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Efficacy and Immunomodulating Properties of Eltrombopag in Aplastic Anemia following Autologous Stem Cell Transplant: Case Report and Review of the Literature. Pharmaceuticals (Basel) 2022; 15:ph15040419. [PMID: 35455416 PMCID: PMC9032708 DOI: 10.3390/ph15040419] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 12/20/2022] Open
Abstract
Thrombopoietin receptor agonists (TPO-RA) are currently indicated for the treatment of chronic immune thrombocytopenia and relapsed refractory aplastic anemia. However, the off-label use of these drugs is more and more frequent, including in the setting of aplasia secondary to chemotherapy and hemopoietic stem cell transplant (SCT). Growing evidence suggests that mechanisms of action of TPO-RA go beyond the TPO-receptor stimulation and point at the immunomodulating properties of these drugs. Here, we present a case of prolonged bone marrow aplasia secondary to autologous SCT treated with eltrombopag. We describe the clinical efficacy and the immunomodulating effect of this drug on inflammatory cytokine profile and bone marrow histology. Furthermore, we provide a review of the most recent literature highlighting the efficacy and safety of TPO-RA after SCT and chemotherapy for hematologic conditions.
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2
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Thrombocytopenia and Therapeutic Strategies after Allogeneic Hematopoietic Stem Cell Transplantation. J Clin Med 2022; 11:jcm11051364. [PMID: 35268455 PMCID: PMC8911458 DOI: 10.3390/jcm11051364] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/20/2022] [Accepted: 02/28/2022] [Indexed: 02/01/2023] Open
Abstract
Thrombocytopenia following allogeneic hematopoietic stem cell transplantation is a usual complication and can lead to high morbidity and mortality. New strategies, such as the use of another graft versus host-disease prophylaxis, alternative donors, and management of infections, have improved the survival of these patients. The mechanisms are unknown; therefore, the identification of new strategies to manage this potentially serious problem is needed. Thrombopoietin receptor agonists are currently available to stimulate platelet production. Some small retrospective studies have reported their potential efficacy in an allogeneic stem cell transplant setting, confirming good tolerability. Recent studies with higher numbers of patients also support their safety and efficacy in this setting, hence establishing the use of these drugs as a promising strategy for this post-transplant complication. However, prospective trials are needed to confirm these results.
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Eltrombopag in the treatment of patients with persistent thrombocytopenia after haploidentical peripheral blood stem cell transplantation: a single-center experience. Ann Hematol 2021; 101:397-408. [PMID: 34735613 DOI: 10.1007/s00277-021-04706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
Persistent thrombocytopenia (PT) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is associated with an increased risk of bleeding and poor survival. The exact pathogenesis underlying PT remains unclear, and its management is difficult. Here we conducted a retrospective study to evaluate the efficacy and safety of eltrombopag (EPAG) in 34 patients with PT after allo-HSCT. Seven patients suffered from prolonged isolated thrombocytopenia (PIT), and 27 had secondary failure of platelet recovery (SFPR). For most patients, the initial dose was 25 mg or 50 mg daily, then adjusted to the maximum dose of 50-100 mg per day according to the response of platelet recovery and toleration of patients. The cumulative incidence (CI) of platelet recovery to at least 20 × 109/L and 50 × 109/L without transfusion support for at least 7 days was 72.1% and 60.7%, respectively. Nineteen (86.4%) of 22 responders were able to taper off the medication; furthermore, the platelet counts remained stable 1 month after withdrawal of EPAG. Although two patients discontinued EPAG during treatment due to headache and nausea, no patients developed grade 3 or 4 toxicities. Hypoplasia of bone marrow and decreased megakaryocytes (MKs) were found to be risk factors for overall response (OR) and complete response (CR) in multivariate analysis, respectively. Overall, our results indicated that EPAG can be used in the treatment of PT and that continuous exposure to EPAG may not be necessary.
