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Semple JW, Schifferli A, Cooper N, Saad H, Mytych DT, Chea LS, Newland A. Immune thrombocytopenia: Pathophysiology and impacts of Romiplostim treatment. Blood Rev 2024; 67:101222. [PMID: 38942688 DOI: 10.1016/j.blre.2024.101222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/04/2024] [Accepted: 06/18/2024] [Indexed: 06/30/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disease caused by immune-mediated platelet destruction and decreased platelet production. ITP is characterized by an isolated thrombocytopenia (<100 × 109/L) and increased risk of bleeding. The disease has a complex pathophysiology wherein immune tolerance breakdown leads to platelet and megakaryocyte destruction. Therapeutics such as corticosteroids, intravenous immunoglobulins (IVIg), rituximab, and thrombopoietin receptor agonists (TPO-RAs) aim to increase platelet counts to prevent hemorrhage and increase quality of life. TPO-RAs act via stimulation of TPO receptors on megakaryocytes to directly stimulate platelet production. Romiplostim is a TPO-RA that has become a mainstay in the treatment of ITP. Treatment significantly increases megakaryocyte maturation and growth leading to improved platelet production and it has recently been shown to have additional immunomodulatory effects in treated patients. This review will highlight the complex pathophysiology of ITP and discuss the usage of Romiplostim in ITP and its ability to potentially immunomodulate autoimmunity.
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Affiliation(s)
- John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden, Clinical Immunology and Transfusion Medicine, Office of Medical Services, Region Skåne, Lund, Sweden; Departments of Pharmacology, Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, USA.
| | - Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | | | | | | | | | - Adrian Newland
- Barts and The London School of Medicine and Dentistry, London, UK.
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Chiang-Wong H, González-Saldaña P. Romiplostim use in immune thrombocytopenia: Experience in Cuenca, Ecuador. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2024; 44:198-204. [PMID: 39079145 PMCID: PMC11361702 DOI: 10.7705/biomedica.7059] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 04/16/2024] [Indexed: 08/04/2024]
Abstract
Introduction. The international consensus and the American Society of Hematology guidelines from 2019 established thrombopoietin analogues as the second-line therapy for primary immune thrombocytopenia cases. Objectives. To describe romiplostim usefulness in patients with immune thrombocytopenia in a third-level hospital in Cuenca, Ecuador. Materials and methods. We conducted a descriptive and retrospective study in patients with immune thrombocytopenia treated with romiplostim. We evaluated the following variables: age, gender, previous therapies to romiplostim, dose, frequency, complications, change of thrombopoietin analogue, and treatment discontinuation. Results. We included 21 patients with immune thrombocytopenia treated with romiplostim, with a median age of 49 years. All patients received corticosteroids as first-line treatment. Three patients required longer administration intervals (over a week), with weekly doses lower than those recommended (< 1 μg/kg). Due to lack of efficacy, six patients replaced elthrombopag with romiplostim. Of the total, three suffered thrombotic complications: two had portal venous thrombosis, and one had pulmonary thromboembolism; five of the patients discontinued romiplostim scheme without resuming it. Conclusions. Romiplostim constitutes a convenient second-line therapy in immune thrombocytopenia. Despite the small sample size, romiplostim early use can minimize toxicities and infectious risks.
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Affiliation(s)
- Héctor Chiang-Wong
- Unidad de Hematología, Hospital José Carrasco Arteaga, Cuenca, EcuadorHospital José Carrasco ArteagaHospital José Carrasco ArteagaCuencaCuenca
| | - Patricio González-Saldaña
- Unidad de Patología Clínica, Hospital José Carrasco Arteaga, Cuenca, EcuadorHospital José Carrasco ArteagaHospital José Carrasco ArteagaCuencaCuenca
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3
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Barlassina A, González-López TJ, Cooper N, Zaja F. European Delphi panel to build consensus on tapering and discontinuing thrombopoietin receptor agonists in immune thrombocytopenia. Platelets 2023; 34:2170999. [PMID: 36803535 DOI: 10.1080/09537104.2023.2170999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 02/23/2023]
Abstract
To establish pan-European consensus on tapering and discontinuing thrombopoietin receptor agonists (TPO-RAs) in patients with immune thrombocytopenia (ITP), we applied a three-step Delphi technique consisting of a one-to-one interview round and two online survey rounds. Three healthcare professionals (HCPs) from Italy, Spain, and the United Kingdom formed the Steering Committee (SC), which advised on study design, panelist selection, and survey development. A literature review also informed the development of the consensus statements. Likert scales were used to collect quantitative data on panelists' level of agreement. Twelve hematologists representing nine European countries assessed 121 statements spanning three categories: (1) patient selection; (2) tapering and discontinuation strategies; (3) post-discontinuation management. Consensus was reached on approximately half of the statements in each category (32.2%; 44.6%; 66%). Panelists agreed on patients' main selection criteria, patients' involvement in decision-making, tapering strategies, and follow-up criteria. Areas not reaching consensus were risk factors and predictors of successful discontinuation, monitoring intervals, and rates of successful discontinuation or relapse. This lack of consensus signals knowledge and practice gaps among European countries and suggests the need for the development of clinical practice guidelines that outline a pan-European, evidence-based approach to tapering and discontinuing TPO-RAs.
