1
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González-López TJ, Bárez A, Bernardo-Gutiérrez Á, Bernat S, Fernández-Fuertes F, Guinea de Castro JM, Jiménez-Bárcenas R, Jarque I. Real-life clinical practice in Spain in the setting of new drug availability for ITP treatment. A Delphi-based Spanish expert panel consensus. Platelets 2024; 35:2336104. [PMID: 38742687 DOI: 10.1080/09537104.2024.2336104] [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: 11/15/2023] [Accepted: 03/22/2024] [Indexed: 05/16/2024]
Abstract
Immune thrombocytopenia (ITP) is a common autoimmune hematological disorder. Despite this, diagnosis is still challenging due to clinical heterogeneity and the lack of a specific diagnostic test. New findings in the pathology and the availability of new drugs have led to the development of different guidelines worldwide. In the present study, the Delphi methodology has been used to get a consensus on the management of adult patients with ITP in Spain and to help in decision-making. The Delphi questionnaire has been designed by a scientific ad hoc committee and has been divided into 13 topics, with a total of 127 items, covering the maximum possible scenarios for the management of ITP. As a result of the study, a total consensus of 81% has been reached. It is concluded that this Delphi consensus provides practical recommendations on topics related to diagnosis and management of ITP patients to help doctors to improve outcomes. Some aspects remain unclear, without consensus among the experts. Thus, more advances are needed to optimize ITP management.
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Affiliation(s)
| | - Abelardo Bárez
- Department of Hematology, Complejo Asistencial de Ávila, Ávila, Spain
| | | | - Silvia Bernat
- Department of Hematology, Hospital Universitario de La Plana, Villarreal, Spain
| | - Fernando Fernández-Fuertes
- Department of Hematology, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
| | | | | | - Isidro Jarque
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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2
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Cooper N, Scully M, Percy C, Nicolson PLR, Lowe G, Bagot CN, Thachil J, Grech H, Nokes T, Hill QA, Bradbury C, Talks K, Dutt T, Evans G, Pavord S, Wexler S, Charania A, Collington SJ, Ervin A, Ramscar N, Provan D. Real-world use of thrombopoietin receptor agonists for the management of immune thrombocytopenia in adult patients in the United Kingdom: Results from the TRAIT study. Br J Haematol 2024; 204:2442-2452. [PMID: 38429869 DOI: 10.1111/bjh.19345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 03/03/2024]
Abstract
Few studies have reported the real-world use of both romiplostim and eltrombopag in immune thrombocytopenia (ITP). TRAIT was a retrospective observational study aimed to evaluate the platelet responses and adverse effects associated with the use of these thrombopoietin receptor agonists (TPO-RAs) in adult patients with ITP in the United Kingdom. Of 267 patients (median age at diagnosis, 48 years) with ITP (primary ITP [n = 218], secondary ITP [n = 49]) included in the study, 112 (42%) received eltrombopag and 155 (58%) received romiplostim as the first prescribed TPO-RA. A platelet count ≥30 × 109/L was achieved in 89% of patients with the first TPO-RA treatments, while 68% achieved a platelet count ≥100 × 109/L. Treatment-free response (TFR; platelet count ≥30 × 109/L, 3 months after discontinuing treatment) was achieved by 18% of the total patients. Overall, 61 patients (23%) switched TPO-RAs, most of whom achieved platelet counts ≥30 × 109/L with the second TPO-RA (23/25 who switched from eltrombopag to romiplostim [92%]; 28/36 who switched from romiplostim to eltrombopag [78%]). TFR was associated with secondary ITP, early TPO-RA initiation after diagnosis, the presence of comorbidity and no prior splenectomy or treatment with steroids or mycophenolate mofetil. Both TPO-RAs had similar efficacy and safety profiles to those reported in clinical studies.