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Eltrombopag for the treatment of poor graft function following allogeneic stem cell transplant: a retrospective multicenter study. Int J Hematol 2021; 114:228-234. [PMID: 33886103 DOI: 10.1007/s12185-021-03153-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
This retrospective study assessed the effectiveness of eltrombopag (EPAG), a thrombopoietin receptor agonist, in the treatment of poor graft function (PGF) following an allogeneic haemopoietic stem cell transplantation (HSCT). Complete response was defined as normalization of blood counts, whereas partial response was defined as transfusion independence. A total of 48 patients with full donor chimerism after HSCT, received EPAG for a median of 120 days (range 10-591). Patients with uni- bi- or tri-lineage cytopenia started treatment at a median of 95 days (range 17-877) after HSCT. The overall response rate was 75%: 24 patients had a complete response and 12 had a partial response. Positive predictors of response were an HLA-matched donor, a CD34+ dose at transplant > 4 × 106/kg, and starting EPAG treatment at least 90 days after HSCT. Patients with more than one positive predictor had a response rate of 92% for the overall patient cohort and 94% for patients with tri-lineage cytopenia. One-year survival was 89% for complete responders, 60% for partial responders and 20% for non-responders (p = 0.0004). EPAG improves peripheral blood counts in patients with poor graft function following HSCT. Response to EPAG can be predicted and has a significant impact on survival.
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Christakopoulos GE, DeFor TE, Hage S, Wagner JE, Linden MA, Brunstein C, Bejanyan N, Verneris MR, Smith AR. Phase I Dose-Finding, Safety, and Tolerability Trial of Romiplostim to Improve Platelet Recovery After UCB Transplantation. Transplant Cell Ther 2021; 27:497.e1-497.e6. [PMID: 33785364 DOI: 10.1016/j.jtct.2021.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/22/2020] [Accepted: 02/26/2021] [Indexed: 11/18/2022]
Abstract
Platelet recovery is delayed after umbilical cord blood transplant (UCBT). Romiplostim is a thrombopoietin receptor agonist that has the potential to improve platelet engraftment after UCBT. The purpose of this study was to determine the safety profile and maximum tolerated dose (MTD) of romiplostim and to investigate whether romiplostim accelerates platelet recovery post-UCBT. It was a single-center, dose-finding, safety and tolerability phase I trial of weekly romiplostim in 20 adult patients who failed to achieve an un-transfused platelet count of 20 × 109/L by day +28 post-UCBT. Romiplostim was administered at the assigned dose as 6 weekly injections beginning by day +42 post-UCBT. Four dose levels (4, 6, 8, and 10 µg/kg per dose) were evaluated. The MTD of romiplostim was determined by the continual reassessment method, with a goal to identify a dose level with desired toxicity rate of ≤20%. Median age of the patients was 59.5 years, and 60% were female. Eleven patients received nonmyeloablative (NMA) double UCBT, seven patients received myeloablative single UCBT, and two patients received NMA single UCBT. Two patients received 4 µg/kg per dose, two received 6 µg/kg per dose, four received 8 µg/kg per dose, and the remaining 12 received 10 µg/kg per dose. Only five patients completed the full six doses of treatment. Of the 15 patients who received fewer than six doses, 12 were due to a platelet count of >100 × 109/L, two were due to platelet count of >400 × 109/L, and one was due to right upper extremity edema without thrombosis. All romiplostim-treated patients achieved platelet engraftment to 20 × 109/L at a median of 45 days post-UCBT compared to 90% of controls at a median of 45 days (P = .08). Similarly, 90% of romiplostim-treated patients achieved platelet engraftment to 50 × 109/L at a median of 48 days compared to 75% of controls at a median of 52 days (P = .09). All dose levels were effective with low toxicity; therefore, the MTD of romiplostim was 10 µg/kg per dose, and romiplostim is a safe and potentially effective therapy to counter delayed platelet recovery post-UCBT.
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Affiliation(s)
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Stefanie Hage
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - John E Wagner
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Michael A Linden
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Claudio Brunstein
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Nelli Bejanyan
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Michael R Verneris
- Division of Hematology, Oncology, and Bone Marrow Transplantation, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Angela R Smith
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota.