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Affiliation(s)
- Adele Barlassina
- Patient-Centered Outcomes and Patient Engagement, OPEN Health Evidence & Access, Marlow, United Kingdom
| | | | - Nichola Cooper
- Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Francesco Zaja
- Dipartimento Clinico di Scienze Mediche, Chirurgiche e della Salute, Università degli Studi, Trieste, Italy
- UCO Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
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Li J, Karakas D, Xue F, Chen Y, Zhu G, Yucel YH, MacParland SA, Zhang H, Semple JW, Freedman J, Shi Q, Ni H. Desialylated Platelet Clearance in the Liver is a Novel Mechanism of Systemic Immunosuppression. RESEARCH (WASHINGTON, D.C.) 2023; 6:0236. [PMID: 37808178 PMCID: PMC10551749 DOI: 10.34133/research.0236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/02/2023] [Indexed: 10/10/2023]
Abstract
Platelets are small, versatile blood cells that are critical for hemostasis/thrombosis. Local platelet accumulation is a known contributor to proinflammation in various disease states. However, the anti-inflammatory/immunosuppressive potential of platelets has been poorly explored. Here, we uncovered, unexpectedly, desialylated platelets (dPLTs) down-regulated immune responses against both platelet-associated and -independent antigen challenges. Utilizing multispectral photoacoustic tomography, we tracked dPLT trafficking to gut vasculature and an exclusive Kupffer cell-mediated dPLT clearance in the liver, a process that we identified to be synergistically dependent on platelet glycoprotein Ibα and hepatic Ashwell-Morell receptor. Mechanistically, Kupffer cell clearance of dPLT potentiated a systemic immunosuppressive state with increased anti-inflammatory cytokines and circulating CD4+ regulatory T cells, abolishable by Kupffer cell depletion. Last, in a clinically relevant model of hemophilia A, presensitization with dPLT attenuated anti-factor VIII antibody production after factor VIII ( infusion. As platelet desialylation commonly occurs in daily-aged and activated platelets, these findings open new avenues toward understanding immune homeostasis and potentiate the therapeutic potential of dPLT and engineered dPLT transfusions in controlling autoimmune and alloimmune diseases.