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Affiliation(s)
| | - Marie Scully
- Haematology Programme, NIHR UCLH/UCL BRC, London, UK
| | - Charles Percy
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Queen Elizabeth Hospital, Birmingham, UK
| | - Phillip L R Nicolson
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- HaemSTAR, Torquay, UK
| | - Gillian Lowe
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
- Queen Elizabeth Hospital, Birmingham, UK
| | - Catherine N Bagot
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde NHS Board, Glasgow, UK
| | - Jecko Thachil
- Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - Henri Grech
- Royal Berkshire Hospital NHS Foundation Trust, Reading, UK
| | - Tim Nokes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | - Kate Talks
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tina Dutt
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Gillian Evans
- East Kent Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Kent, UK
| | - Sue Pavord
- Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, UK
| | - Sarah Wexler
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | | | | | | | | | - Drew Provan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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3
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Delshad M, Davoodi-Moghaddam Z, Pourbagheri-Sigaroodi A, Faranoush M, Abolghasemi H, Bashash D. Translating mechanisms into therapeutic strategies for immune thrombocytopenia (ITP): Lessons from clinical trials. Thromb Res 2024; 235:125-147. [PMID: 38335568 DOI: 10.1016/j.thromres.2024.02.005] [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: 12/26/2023] [Revised: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 02/12/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder that causes a significant reduction in peripheral blood platelet count. Fortunately, due to an increased understanding of ITP, there have been significant improvements in the diagnosis and treatment of these patients. Over the past decade, there have been a variety of proven therapeutic options available for ITP patients, including intravenous immunoglobulins (IVIG), Rituximab, corticosteroids, and thrombopoietin receptor agonists (TPO-RAs). Although the effectiveness of current therapies in treating more than two-thirds of patients, still some patients do not respond well to conventional therapies or fail to achieve long-term remission. Recently, a significant advancement has been made in identifying various mechanisms involved in the pathogenesis of ITP, leading to the development of novel treatments targeting these pathways. It seems that new agents that target plasma cells, Bruton tyrosine kinase, FcRn, platelet desialylation, splenic tyrosine kinase, and classical complement pathways are opening new ways to treat ITP. In this study, we reviewed the pathophysiology of ITP and summarized updates in this population's management and treatment options. We also took a closer look at the 315 ongoing trials to investigate their progress status and compare the effectiveness of interventions. May our comprehensive view of ongoing clinical trials serve as a guiding beacon, illuminating the path towards future trials of different drugs in the treatment of ITP patients.
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Affiliation(s)
- Mahda Delshad
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Laboratory Sciences, School of Allied Medical Sciences, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Zeinab Davoodi-Moghaddam
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atieh Pourbagheri-Sigaroodi
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Faranoush
- Pediatric Growth and Development Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Abolghasemi
- Pediatric Congenital Hematologic Disorders Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Davood Bashash
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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4
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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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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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7
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González-López TJ, Provan D. Sustained Remission Off-Treatment (SROT) of TPO-RAs: The Burgos Ten-Step Eltrombopag Tapering Scheme. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:659. [PMID: 37109617 PMCID: PMC10145072 DOI: 10.3390/medicina59040659] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/15/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
Background and Objectives: TPO-RAs (romiplostim/eltrombopag/avatrombopag) have broadly demonstrated high efficacy rates (59-88%), durable responses (up to three years) and a satisfactory safety profile in clinical trials. The effect of TPO-RAs is classically considered to be transient because platelet numbers usually dropped rapidly to baseline unless therapy was maintained. However, several groups have reported the possibility of successfully discontinuing TPO-RAs in some patients without further need for concomitant treatments. This concept is usually referred as sustained remission off-treatment (SROT). Materials and Methods: Unfortunately, we still lack predictors of the response to discontinuation even after the numerous biological, clinical and in vitro studies performed to study this phenomenon. The frequency of successful discontinuation is matter of controversy, although a percentage in the range of 25-40% may probably be considered a consensus. Here, we describe all major routine clinical practice studies and reviews that report the current position on this topic and compare them with our own results in Burgos. Results: We report our Burgos ten-step eltrombopag tapering scheme with which we have achieved an elevated percentage rate of success (70.3%) in discontinuing treatment. Conclusions: We hope this protocol may help successfully taper and discontinue TPO-RAs in daily clinical practice.