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6
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Samarkandi H, Al Nahedh M, Alfattani A, Alsharif F, Bakshi N, Rasheed W, Alfraih F, Alhumaid M, Alkhudair N, Alhayli S, Alsaedi H, Shaheen M, Hanbali A, Hashmi SK, Devol E, Alseraihy A, Alzahrani H, Aljurf M. Evaluation of eltrombopag in thrombocytopenia post Hematopoietic cell transplantation: Rertrospective observational trial. Hematol Oncol Stem Cell Ther 2020; 15:285-290. [PMID: 32755559 DOI: 10.1016/j.hemonc.2020.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Thrombocytopenia remains a life-threatening late complication of HCT with an incidence of 5-20%. Currently, there is no approved drug for the treatment of persistent thrombocytopenia post HCT and platelet transfusion is the maintain stay of treatment. Eltrombopag is approved for the treatment of thrombocytopenia associated with different diseases, however; data on eltrombopag treatment post HCT are limited. METHODS This is a retrospective cohort study evaluating the effect of eltrombopag on platelet recovery in patients with persistent thrombocytopenia post HCT. The primary endpoint was platelet recovery to ≥ 20,000/μL for 7 consecutive days without transfusion support after starting eltrombopag. Secondary endpoint was platelet recovery to ≥ 50,000/μL for 7 consecutive days. RESULTS Twenty-one patients were included. Twelve (75%) of 16 patients became independent from platelet transfusions. Median time from starting eltrombopag to last transfusion was 60 days (range, 9-226 days). Ten (63%) of 16 transfusion dependent patients with platelet count < 20,000/μL achieved the primary endpoint. Seven (33%) patients of 21 included had successful platelet recovery (ie, ≥50,000/μL without transfusion support) and the median time to platelet recovery in patients who achieved it was 32 days (range, 13-265 days). Ten patients (48%) were able to successfully discontinue eltrombopag without recurrence of thrombocytopenia. CONCLUSION Our findings demonstrated that eltrombopag appears to have a clinically significant impact on platelet recovery in persistent thrombocytopenic patients post HCT.
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Affiliation(s)
- H Samarkandi
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Al Nahedh
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - A Alfattani
- Biostatistics Epidemiology and Scientific Computing Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - F Alsharif
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - N Bakshi
- Pathology and Laboratory Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - W Rasheed
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - F Alfraih
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Alhumaid
- Oncology Centre, King Saud Medical City, Riyadh, Saudi Arabia
| | - Nora Alkhudair
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - S Alhayli
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - H Alsaedi
- Pediatric Hematology/Oncology Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Shaheen
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - A Hanbali
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - S K Hashmi
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - E Devol
- Biostatistics Epidemiology and Scientific Computing Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - A Alseraihy
- Pediatric Hematology/Oncology Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - H Alzahrani
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Aljurf
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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7
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Mahat U, Rotz SJ, Hanna R. Use of Thrombopoietin Receptor Agonists in Prolonged Thrombocytopenia after Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:e65-e73. [DOI: 10.1016/j.bbmt.2019.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 01/09/2023]
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8
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Bento L, Bastida JM, García-Cadenas I, García-Torres E, Rivera D, Bosch-Vilaseca A, De Miguel C, Martínez-Muñoz ME, Fernández-Avilés F, Roldán E, Chinea A, Yáñez L, Zudaire T, Vaz CP, Espigado I, López J, Valcárcel D, Duarte R, Cabrera R, Herrera C, González-Porras JR, Gutiérrez A, Solano C, Sampol A. Thrombopoietin Receptor Agonists for Severe Thrombocytopenia after Allogeneic Stem Cell Transplantation: Experience of the Spanish Group of Hematopoietic Stem Cell Transplant. Biol Blood Marrow Transplant 2019; 25:1825-1831. [PMID: 31152794 DOI: 10.1016/j.bbmt.2019.05.023] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/15/2019] [Accepted: 05/22/2019] [Indexed: 12/11/2022]
Abstract
Persistent thrombocytopenia is a common complication after allogeneic hematopoietic stem cell transplantation (allo-SCT). Romiplostim and eltrombopag are the currently available thrombopoietin receptor agonists (TPO-RAs), and some studies with very small numbers of cases have reported their potential efficacy in the allo-SCT setting. The present retrospective study evaluated the safety and efficacy of TPO-RAs in 86 patients with persistent thrombocytopenia after allo-HSCT. Sixteen patients (19%) had isolated thrombocytopenia (PT), and 71 (82%) had secondary failure of platelet recovery (SFPR). TPO-RA therapy was started at a median of 127 days (range, 27 to 1177 days) after allo-SCT. The median initial and maximum administered doses were 50 mg/day (range, 25 to 150 mg/day) and 75 mg/day (range, 25 to 150 mg/day), respectively, for eltrombopag and 1 µg/kg (range, 1 to 7 µg/kg) and 5 µg/kg (range, 1 to 10 µg/kg), respectively, for romiplostin. The median platelet count before initiation of TPO-RA therapy was 14,000/µL (range, 1000 to 57,000/µL). Platelet recovery to ≥50,000/µL without transfusion support was achieved in 72% of patients at a median time of 66 days (range, 2 to 247 days). Eighty-one percent of the patients had a decreased number of megakaryocytes before treatment, showing a slower response to therapy (P = .011). The median duration of treatment was 62 days (range, 7 to 700 days). Grade 3-4 adverse events (hepatic and asthenia) were observed in only 2% of the patients. At last follow-up, 81% of patients had discontinued TPO-RAs and maintained response, and 71% were alive. To our knowledge, this is the largest series analyzing the use of TPO-RAs after allo-SCT reported to date. Our results support the efficacy and safety in this new setting. Further prospective trials are needed to increase the level of evidence and to identify predictors of response.