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Affiliation(s)
- June Li
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Canadian Blood Services Centre for Innovation, Toronto, ON, Canada
| | - Danielle Karakas
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
| | - Feng Xue
- Departments of Pediatrics,
Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA
| | - Yingyu Chen
- Departments of Pediatrics,
Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA
| | - Guangheng Zhu
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
| | - Yeni H. Yucel
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Departments of Ophthalmology and Vision Sciences Medicine,
University of Toronto, Toronto, ON, Canada
- Faculty of Engineering and Architectural Science,
Ryerson University, Toronto, ON, Canada
| | - Sonya A. MacParland
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Multi-Organ Transplant Program,
Toronto General Hospital Research Institute, Toronto, ON, Canada
- Department of Immunology,
University of Toronto, Toronto, ON, Canada
| | - Haibo Zhang
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Critical Care Medicine, Department of Anesthesiology and Pain,
University of Toronto, Toronto, ON, Canada
- Department of Physiology,
University of Toronto, Toronto, ON, Canada
| | - John W. Semple
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Department of Pharmacology,
University of Toronto, Toronto, ON, Canada
- Division of Hematology and Transfusion Medicine,
Lund University, Lund, Sweden
- Clinical Immunology and Transfusion Medicine,
Office of Medical Services, Region Skåne, Lund, Sweden
| | - John Freedman
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Department of Medicine,
University of Toronto, Toronto, ON, Canada
| | - Qizhen Shi
- Departments of Pediatrics,
Medical College of Wisconsin, Milwaukee, WI, USA
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA
- Children’s Research Institute, Children’s Wisconsin, Wauwatosa, WI, USA
- Midwest Athletes Against Childhood Cancer Fund Research Center, Milwaukee, WI, USA
| | - Heyu Ni
- Department of Laboratory Medicine and Pathobiology,
University of Toronto, Toronto, ON, Canada
- Toronto Platelet Immunobiology Group, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, ON, Canada
- Canadian Blood Services Centre for Innovation, Toronto, ON, Canada
- Department of Physiology,
University of Toronto, Toronto, ON, Canada
- Department of Medicine,
University of Toronto, Toronto, ON, Canada
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5
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Schifferli A, Rüfer A, Rovo A, Nimmerjahn F, Cantoni N, Holbro A, Favre G, Dirks J, Wieland A, Faeth H, Pereira R, Kühne T. Immunomodulation with romiplostim as a second-line strategy in primary immune thrombocytopenia: The iROM study. Br J Haematol 2023; 203:119-130. [PMID: 37735543 DOI: 10.1111/bjh.19074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 09/23/2023]
Abstract
Thrombopoietin receptor agonists (TPO-RAs) stimulate platelet production, which might restore immunological tolerance in primary immune thrombocytopenia (ITP). The iROM study investigated romiplostim's immunomodulatory effects. Thirteen patients (median age, 31 years) who previously received first-line treatment received romiplostim for 22 weeks, followed by monitoring until week 52. In addition to immunological data, secondary end-points included the sustained remission off-treatment (SROT) rate at 1 year, romiplostim dose, platelet count and bleedings. Scheduled discontinuation of romiplostim and SROT were achieved in six patients with newly diagnosed ITP, whereas the remaining seven patients relapsed. Romiplostim dose titration was lower and platelet count response was stronger in patients with SROT than in relapsed patients. In all patients, regulatory T lymphocyte (Treg) counts increased until study completion and the counts were higher in patients with SROT. Interleukin (IL)-4, IL-9 and IL-17F levels decreased significantly in all patients. FOXP3 (Treg), GATA3 (Th2) mRNA expression and transforming growth factor-β levels increased in patients with SROT. Treatment with romiplostim modulates the immune system and possibly influences ITP prognosis. A rapid increase in platelet counts is likely important for inducing immune tolerance. Better outcomes might be achieved at an early stage of autoimmunity, but clinical studies are needed for confirmation.
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Affiliation(s)
- Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Axel Rüfer
- Department of Hematology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Alicia Rovo
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Falk Nimmerjahn
- Department of Biology, Institute of Genetics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Nathan Cantoni
- Department of Hematology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Andreas Holbro
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Geneviève Favre
- Department of Hematology, Cantonal Hospital Liestal, Switzerland
| | - Jan Dirks
- Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Anna Wieland
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heike Faeth
- Medical University of Basel, Basel, Switzerland
| | | | - Thomas Kühne
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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6
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González-López TJ, Schifferli A. Early immunomodulation in immune thrombocytopenia-A report of the ICIS meeting in Lenzerheide, Switzerland 2022. Br J Haematol 2023; 203:101-111. [PMID: 37735547 DOI: 10.1111/bjh.19082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/31/2023] [Indexed: 09/23/2023]
Abstract
The only way to prevent immune thrombocytopenia (ITP) from becoming refractory would be to restore tolerance to platelets at an early phase of the disease. Numerous immune alterations probably accumulate in chronic ITP; thus, the chances of cure decrease significantly with time. Currently, sustained remission off treatment (SROT) is a clinical definition describing patients who can discontinue their ITP treatment without risk and maintain a state of remission. Different treatment strategies are presently being evaluated with the goal of attaining SROT, mostly combining drugs targeting the innate and/or the adaptive immune system, the inflammation state, so as increasing the platelet load. In this sense, thrombopoietin receptor agonists (TPO-RAs) have shown promising results if used as upfront treatment. TPO-RAs seem to exhibit immunomodulation and immune tolerance properties, increasing not only the platelet antigen mass but also increasing the transforming growth factor-β concentration, and stimulating regulatory T and B lymphocytes. However, more immunological studies are needed to establish accurate molecular alterations in ITP that are potentially reversed with treatments.