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Affiliation(s)
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2BB, UK;
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8
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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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9
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María S, Rubén B, Elena S, Áurea C, Ana S, Itziar A, Bienvenida A, Ángeles DM, Luís DJ, Emilio M. Tapering of thrombopoietin receptor agonist in pediatric patients with chronic immune thrombocytopenia. Is it possible? Br J Clin Pharmacol 2022; 88:4220-4223. [PMID: 35491467 DOI: 10.1111/bcp.15378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 11/29/2022] Open
Abstract
It is not clear if platelet responses will be sustained after thrombopoietin receptor agonist (ar-TPO) withdrawal in pediatric patients. A multicenter retrospective observational study was performed in children with chronic immune thrombopenia (cITP) to describe ar-TPO tapering and withdrawal in patients who had achieved a sustained complete response to ar-TPO. Ten patients (eltrombopag (n=6), romiplostim (n=4) were included. Treatment withdrawal was performed after a mean tapering time of 7.6 months. Two patients relapsed (median follow-up time of 24 months). Slow tapering and withdrawal of ar-TPO can be safely performed in cITP pediatric patients after achieving a sustained complete response.
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Affiliation(s)
- Solsona María
- Servicio de Hematología Pediátrica. Hospital Sant Joan de Déu. Hospital Sant Joan de Déu Barcelona Passeig Sant Joan de Déu 2, Esplugues de Llobregat, Spain
| | - Berrueco Rubén
- Servicio de Hematología Pediátrica. Hospital Sant Joan de Déu. Hospital Sant Joan de Déu Barcelona Passeig Sant Joan de Déu 2, Esplugues de Llobregat, Spain.,Grupo trabajo de la PTI de la Sociedad Española de Hematología y Oncología Pediátricas (SEHOP)
| | - Sebastián Elena
- Grupo trabajo de la PTI de la Sociedad Española de Hematología y Oncología Pediátricas (SEHOP).,Servicio de Hematología. Hospital Infantil Universitario Niño Jesús, Madrid
| | - Cervera Áurea
- Servicio de Hematología Pediátrica. Hospital Sant Joan de Déu. Hospital Sant Joan de Déu Barcelona Passeig Sant Joan de Déu 2, Esplugues de Llobregat, Spain.,Servicio de Pediatría. Hospital Universitario de Móstoles
| | - Sastre Ana
- Grupo trabajo de la PTI de la Sociedad Española de Hematología y Oncología Pediátricas (SEHOP).,Servicio de Hematología y Oncología Pediátricas. Hospital La Paz, Madrid
| | - Astigarraga Itziar
- Servicio de Hematología Pediátrica. Hospital Sant Joan de Déu. Hospital Sant Joan de Déu Barcelona Passeig Sant Joan de Déu 2, Esplugues de Llobregat, Spain.,Servicio de Pediatría. Hospital Universitario Cruces. IIS Biocruces Bizkaia. UPV/EHU, Barakaldo
| | | | - Dasí María Ángeles
- Grupo trabajo de la PTI de la Sociedad Española de Hematología y Oncología Pediátricas (SEHOP).,Servicio de Pediatría. Hospital Universitario La Fe, Valencia
| | - Dapena José Luís
- Servicio de Hematología Pediátrica. Hospital Sant Joan de Déu. Hospital Sant Joan de Déu Barcelona Passeig Sant Joan de Déu 2, Esplugues de Llobregat, Spain.,Grupo trabajo de la PTI de la Sociedad Española de Hematología y Oncología Pediátricas (SEHOP)
| | - Monteagudo Emilio
- Grupo trabajo de la PTI de la Sociedad Española de Hematología y Oncología Pediátricas (SEHOP).,Servicio de Pediatría. Hospital Universitario La Fe, Valencia
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10
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Mei H, Liu X, Li Y, Zhou H, Feng Y, Gao G, Cheng P, Huang R, Yang L, Hu J, Hou M, Yao Y, Liu L, Wang Y, Wu D, Zhang L, Zheng C, Shen X, Hu Q, Liu J, Jin J, Luo J, Zeng Y, Gao S, Zhang X, Zhou X, Shi Q, Xia R, Xie X, Jiang Z, Gao L, Bai Y, Li Y, Xiong J, Li R, Zou J, Niu T, Yang R, Hu Y. Dose tapering to withdrawal stage and long-term efficacy and safety of hetrombopag for the treatment of immune thrombocytopenia: Results from an open-label extension study. J Thromb Haemost 2022; 20:716-728. [PMID: 34821020 DOI: 10.1111/jth.15602] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/18/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND The efficacy of hetrombopag in Chinese patients with immune thrombocytopenia (ITP) has been demonstrated in a randomized, double-blind, placebo-controlled, multicenter, phase III trial (NCT03222843). OBJECTIVE This study aimed to report comprehensive data on a ≤6-week dose tapering to withdrawal (Stage 3) and an additional 24-week long-term extension period (Stage 4) in this phase III trial. PATIENTS/METHODS Patients who fulfilled the screening criteria were eligible to enter Stage 3 or 4. During Stage 3, hetrombopag was gradually tapered to withdrawal. During Stage 4, hetrombopag treatment was initiated at 2.5, 3.75, 5, or 7.5 mg once daily. The efficacy endpoints during Stage 3 or 4 and the safety profile during the entire treatment period were reported. RESULTS Among 194 patients who entered Stage 3, 171 (88.1%) relapsed. The median time to the first relapse since the start of Stage 3 was 15.0 days (95% CI, 14.0-16.0). In Stage 4, 144 (42.5%) patients responded at ≥75% of their assessments and 254 (74.9%) patients achieved platelet count ≥30 × 109 /L at least once, which was at least twice their baseline platelet count in the hetrombopag group (n = 339). The most common adverse events were upper respiratory tract infection (53.1%), thrombocytopenia (27.1%), and urinary tract infection (21.2%) in the hetrombopag group. CONCLUSION The majority of patients who experienced dose tapering to withdrawal experienced a relapse. Long-term treatment with hetrombopag was effective in increasing and maintaining platelet count within the desired range in Chinese adults with ITP. Hetrombopag was well tolerated.