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Affiliation(s)
- Leyre Bento
- Hematology Department, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Islas Baleares, Palma de Mallorca, Spain.
| | - José María Bastida
- Hematology Department, Hospital Universitario de Salamanca, Salamanca, Spain
| | | | | | - Daniel Rivera
- Hematology Department, Hospital Universitario de Salamanca, Salamanca, Spain
| | | | - Carlos De Miguel
- Hematology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | | - Elisa Roldán
- Hematology Department, Hospital Vall D'hebron, Barcelona, Spain
| | - Anabelle Chinea
- Hematology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Lucrecia Yáñez
- Hematology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Teresa Zudaire
- Hematology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Carlos Pinho Vaz
- Hematology Department, Instituto Português de Oncologia, Oporto, Spain
| | | | - Javier López
- Hematology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - David Valcárcel
- Hematology Department, Hospital Vall D'hebron, Barcelona, Spain
| | - Rafael Duarte
- Hematology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Rafael Cabrera
- Hematology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Concepción Herrera
- Hematology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | | | - Antonio Gutiérrez
- Hematology Department, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Islas Baleares, Palma de Mallorca, Spain
| | | | - Antonia Sampol
- Hematology Department, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Islas Baleares, Palma de Mallorca, Spain
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9
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Yuan C, Boyd AM, Nelson J, Patel RD, Varela JC, Goldstein SC, Ahmad S, Zhu X, Mori S. Eltrombopag for Treating Thrombocytopenia after Allogeneic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1320-1324. [PMID: 30710685 DOI: 10.1016/j.bbmt.2019.01.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/22/2019] [Indexed: 01/18/2023]
Abstract
Thrombocytopenia after allogeneic hematopoietic stem cell transplantation (allo-SCT) can pose significant problems in management of patients. Eltrombopag is a small-molecule thrombopoietin receptor agonist that has been approved for use in immune thrombocytopenic purpura and aplastic anemia; but its use after allo-SCT is limited. Between 2014 and 2017, we treated 13 patients with eltrombopag for poor platelet engraftment without evidence of relapse at the time of initiation, including 6 patients with primary platelet engraftment failure and 7 with secondary platelet engraftment failure. Eltrombopag was started at an initial dose of 25 or 50 mg per day, and dose adjustments were made in accordance with the manufacturer's recommendation. The cumulative incidence of platelet recovery to ≥50,000/μL without the need for transfusion for at least 7 days was defined as response. The overall response rate was 62% (n = 8). Of the 6 patients with primary isolated platelet failure, 3 (50%) responded, and of the 7 patients with secondary platelet failure, 5 (71%) responded. The median time to response was 33 days (range, 11 to 68 days). In addition, no significant differences in platelet recovery were noted in patients with adequate and decreased bone marrow megakaryocytic reserve (60% and 67%, respectively). Although eltrombopag was well tolerated, and no patient discontinued treatment because of adverse events, only 3 patients were alive at the end of the observation period, with relapse and graft-versus-host disease accounting for majority of the deaths. This suggested that despite the relatively good overall response rate to eltrombopag, inadequate platelet engraftment is a harbinger of poor outcome in allo-SCT.
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Affiliation(s)
- Cai Yuan
- Department of Hematology and Oncology, University of Florida, Gainesville, Florida
| | - Angela M Boyd
- Pharmacy Department, Florida Hospital, Orlando, Florida
| | - Jan Nelson
- Pharmacy Department, Florida Hospital, Orlando, Florida
| | - Rushang D Patel
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida
| | - Juan C Varela
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida
| | - Steven C Goldstein
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Florida Hospital Cancer Institute, Orlando, Florida
| | - Xiang Zhu
- Center for Collaborative Research, Florida Hospital, Orlando, Florida
| | - Shahram Mori
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida.