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Affiliation(s)
| | - Alexandra Schifferli
- Department of Haematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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Giordano P, Lassandro G, Barone A, Cesaro S, Fotzi I, Giona F, Gorio C, Maggio A, Miano M, Marzollo A, Nardi M, Pession A, Ruggiero A, Russo G, Saracco P, Spinelli M, Tolva A, Tornesello A, Palladino V, Del Vecchio GC. Long term use of eltrombopag in children with chronic immune thrombocytopenia: extended real life retrospective multicenter experience of the Italian Association of Pediatric Hematology and Oncology. Front Med (Lausanne) 2023; 10:1214308. [PMID: 37521342 PMCID: PMC10375288 DOI: 10.3389/fmed.2023.1214308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/02/2023] [Indexed: 08/01/2023] Open
Abstract
Background The present multicenter retrospective study on eltrombopag administration in Italian children with chronic ITP aims to extend follow-up of our previous study. Materials and methods This retrospective multicenter study was conducted in 17 centers affiliated to the Italian Association of Pediatric Hematology and Oncology (AIEOP). Patients were classified into three subgroups: group 1 included patients who discontinued treatment due to a stable platelet count; group 2 included patients who discontinued treatment due to ineffectiveness; group 3 included patients who did not permanently discontinue treatment. Results 56 patients were eligible for analysis. The median duration of eltrombopag treatment was 40 months (7-71 months). Twenty patients (36%) discontinued permanently eltrombopag. The reasons of permanent discontinuation were adverse effects (n = 1), inefficacy (n = 10), stable platelet count (n = 9). All patients of group 1 maintained a durable response without additional treatments after eltrombopag discontinuation. We found that patients of group 2 were on treatment for less time (median treatment time: 13.5 months, min: 6.0 - max: 56.0) than patients of group 1 (median treatment time: 34 months, min: 16.0 - max: 62.0) (p < 0.05). Patients of group 2 mostly did not achieve a stable platelet count in the first 6 months of treatment and underwent concomitant therapies during follow-up respect of group 1 and group 3 (p < 0.01). Conclusion Our study found that the benefits of eltrombopag treatment, in terms of platelet count improvement and use of additional therapies, are identifiable from the first 6 months of treatment.
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Affiliation(s)
- Paola Giordano
- Interdisciplinary Department of Medicine, Pediatric Unit “B. Trambusti”, University of Bari Aldo Moro, Bari, Italy
| | - Giuseppe Lassandro
- Interdisciplinary Department of Medicine, Pediatric Unit “B. Trambusti”, University of Bari Aldo Moro, Bari, Italy
| | - Angelica Barone
- Department of Pediatric Onco-Hematology, University Hospital of Parma, Parma, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Ilaria Fotzi
- Department Pediatric Hematology Oncology, Azienda Ospedaliero Universitaria A. Meyer Children Hospital, Florence, Italy
| | - Fiorina Giona
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Gorio
- Hemato-Oncology Unit, Children Hospital, Spedali Civili, Brescia, Italy
| | - Angela Maggio
- Department of Hematology, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Maurizio Miano
- Clinical and Experimental Hematology Unit, “G. Gaslini” Children's Hospital, Genoa, Italy
| | - Antonio Marzollo
- Pediatric Hematology-Oncology Unit, Department of Women's and Children's Health, Azienda Ospedaliera-University of Padova, Padua, Italy
| | - Margherita Nardi
- Pediatric Hematology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Andrea Pession
- Department of Pediatrics, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Antonio Ruggiero
- Pediatric Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Giovanna Russo
- Pediatric Hemato-Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Paola Saracco
- Pediatric Hematology, Department of Pediatrics, University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Marco Spinelli
- Clinica Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alessandra Tolva
- Pediatric Hematology/Oncology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Assunta Tornesello
- Pediatric Hematology Oncology, Presidio Ospedaliero Vito Fazzi, Lecce, Italy
| | - Valentina Palladino
- Interdisciplinary Department of Medicine, Pediatric Unit “B. Trambusti”, University of Bari Aldo Moro, Bari, Italy
| | - Giovanni Carlo Del Vecchio
- Interdisciplinary Department of Medicine, Pediatric Unit “B. Trambusti”, University of Bari Aldo Moro, Bari, Italy
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Nationwide Survey on the Use of Thrombopoietin Receptor Agonists (TPO-RA) for the Management of Immune Thrombocytopenia in Current Clinical Practice in Italy. Mediterr J Hematol Infect Dis 2023; 15:e2023019. [PMID: 36908864 PMCID: PMC10000838 DOI: 10.4084/mjhid.2023.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/19/2023] [Indexed: 03/05/2023] Open
Abstract