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Affiliation(s)
- Heng Mei
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Liu
- Thrombosis and Hemostasis Center, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Hematological Disorders, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yan Li
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Hu Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Feng
- Department of Hematopathology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guangxun Gao
- The Blood Internal Medicine, The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Peng Cheng
- Hematology Department, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ruibin Huang
- Hematology Department, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linhua Yang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Jianda Hu
- Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Yazhou Yao
- Hematology Department, Baoji Central Hospital, Baoji, China
| | - Li Liu
- Department of Hematopathology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Yi Wang
- Department of Hematopathology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Depei Wu
- Hematology Department, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liansheng Zhang
- Hematology Department, Lanzhou University Second Hospital, Lanzhou, China
| | - Changcheng Zheng
- Hematology Department, The First Affiliated Hospital of USTC, Hefei, China
| | - Xuliang Shen
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Qi Hu
- Department of Hematology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Jing Liu
- Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Jianmin Luo
- Department of Hematology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yun Zeng
- Department of Hematology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Sujun Gao
- Hematology, The First Hospital of Jilin University, Changchun, China
| | - Xiaohui Zhang
- Department of Hematology, Peking University People's Hospital, Beijing, China
| | - Xin Zhou
- Hematology Department, Wuxi People's Hospital, Wuxi, China
| | - Qingzhi Shi
- Hematology Department, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ruixiang Xia
- Hematology Department, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaobao Xie
- Hematology Department, The First People's Hospital of Changzhou, Changzhou, China
| | - Zhongxing Jiang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Gao
- Department of Hematology, The Second Affiliated Hospital of Military Medical University PLA, Chongqing, China
| | - Yuansong Bai
- Hematology & Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yan Li
- Hematology Department, The First Hospital of China Medical University, Shenyang, China
| | - Junye Xiong
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Runzi Li
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Jianjun Zou
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd, Shanghai, China
| | - Ting Niu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Renchi Yang
- Thrombosis and Hemostasis Center, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Hematological Disorders, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yu Hu
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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11
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Vianelli N, Auteri G, Buccisano F, Carrai V, Baldacci E, Clissa C, Bartoletti D, Giuffrida G, Magro D, Rivolti E, Esposito D, Podda GM, Palandri F. Refractory primary immune thrombocytopenia (ITP): current clinical challenges and therapeutic perspectives. Ann Hematol 2022; 101:963-978. [PMID: 35201417 PMCID: PMC8867457 DOI: 10.1007/s00277-022-04786-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/01/2022] [Indexed: 01/19/2023]
Abstract
Chronic primary immune thrombocytopenia (ITP) can today benefit from multiple therapeutic approaches with proven clinical efficacy, including rituximab, thrombopoietin receptor agonists (TPO-RA), and splenectomy. However, some ITP patients are unresponsive to multiple lines of therapy with prolonged and severe thrombocytopenia. The diagnosis of refractory ITP is mainly performed by exclusion of other disorders and is based on the clinician's expertise. However, it significantly increases the risk of drug-related toxicity and of bleedings, including life-threatening events. The management of refractory ITP remains a major clinical challenge. Here, we provide an overview of the currently available treatment options, and we discuss the emerging rationale of new therapeutic approaches and their strategic combination. Particularly, combination strategies may target multiple pathogenetic mechanisms and trigger additive or synergistic effects. A series of best practices arising both from published studies and from real-life clinical experience is also included, aiming to optimize the management of refractory ITP.