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10
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Eltrombopag for post-transplant cytopenias due to poor graft function. Bone Marrow Transplant 2019; 54:1346-1353. [PMID: 30679824 DOI: 10.1038/s41409-019-0442-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 01/06/2023]
Abstract
Persistent cytopenia due to poor graft function (PoGF) is a relatively common complication which may affect up to 20% of patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Treatment options for PoGF remain limited, and reinfusion of additional HSC is often the only way to rescue hematopoiesis. Here we describe a retrospective single-center experience with the thrombopoietin-mimetic agent eltrombopag for the treatment of PoGF. Thirteen patients have received eltrombopag for either PoGF (n = 12) or primary graft failure (n = 1). In the 12 PoGF patients eltrombopag was started at the median time of 79 days after HSCT, due to persistent thrombocytopenia, with concomitant anemia and neutropenia in 7 and 3 patients, respectively. The treatment was started at the dose of 50 mg per day, and eventually increased up to 150 mg in case of lack of response. Hematological response was seen in 7 patients, with 6 complete responses. Hematological responses were seen both in patients with evidence of immune-mediated pathophysiology, and with possible infectious/iatrogenic causes. In responding patients, eltrombopag was discontinued in 6/7 patients without further relapse. These results suggest that eltrombopag is safe and possibly effective in the setting of the treatment of PoGF, and pave the way for future prospective studies.
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11
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Eltrombopag is an effective and safe therapy for refractory thrombocytopenia after haploidentical hematopoietic stem cell transplantation. Bone Marrow Transplant 2019; 54:1310-1318. [PMID: 30664724 DOI: 10.1038/s41409-019-0435-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/20/2018] [Accepted: 12/23/2018] [Indexed: 12/13/2022]
Abstract
Refractory thrombocytopenia is a frequent and severe complication after haploidentical allogeneic hematopoietic stem cell transplantation (haplo-HSCT) and lacks effective treatment strategies. Eltrombopag has shown promising results in several thrombocytopenia disorders. We report 38 patients treated with eltrombopag for refractory thrombocytopenia after haplo-HSCT. Eight patients had delayed platelet engraftment, 15 patients had secondary failure of platelet recovery, and 15 patients had poor graft function (PGF). Eltrombopag was initiated at 25 or 50 mg daily, and the dosage was adjusted to a maximum of 50-100 mg daily to maintain platelet between 50 × 109/L and 100 × 109/L. The cumulative incidence of platelet recovery to transfusion independence was 63.2% and to ≥50 × 109/L without transfusion support was 52.3%. Furthermore, neutrophil counts and hemoglobin were also increased in the nine responders with PGF. Nineteen (79.2%) of the 24 responders were able to taper off eltrombopag, and the remaining 5 patients were able to begin a taper. The median duration of treatment was 64 (range 14-195) days. The presence of megakaryocyte before initiation was the only independent factor influencing the efficacy of eltrombopag (P = 0.044). Eltrombopag was well tolerated in all patients. In summary, eltrombopag was a safe and effective therapy for refractory thrombocytopenia after haplo-HSCT.
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12
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[Eltrombopag for refractory thrombocytopenia in patients with allogeneic hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 37:1065-1069. [PMID: 28088971 PMCID: PMC7348487 DOI: 10.3760/cma.j.issn.0253-2727.2016.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
目的 观察艾曲波帕治疗异基因造血干细胞(allo-HSCT)移植后难治性血小板减少的疗效及安全性。 方法 2015年5月1日至2016年5月1日,应用艾曲波帕治疗10例allo-HSCT后难治性血小板减少(糖皮质激素等治疗无效)患者。10例患者中,男、女各5例,中位年龄34(17~54)岁。急性髓系白血病5例,急性淋巴细胞白血病3例,重型再生障碍性贫血2例。同胞HLA配型全相合移植1例,单倍型相合移植9例。allo-HSCT至接受艾曲波帕治疗的中位时间为221(73~917) d。艾曲波帕剂量为50~75 mg/d(口服)。 结果 5例(50%)患者获得完全有效(PLT≥50×109/L且脱离血小板输注),用药30 d累积完全有效率为35.7%,治疗后达到第1次PLT≥50×109/L的中位时间为16(10~56) d。至随访截止,3例完全有效患者已分别停药39、342、84 d, PLT均≥100×109/L。5例患者无效。未发生药物相关不良反应。 结论 艾曲波帕对于部分allo-HSCT后难治性血小板减少患者有效且耐受性良好,值得进一步研究。
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13
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Ali S, Gassas A, Kirby-Allen M, Krueger J, Ali M, Schechter T. Eltrombopag for secondary failure of platelet recovery post-allogeneic hematopoietic stem cell transplant in children. Pediatr Transplant 2017; 21. [PMID: 28653480 DOI: 10.1111/petr.13017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2017] [Indexed: 01/04/2023]
Abstract
Secondary failure of platelet engraftment occurs in 20% of patients undergoing allogeneic HSCT and is associated with poor outcome. Currently, there are no guidelines for treatment of late thrombocytopenia and platelet transfusion is the mainstay of treatment. Here, we describe the use of Eltrombopag to treat secondary failure of platelet recovery following HSCT in a child with severe aplastic anemia. Eltrombopag resulted in recovery of platelet count with no need for platelet transfusion support with no reported side effects. Eltrombopag may be used successfully in children with secondary failure of platelet recovery post-HSCT for SAA.
