy
- Sir Mortimer B Davis Hospital, McGill University, Montreal, Quebec, Canada
| | - Mohamed Elemary
- Saskatoon Cancer Center, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Kao YR, Chen J, Narayanagari SR, Todorova TI, Aivalioti MM, Ferreira M, Ramos-Marques P, Pallaud C, Mantzaris I, Shastri A, Bussel JB, Verma A, Steidl U, Will B. Thrombopoietin receptor-independent stimulation of hematopoietic stem cells by eltrombopag. Sci Transl Med 2018; 10:10/458/eaas9563. [PMID: 30209246 PMCID: PMC9899005 DOI: 10.1126/scitranslmed.aas9563] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/13/2018] [Accepted: 08/22/2018] [Indexed: 02/06/2023]
Abstract
Eltrombopag (EP), a small-molecule thrombopoietin receptor (TPO-R) agonist and potent intracellular iron chelator, has shown remarkable efficacy in stimulating sustained multilineage hematopoiesis in patients with bone marrow failure syndromes, suggesting an effect at the most immature hematopoietic stem and multipotent progenitor level. Although the functional and molecular effects of EP on megakaryopoiesis have been studied in the past, mechanistic insights into its effects on the earliest stages of hematopoiesis have been limited. We investigated the effects of EP treatment on hematopoietic stem cell (HSC) function using purified primary HSCs in separation-of-function mouse models, including a TPO-R-deficient strain, and stem cells isolated from patients undergoing TPO-R agonist treatment. Our mechanistic studies showed a stimulatory effect on stem cell self-renewal independently of TPO-R. Human and mouse HSCs responded to acute EP treatment with metabolic and gene expression alterations consistent with a reduction of intracellular labile iron pools that are essential for stem cell maintenance. Iron preloading prevented the stem cell stimulatory effects of EP. Moreover, comparative analysis of stem cells in the bone marrow of patients receiving EP showed a marked increase in the number of functional stem cells compared to patients undergoing therapy with romiplostim, another TPO-R agonist lacking an iron-chelating ability. Together, our study demonstrates that EP stimulates hematopoiesis at the stem cell level through iron chelation-mediated molecular reprogramming and indicates that labile iron pool-regulated pathways can modulate HSC function.
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Affiliation(s)
- Yun-Ruei Kao
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Jiahao Chen
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | | | - Tihomira I. Todorova
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Maria M. Aivalioti
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Mariana Ferreira
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | | | | | - Ioannis Mantzaris
- Department of Oncology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Aditi Shastri
- Department of Oncology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - James B. Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY 10065
| | - Amit Verma
- Department of Medicine, Albert Einstein College, Bronx, NY 10461,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Ulrich Steidl
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461,Department of Medicine, Albert Einstein College, Bronx, NY 10461,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY 10461,Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, Bronx, NY 10461,Corresponding authors: Britta Will or Ulrich Steidl
| | - Britta Will
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461,Department of Medicine, Albert Einstein College, Bronx, NY 10461,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY 10461,Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, Bronx, NY 10461,Corresponding authors: Britta Will or Ulrich Steidl
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94
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Basood M, Oster HS, Mittelman M. Thrombocytopenia in Patients with Myelodysplastic Syndromes: Still an Unsolved Problem. Mediterr J Hematol Infect Dis 2018; 10:e2018046. [PMID: 30002802 PMCID: PMC6039085 DOI: 10.4084/mjhid.2018.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/24/2018] [Indexed: 12/12/2022] Open
Abstract
The myelodysplastic syndromes (MDS) are a group of clonal bone marrow (BM) stem cell disorders, characterized by ineffective hematopoiesis, peripheral cytopenias, and hematologic cellular dysfunction, as well as potential transformation to acute leukemia. Thrombocytopenia is common in MDS and is associated with bleeding complications, occasionally life-threatening. Low platelet count (PLT), as well declining PLT also serves as a prognostic marker. Understanding thrombopoiesis led to the cloning of thrombopoietin, resulting in the development of platelet stimulating agents, thrombomimetics, romiplostim and eltrombopag. Both agents have been shown to increase PLT, decrease the need for platelet transfusions and reduce the number of bleeding episodes, with a reasonable tolerance. They are already approved for immune thrombocytopenia and thrombocytopenia related to liver disease. Romiplostim and eltrombopag have proven efficacy in lower- and higher-risk MDS with thrombocytopenia, as monotherapy, as well as a part of a combination, either with lenalidomide, and mainly combined with hypomethylating agents. However, safety concerns have been raised: while several trials have been completed with no evidence of disease progression, others have been early terminated due to an increased number of BM blasts and possible leukemic transformation in treated-patients. The jury is still out regarding this safety concern, although recent publications are more encouraging.
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Affiliation(s)
- May Basood
- Department of Medicine A, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
| | - Howard S Oster
- Department of Medicine A, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
| | - Moshe Mittelman
- Department of Medicine A, Tel Aviv Sourasky Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, ISRAEL
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95
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96
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Scheinberg P. Developing role of eltrombopag in the treatment of aplastic anemia. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1438260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Phillip Scheinberg
- Division of Hematology, Hospital A Beneficência Portuguesa, São Paulo, Brazil
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