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Affiliation(s)
- Nicola Vianelli
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Francesco Buccisano
- Dipartimento Di Biomedicina E Prevenzione, Università Tor Vergata, Rome, Italy
| | | | | | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | | | | | - Elena Rivolti
- Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniela Esposito
- Presidio Ospedaliero San G. Moscati Di Aversa - ASL Caserta, Caserta, Italy
| | - Gian Marco Podda
- Medicina III, Ospedale San Paolo, ASST Santi Paolo E Carlo, Dipartimento Di Scienze Della Salute, Università Degli Studi Di Milano, Milano, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.
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12
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Provan D, Semple JW. Recent advances in the mechanisms and treatment of immune thrombocytopenia. EBioMedicine 2022; 76:103820. [PMID: 35074629 PMCID: PMC8792416 DOI: 10.1016/j.ebiom.2022.103820] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/30/2021] [Accepted: 01/07/2022] [Indexed: 01/09/2023] Open
Abstract
Primary immune thrombocytopenia is an autoimmune disease associated with a reduced peripheral blood platelet count. The phenotype is variable with some patients suffering no bleeding whilst others have severe bleeding which may be fatal. Variability in clinical behaviour and treatment responses reflects its complex underlying pathophysiology. Historically the management has relied heavily on immune suppression. Recent studies have shown that the older empirical immune suppressants fail to alter the natural history of the disease and are associated with a poor quality of life for patients. Newer treatments, such as the thrombopoietin receptor agonists, have transformed ITP care. They have high efficacy, are well tolerated and improve patients’ quality of life. A greater understanding of the underlying pathophysiology of this disorder has helped develop a number of new targeted therapies. These include inhibitors of the neonatal Fc receptor inhibitors, Bruton tyrosine kinase and complement pathway. Here we discuss the mechanisms underlying ITP and the new approach to ITP care.
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Affiliation(s)
- Drew Provan
- Centre for Immunology, Blizard Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London UK.
| | - 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; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.
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13
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Capecchi M, Serpenti F, Giannotta J, Pettine L, Reda G, Martinelli I, Artoni A, Barcellini W, Fattizzo B. Off-Label Use of Thrombopoietin Receptor Agonists: Case Series and Review of the Literature. Front Oncol 2021; 11:680411. [PMID: 34650908 PMCID: PMC8505995 DOI: 10.3389/fonc.2021.680411] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/06/2021] [Indexed: 12/15/2022] Open
Abstract
Since their license in 2008, studies on thrombopoietin receptor agonists (TPO-RAs) are proceeding at a fast pace. Their favorable efficacy and safety profile makes them good candidates for the management of thrombocytopenia in different settings, even beyond their current indications. In the last 10 years, we faced patients with refractory thrombocytopenia that required treatment with off-label TPO-RA, despite the paucity of data in the literature and the possible risks, particularly that of thrombosis. We hereby report our 10-year real-life single-center experience of TPO-RA used off-label. Fourteen patients were divided into three groups according to the etiology of thrombocytopenia: myelodysplastic syndromes, post-transplantation, and lymphoproliferative diseases. Clinical features and results are reported within each group. Overall, TPO-RA proved effective in all these conditions achieving responses also in heavily pretreated patients. The overall response rate (ORR) was 100% in patients with thrombocytopenia after transplantation and in those with lymphoproliferative diseases and 75% in patients with myelodysplastic syndromes. The median duration of therapy was 285 days (range 93–1,513 days). Four patients (29%) discontinued treatment because of lack of response (n=2) or a sustained response (n=2). No grade 3–4 adverse events occurred, particularly no thrombosis. In our real-life experience, TPO-RAs were effective and safe and proved of value in the challenging management of patients with refractory thrombocytopenia associated with different conditions.