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Affiliation(s)
- Salah Ali
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Adam Gassas
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Kirby-Allen
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Joerg Krueger
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Ali
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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14
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Huang N, Lou M, Liu H, Avila C, Ma Y. Identification of a potent small molecule capable of regulating polyploidization, megakaryocyte maturation, and platelet production. J Hematol Oncol 2016; 9:136. [PMID: 27927231 PMCID: PMC5143458 DOI: 10.1186/s13045-016-0358-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/11/2016] [Indexed: 12/21/2022] Open
Abstract
Background Megakaryocytic cell maturation involves polyploidization, and megakaryocyte (MK) ploidy correlates with their maturation and platelet production. Retardation of MK maturation is closely associated with poor MK engraftment after cord blood transplantation and neonatal thrombocytopenia. Despite the high prevalence of thrombocytopenia in a range of setting that affect infants to adults, there are still very limited modalities of treatment. Methods Human CD34+ cells were isolated from cord blood or bone marrow samples acquired from consenting patients. Cells were cultured and induced using 616452 and compared to current drugs on the market such as rominplostim or TPO. Ploidy analysis was completed using propidium iodide staining and flow cytometry analysis. Animal studies consisted of transplanting human CD34+ cells into NOD.Cg-PrkdcscidIl2rgtm1Wjl/SzJ mice followed by daily injections of 15 mg/kg of 616452. Results Within one week of culture, the chemical was able to induce polyploidization, the process required for megakaryocyte maturation with the accumulation of DNA content, to 64 N or greater to achieve a relative adult size. We observed fold increases as high as 200-fold in cells of 16 N or greater compared to un-induced cells with a dose-dependent manner. In addition, MK differentiated in the presence of 616452 demonstrated a more robust capacity of MK differentiation than that of MKs cultured with rominplostim used for adult idiopathic thrombocytopenic purpura (ITP) patients. In mice transplanted with human cord blood, 616452 strikingly enhanced MK reconstitution in the marrow and human peripheral platelet production. The molecular therapeutic actions for this chemical may be through TPO-independent pathways. Conclusion Our studies may have an important impact on our fundamental understanding of fetal MK biology, the clinical management of thrombocytopenic neonates and leukemic differentiation therapy. Electronic supplementary material The online version of this article (doi:10.1186/s13045-016-0358-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nick Huang
- Department of Pathology, State University of New York, Stony Brook Medicine, Stony Brook, NY, 11794, USA
| | - Mabel Lou
- Department of Pathology, State University of New York, Stony Brook Medicine, Stony Brook, NY, 11794, USA
| | - Hua Liu
- Department of Pathology, State University of New York, Stony Brook Medicine, Stony Brook, NY, 11794, USA
| | - Cecilia Avila
- Department of Obstetrics & Gynecology, State University of New York, Stony Brook Medicine, Stony Brook, NY, USA
| | - Yupo Ma
- Department of Pathology, State University of New York, Stony Brook Medicine, Stony Brook, NY, 11794, USA.
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15
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Dysfonctionnement du greffon et érythroblastopénie après allogreffe de cellules souches hématopoïétiques : recommandations de la Société francophone de greffe de moelle et de thérapie cellulaire (SFGM-TC). Bull Cancer 2016; 103:S248-S254. [DOI: 10.1016/j.bulcan.2016.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 09/01/2016] [Indexed: 11/23/2022]
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16
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Tanaka T, Inamoto Y, Yamashita T, Fuji S, Okinaka K, Kurosawa S, Kim SW, Tanosaki R, Fukuda T. Eltrombopag for Treatment of Thrombocytopenia after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:919-24. [DOI: 10.1016/j.bbmt.2016.01.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/11/2016] [Indexed: 11/25/2022]
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