Background Two thrombopoietin receptor agonists (TPO-RA), romiplostim and eltrombopag, are currently widely adopted as second-line ITP therapy even in the absence of robust evidence on their comparative advantages over rituximab or splenectomy or their preferential use in some specific clinical contexts. Methods An online survey was distributed between May 2021 and June 2021 to collect standardized information on TPO-RA use in Italy. Results Eighty-eight hematologists from 79 centers completed the survey. Eighty-four percent would use TPO-RA earlier than formally indicated, without a preference for young or elderly in 82% of respondents. No clear preference for either romiplostim or eltrombopag was indicated. Seventy-two percent would use TPO-RA in young patients aiming at a complete response followed by tapering, a strategy considered by only 16% in the elderly. Switching between the two agents was considered appropriate in case of insufficient response or intolerance. Tapering schedule by reducing the dosage and prolonging the intervals between administrations was preferred by 73% of respondents. TPO-RA was considered a risk factor for thrombosis by only 35%, and 94% would administer TPO-RA in elderly patients also in the presence of other thrombotic risk factors. Thirty-three percent of respondents would withdraw TPO-RA in case of thrombosis. The TPORA administration has been reported to be preferred over anti-CD20 or splenectomy by about half of the participants due to the ongoing COVID-19 pandemic. Conclusions Significant discrepancies in TPO-RA use emerged from the survey, and participants would appreciate consensus-based specific guidance on the practical use of TPO-RA.
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Cuker A, Lal L, Roy A, Elliott C, Carlyle M, Martin C, Haenig J, Viana R. Thrombopoietin receptor agonist discontinuation rates and reasons among patients with immune thrombocytopenia: a study of administrative claims linked with medical chart review. Ann Hematol 2022; 101:1915-1924. [PMID: 35849155 DOI: 10.1007/s00277-022-04888-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/04/2022] [Indexed: 11/01/2022]
Abstract
Administrative claims provide a rich data source for retrospective studies of real-world clinical practice, yet some important data may be inconsistent or unavailable. This study explored factors influencing discontinuation of thrombopoietin receptor agonists (TPO-RAs) among patients with immune thrombocytopenia (ITP), by adding medical chart abstraction for additional details. Adult (≥ 18 years) patients with continuous commercial or Medicare Advantage with Part D health insurance coverage were included. Inclusion criteria were ≥ 1 claim for eltrombopag or romiplostim and ≥ 2 diagnoses of ITP between December 31, 2017, and January 1, 2020. Providers were asked to provide access to medical charts for abstraction. The analyses included only patients who discontinued TPO-RA and described patient characteristics, treatment patterns, platelet values, and reasons for discontinuation. Among 207 ITP patients treated with a TPO-RA, 137 (66%) discontinued treatment during the observation period. The mean TPO-RA treatment duration was 185 days. Mean platelet count at the time of discontinuation was 197 × 109/L. The most common reason for discontinuation was improvement of the patient's condition (42%). Other reasons included worsening of ITP/lack of response (12%), adverse events (12%), and cost-related or social reasons (23%). No reason was reported for 10%. Notably 26% of patients who discontinued remained off all ITP therapy for the remainder of the study, with a mean treatment-free period of 262 days. These results emphasize that some patients with ITP are able to discontinue TPO-RA therapy and achieve durable treatment-free periods.
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Affiliation(s)
- Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Anuja Roy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Kim DS. Recent advances in treatments of adult immune thrombocytopenia. Blood Res 2022; 57:112-119. [PMID: 35483935 PMCID: PMC9057657 DOI: 10.5045/br.2022.2022038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 01/19/2023] Open
Abstract
Immune thrombocytopenia (ITP) is isolated thrombocytopenia characterized by autoimmune-mediated disruption of platelet without other etiologies. Treatments for chronic ITP consist of corticosteroids, intravenous immunoglobulins, anti-D immunoglobulin, rituximab, thrombopoietin receptor agonists, immunosuppressants and splenectomy. Although current therapies are effective in over two-thirds of patients, some patients are refractory to therapies or fail to achieve long-term responses. Recently, great advance has been made in identifying various mechanisms involved in ITP pathogenesis, and new treatments targeting these pathways are being developed. Novel agents such as splenic tyrosine kinase inhibitor, Bruton kinase inhibitor, plasma cell targeting therapies, neonatal Fc receptor inhibitor, platelet desialylation inhibitor, and inhibition of the classical complement pathway are expected to be effective for ITP treatment. This review summarizes current strategies and emerging therapies of ITP.