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Affiliation(s)
- Marco Capecchi
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Fabio Serpenti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Oncology and Onco-hematology, Università degli Studi di Milano, Milan, Italy
| | - Juri Giannotta
- Department of Oncology and Onco-hematology, Università degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Loredana Pettine
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Gianluigi Reda
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Ida Martinelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Bruno Fattizzo
- Department of Oncology and Onco-hematology, Università degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
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14
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Carpenedo M, Baldacci E, Baratè C, Borchiellini A, Buccisano F, Calvaruso G, Chiurazzi F, Fattizzo B, Giuffrida G, Rossi E, Palandri F, Scalzulli PR, Siragusa SM, Vitucci A, Zaja F. Second-line administration of thrombopoietin receptor agonists in immune thrombocytopenia: Italian Delphi-based consensus recommendations. Ther Adv Hematol 2021; 12:20406207211048361. [PMID: 34646432 PMCID: PMC8504223 DOI: 10.1177/20406207211048361] [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] [Received: 04/16/2021] [Accepted: 09/06/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction: In patients with primary immune thrombocytopenia (ITP), a short course of steroids is routinely given as first-line therapy. However, the response is often transient and additional therapy is usually needed. Thrombopoietin receptor agonists (TPO-RAs) are frequently used as second-line therapy, although there is little clinical guidance on the timing of their administration and on tapering/discontinuation of the drug. To provide clinical recommendations, we used the Delphi technique to obtain consensus for statements regarding administration and on tapering/discontinuation of second-line TPO-RAs among a group of Italian clinicians with expertise in management of ITP. Methods: The Delphi process was used to obtain agreement on five statements regarding initiation and on tapering/discontinuation of second-line TPO-RAs. Agreement was considered when 75% of participants approved the statement. Eleven experts participated in the voting. Results: Full consensus was reached for three of the five statements. The experts held that an early switch from corticosteroids to a TPO-RA has the dual advantage of sparing patients from corticosteroid abuse and improve long-term clinical outcomes. All felt that dose reduction of TPO-RAs can be considered in patients with a stable response and platelet count >100 × 109/L that is maintained for at least 6 months in the absence of concomitant treatments, although there was less agreement in patients with a platelet count >50 × 109/L. Near consensus was reached regarding the statement that early treatment with a TPO-RA is associated with an increase in clinically significant partial or complete response. The experts also agreed that optimization of tapering and discontinuation of TPO-RA therapy in selected patients can improve the quality of life. Conclusion: The present consensus can help to provide guidance on use of TPO-RAs in daily practice in patients with ITP. Plain language summary Second-line administration of thrombopoietin receptor agonists in immune thrombocytopenia
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Affiliation(s)
- Monica Carpenedo
- Hematology and Transplantation Unit, ASST San Gerardo Hospital, Via G. B. Pergolesi, 33, 20900 Monza MB, Italy
| | - Erminia Baldacci
- Department of Hematology, Policlinico Umberto I University Hospital, Rome, Italy
| | - Claudia Baratè
- Hematology and Bone Marrow Transplant Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandra Borchiellini
- Regional Reference Center of Haemostasis and Thrombosis Haematology Unit, Città della Salute e della Scienza, Turin, Italy
| | - Francesco Buccisano
- Hematology, Department of BioMedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Giuseppina Calvaruso
- Campus of Hematology Franco and Piera Cutino, AOOR Villa Sofia-V. Cervello, Palermo, Italy
| | - Federico Chiurazzi
- Department of Clinical Medicine, University "Federico II" of Naples, Naples, Italy
| | - Bruno Fattizzo
- UOC Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gaetano Giuffrida
- Division of Haematology, A.O.U. Policlinico Vittorio Emanuele, Catania, Italy
| | - Elena Rossi
- Department of Radiological and Hematological Sciences, Universita Cattolica del Sacro Cuore and Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Potito Rosario Scalzulli
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | | | - Angelantonio Vitucci
- Haematology with Transplant Unit, Az. Universitario-Ospedaliera Consorziale Policlinico, Bari, Italy
| | - Francesco Zaja
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
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15
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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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16
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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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17
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Cuker A, Despotovic JM, Grace RF, Kruse C, Lambert MP, Liebman HA, Lyons RM, McCrae KR, Pullarkat V, Wasser JS, Beenhouwer D, Gibbs SN, Yermilov I, Broder MS. Tapering thrombopoietin receptor agonists in primary immune thrombocytopenia: Expert consensus based on the RAND/UCLA modified Delphi panel method. Res Pract Thromb Haemost 2021; 5:69-80. [PMID: 33537531 PMCID: PMC7845076 DOI: 10.1002/rth2.12457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thrombopoietin receptor agonists (TPO-RAs) are used to treat primary immune thrombocytopenia (ITP). Some patients have discontinued treatment while maintaining a hemostatic platelet count. OBJECTIVES To develop expert consensus on when it is appropriate to consider tapering TPO-RAs in ITP, how to taper patients off therapy, how to monitor patients after discontinuation, and how to restart therapy. METHODS We used a RAND/UCLA modified Delphi panel method. Ratings were completed independently by each expert before and after a meeting. Second-round ratings were used to develop the panel's guidance. The panel was double-blinded: The sponsor and nonchair experts did not know each other's identities. RESULTS Guidance on when it is appropriate to taper TPO-RAs in children and adults was developed based on patient platelet count, history of bleeding, intensification of treatment, trauma risk, and use of anticoagulants/platelet inhibitors. For example, it is appropriate to taper TPO-RAs in patients who have normal/above-normal platelet counts, have no history of major bleeding, and have not required an intensification of treatment in the past 6 months; it is inappropriate to taper TPO-RAs in patients with low platelet counts. Duration of ITP, months on TPO-RA, or timing of platelet response to TPO-RA did not have an impact on the panel's guidance on appropriateness to taper. Guidance on how to taper patients off therapy, how to monitor patients after discontinuation, and how to restart therapy is also provided. CONCLUSION This guidance could support clinical decision making and the development of clinical trials that prospectively test the safety of tapering TPO-RAs.
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Affiliation(s)
- Adam Cuker
- Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | - Rachael F. Grace
- Dana‐Farber/Boston Children’s Cancer and Blood Disorders CenterHarvard Medical SchoolBostonMAUSA
| | | | - Michele P. Lambert
- Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPAUSA
| | - Howard A. Liebman
- University of Southern California, Norris Cancer HospitalLos AngelesCAUSA
| | | | | | | | | | - David Beenhouwer
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| | - Sarah N. Gibbs
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| | - Irina Yermilov
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
| | - Michael S. Broder
- Partnership for Health Analytic Research (PHAR), LLCBeverly HillsCAUSA
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18
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Treatment-free remission after thrombopoietin receptor agonist discontinuation in patients with newly diagnosed immune thrombocytopenia: an observational retrospective analysis in real-world clinical practice. Int J Hematol 2020; 112:159-168. [DOI: 10.1007/s12185-020-02893-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/26/2020] [Accepted: 05/22/2020] [Indexed: 12/14/2022]
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19
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Pantić N, Suvajdžić-Vuković N. Treating ITP: What are the options in the era of new guidelines and new drugs? MEDICINSKI PODMLADAK 2020. [DOI: 10.5937/mp71-28216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disease characterized by isolated thrombocytopenia. Treating ITP may be challenging since different treatment modalities are available. While choosing the suitable option for every patient, a physician should take into account both patient's medical characteristics and wishes. The first line treatment options include: corticosteroids, intravenous immunoglobulins and intravenous anti-D immunoglobulin. Second line treatment options comprise medical (thrombopoietin receptor agonists, rituximab, fostamatinib, azathioprine, cyclophosphamide, cyclosporin A, hydroxychloroquine, mycophenolate mofetil, danazol, dapsone, vinca-alcaloids) and surgical (splenectomy) approach. However, there are some treatment gaps which remain uncovered with existing treatment modalities. Therefore, development of novel therapeutic strategies is required. The aim of this review is to provide an illustrative overview of novel treatments for adult ITP.
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