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Affiliation(s)
- Dae Sik Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
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11
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Park YH, Kim DY, Kim S, Choi YB, Shin DY, Kim JS, Lee WS, Mun YC, Jang JH, Lee JW, Kook H, Party OBOKAAW. Management of immune thrombocytopenia: 2022 update of Korean experts recommendations. Blood Res 2022; 57:20-28. [PMID: 35342042 PMCID: PMC8958378 DOI: 10.5045/br.2022.2022043] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 01/19/2023] Open
Abstract
Despite the availability of therapies to treat patients with immune thrombocytopenia (ITP), there is currently little data from randomized trials to assist clinicians in managing patients. The evidence-based guidelines of the Korean Society of Hematology Aplastic Anemia Working Party (KSHAAWP) are intended to support patients and physicians in the management of ITP. Experts from the KSHAAWP discussed and described this guideline according to the current treatment situation for ITP in Korea and finalized the guidelines. The expert panel recommended the management of ITP in adult and pediatric patients with newly diagnosed, persistent, and chronic disease refractory to first-line therapy with minor bleeding. Management approaches include observation and administration of corticosteroids, intravenous immunoglobulin, anti-D immunoglobulin, and thrombopoietin receptor agonists. Currently, evidence supporting strong recommendations for various management approaches is lacking. Therefore, a large focus was placed on shared decision-making, especially regarding second-line treatment.
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Affiliation(s)
- Young Hoon Park
- Division of Hematology-Oncology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Dae-Young Kim
- Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji Univerisity, Seoul, Korea
| | - Seongkoo Kim
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Bae Choi
- Department of Pediatrics, Ajou University School of Medicine, Ajou Univeristy Hospital, Suwon, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Won Sik Lee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Yeung-Chul Mun
- Division of Hematology-Oncology, Department of Internal Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hoon Kook
- Department of Pediatrics, Chonnam National University Hwasun Hospital, Hwasun, Korea
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12
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Autore F, Sora’ F, Chiusolo P, Minnella G, Colangelo M, Rossi E, Sica S. Chronic Myeloid Leukemia in a Patient with Previous Idiopathic Thrombocytopenic Purpura: How to Manage Imatinib Together with Eltrombopag. Medicina (B Aires) 2021; 57:medicina57121326. [PMID: 34946271 PMCID: PMC8708281 DOI: 10.3390/medicina57121326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/25/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
The occurrence of chronic myeloid leukemia (CML), or other myeloproliferative diseases, after the development of idiopathic thrombocytopenic purpura (ITP) is very rare in the current medical literature. Considering the advances in ITP management, and the wide use of new drugs for ITP and CML, we report an unusual case with this association. Our case report focused on a 64-year-old man with long-standing ITP treated with eltrombopag, who developed hyperleukocytosis during follow-up; after specific laboratory exams, it was diagnosed as CML and he began treatment with imatinib. The treatment with eltrombopag was balanced with imatinib to stabilize his platelet count. Data on bcr-abl and JAK2 transcripts were collected and revealed an optimal response with the achievement of negativization of both molecular signatures. We could demonstrate that treatment with imatinib and eltrombopag was well tolerated and allowed complete molecular remission of CML to be achieved, as well as of ITP.
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MESH Headings
- Benzoates
- Humans
- Hydrazines/therapeutic use
- Imatinib Mesylate/therapeutic use
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Male
- Middle Aged
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Pyrazoles
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Affiliation(s)
- Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Correspondence: ; Tel.: +39-06-30155300
| | - Federica Sora’
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Gessica Minnella
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
| | - Maria Colangelo
- UOC Genetica Medica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy;
| | - Elena Rossi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy; (F.S.); (P.C.); (G.M.); (E.R.); (S.S.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
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13
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Chen F, McDonald V, Newland A. Experts' review: the emerging roles of romiplostim in immune thrombocytopenia (ITP). Expert Opin Biol Ther 2021; 21:1383-1393. [PMID: 34313512 DOI: 10.1080/14712598.2021.1960979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The management of ITP has in recent years been transformed from reliance on immunosuppressants and splenectomy to targeted therapy with thrombopoietin receptor agonists (TPO-RA) that directly stimulate platelet production in the bone marrow. This has reduced the long-term infective complications and toxicities associated with the use of potent immunosuppressants and splenectomy. The welltolerated romiplostim, itself a novel drug construct called peptibody, has established itself, alongside other TPO-RA as the preferred 2nd line therapy in major international guidelines on treatment of ITP. AREAS COVERED This review summarizes the data from early licensing trials of romiplostim and discusses the real-world experience to date, the unexpected emerging data on treatment-free long-term remission achieved using TPO-RA, and the case for its early introduction in the therapeutic pathway. The emerging risk of thrombosis is also discussed. EXPERT OPINION The use of romiplostim and other TPO-RA will be increasingly brought forward in the management pathway of ITP with the prospect of modifying the long-term outcome of the disease by increasing sustained treatment-free remission. With the prospect of several new targeted therapies been introduced into clinical practice, TPO-RA will likely be a key component of future combination therapies for difficult cases.
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Affiliation(s)
- Frederick Chen
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Vickie McDonald
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry,QMUL, London, UK
| | - Adrian Newland
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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14
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Song F, Al-Samkari H. Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice. J Blood Med 2021; 12:653-664. [PMID: 34345191 PMCID: PMC8323851 DOI: 10.2147/jbm.s259101] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune process resulting in increased destruction and inadequate production of platelets that can result in bleeding, fatigue, and reduced health-related quality of life. While treatment is not required for many patients with ITP, the occurrence of bleeding manifestations, severe thrombocytopenia, and requirement for invasive procedures are among the reasons necessitating initiation of therapy. Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are typical first-line and rescue treatments, but these agents typically do not result in a durable remission in adult patients. Most patients requiring treatment therefore require subsequent line therapies, such as thrombopoietin receptor agonists (TPO-RAs), rituximab, fostamatinib, splenectomy, or a number of other immunosuppressive agents. In this focused review, we discuss management of adult ITP in the acute and chronic settings.
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Affiliation(s)
- Fei Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA.,Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
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15
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Gilreath J, Lo M, Bubalo J. Thrombopoietin Receptor Agonists (TPO-RAs): Drug Class Considerations for Pharmacists. Drugs 2021; 81:1285-1305. [PMID: 34160821 PMCID: PMC8318934 DOI: 10.1007/s40265-021-01553-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 12/11/2022]
Abstract
The thrombopoietin receptor agonists (TPO-RAs) romiplostim, eltrombopag, avatrombopag, and lusutrombopag carry unique US Food and Drug Administration (US FDA)- and European Medicines Agency (EMA)-approved indications and may be used to increase platelet counts in a variety of conditions. Current indications for available TPO-RAs include treatment of chronic immune thrombocytopenia (ITP) in cases of insufficient response to prior treatment (avatrombopag, eltrombopag, romiplostim), management of thrombocytopenia in adult patients with chronic liver disease who are scheduled to undergo a procedure (avatrombopag, lusutrombopag), management of severe aplastic anemia (eltrombopag), and management of thrombocytopenia associated with interferon-based therapy for hepatitis C (eltrombopag). Across current indications, pharmacists can assist in stabilizing platelet counts and help to reduce large undulations commonly seen when starting, stopping, or transitioning between these agents. If therapy modifications may benefit the patient, pharmacists should discuss possible changes with the patient's treatment team or treating physician. When used for ITP, romiplostim, eltrombopag, and avatrombopag stimulate TPO receptors on hematopoietic stem cells (also known as c-Mpl, or CD110) to promote platelet production; however, romiplostim is the only TPO-RA that binds at the same site as endogenous TPO. These subtle mechanistic differences may explain why switching TPO-RA may be clinically advantageous in some situations. As pharmacists are called to counsel patients on TPO-RA use, a deep understanding of potential adverse events and management strategies, as well as appropriate monitoring, will increase the likelihood that patients meet their goals of therapy in the shortest timeframe. Other uses of TPO-RAs are also discussed in this review, including use following hematopoietic stem cell transplant, use in myelodysplastic syndrome, and use in chemotherapy-induced thrombocytopenia.
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Affiliation(s)
- Jeffrey Gilreath
- Department of Pharmacotherapy, Clinical Hematology/Oncology Pharmacist, University of Utah Hospitals and Clinics Sugar House Clinic, Salt Lake City, UT, USA.
| | - Mimi Lo
- Adult Hematology/Oncology/Blood and Marrow Transplant, University of California, San Francisco Medical Center, San Francisco, CA, USA.,UCSF School of Pharmacy, San Francisco, CA, USA
| | - Joseph Bubalo
- Division of Hematology and Medical Oncology, and Oncology Clinical Pharmacist, OHSU Hospital and Clinics, Portland, OR, USA
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16
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Tian Z, Gao H, Xiao D, Li X. Immune thrombocytopenia associated with Hashimoto thyroiditis in a pediatric patient: A case report. Medicine (Baltimore) 2021; 100:e26140. [PMID: 34087867 PMCID: PMC8183690 DOI: 10.1097/md.0000000000026140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/11/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Immune thrombocytopenia (ITP) is one of the most commonly acquired bleeding diseases in children. Infection and autoimmune disorders are the most common causes of ITP. The pathogenic mechanism of ITP is complex and is not completely understood. Understanding the underlying causes or disorders of ITP will improve the prognosis and make therapy more targeted. PATIENT CONCERNS An 8-year-old girl with ITP responded poorly to first- and second-line treatment. The patient showed multiple scattered petechiae, ecchymoses, and purpura in the skin and blood clots in the oral mucous membrane. DIAGNOSES The patient was diagnosed with ITP associated with Hashimoto thyroiditis. INTERVENTIONS The patient was admitted to our emergency department and received platelet transfusion, IVIG, glucocorticoids and eltrombopag. The patient's thrombocytopenia resolved within 18 days after the administration of levothyroxine treatment. OUTCOMES The patient was diagnosed with Hashimoto thyroiditis, and the platelet count recovered on the 3rd day of levothyroxine treatment. The platelet count became steadily normal with levothyroxine and prednisone treatment within 2 months of follow-up. LESSONS Early identification of the underlying reasons and treatment with multiple modalities may be useful in improving the prognosis of ITP. The treatment of thyroid disease and restoration of the euthyroid state impact the clinical outcome of ITP in children.
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17
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Real-world use of thrombopoietin receptor agonists in elderly patients with primary immune thrombocytopenia. Blood 2021; 138:571-583. [PMID: 33889952 DOI: 10.1182/blood.2021010735] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 04/07/2021] [Indexed: 12/16/2022] Open
Abstract
The efficacy and safety of thrombopoietin-receptor agonists (TRAs) in elderly patients with primary immune thrombocytopenia (ITP) is uncertain. In 384 ITP patients treated with TRAs when aged ≥60 years, we investigated TRAs response and switch, thrombotic/hemorrhagic risk, and sustained responses off-treatment (SROT). After 3 months, 82.5% and 74.3% of eltrombopag and romiplostim-treated patients achieved a response, respectively (p=0.09); 66.7% maintained the response (median follow-up: 2.7 years). Eighty-five (22.2%) patients switched to the alternative TRA; while no cross-toxicity was observed, 83.3% of resistant patients had a response after the switch. During TRA, 34 major thromboses (3 fatal) and 14 major hemorrhages (none fatal) occurred in 18 and 10 patients, respectively, and were associated with thrombosis history (SHR: 2.04, p=0.05) and platelet count <20x109/L at TRA start (SHR: 1.69, p=0.04), respectively. A recurrent event occurred in 15.6% of patients surviving thrombosis, in all cases but one during persisting TRA treatment (incidence rate: 7.7 per 100 patient-years). All recurrences occurred in the absence of adequate antithrombotic secondary prophylaxis. Sixty-two (16.5%) responding patients discontinued TRA; 53 (13.8%) patients maintained SROT, which was associated with TRA discontinuation in complete response (p<0.001). Very old age (≥75, 41.1%) was associated with more frequent TRAs start in persistent/acute phase but not with response or thrombotic/hemorrhagic risk. TRAs are effective in elderly ITP patients, with no fatal haemorrhages and with SROT in a significant portion of patients; in patients with thrombosis history caution is warranted and a careful risk/benefit balance should be carried out.
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