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Matsuda A, Imada K, Obara N, Iida H, Yamazaki H, Tomiyama Y, Miyamura K, Sasaki O, Maeda T, Ohta K, Usuki K, Tokumine Y, Imajo K, Okamoto Y, Murakami M, Nakao S. Dysmegakaryopoiesis and Transient Mild Increase in Bone Marrow Blasts in Patients With Aplastic Anemia Treated With Eltrombopag May Be Signs of Hematologic Improvement and Not Portend Clonal Evolution. Am J Clin Pathol 2022; 158:604-615. [PMID: 36018052 PMCID: PMC9631234 DOI: 10.1093/ajcp/aqac094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 06/24/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Eltrombopag, a thrombopoietin-receptor agonist, stimulates hematopoiesis in patients with acquired aplastic anemia (AA). Cytomorphologic changes in bone marrow after eltrombopag administration are still unclear. This study examined the effect of eltrombopag on cytomorphologic findings using data from prior phase 2 studies (E1201 and E1202). Methods Microscopic examinations were performed in 31 patients with AA (E1201 [n = 21], E1202 [n = 10]). The relationship between hematologic improvement and morphologic findings was also investigated. Results In 5 patients (E1201 [n = 3], E1202 [n = 2]), the bone marrow blast count increased after initiation of eltrombopag treatment compared with screening values. The blast count was less than 5%, and the increase in bone marrow blasts was transient in all 4 patients who had bone marrow examinations at follow-up. In 8 patients (E1201 [n = 5], E1202 [n = 3]), dysplastic forms of megakaryocytes were found in the bone marrow following treatment initiation. Dysmegakaryopoiesis of 10% or more was found in 3 patients. None of the patients revealed micromegakaryocytes. Ten patients showed an increase in bone marrow blasts and/or dysmegakaryopoiesis following treatment initiation. Nine of 10 patients showed hematologic improvement in 1 or more lineages. Conclusions Dysmegakaryopoiesis without micromegakaryocytes and a transient increase of less than 5% in bone marrow blast count may be signs of hematologic improvement with eltrombopag for patients with AA.
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Affiliation(s)
- Akira Matsuda
- Department of Hemato-Oncology and Medical Education, Saitama International Medical Center, Saitama Medical University, SaitamaJapan
| | - Kazunori Imada
- Department of Hematology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Naoshi Obara
- Department of Hematology, University of Tsukuba, Tsukuba, Japan
| | - Hiroatsu Iida
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hirohito Yamazaki
- Division of Transfusion Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology, Osaka University Hospital, Osaka, Japan
| | - Koichi Miyamura
- Department of Hematology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Osamu Sasaki
- Department of Hematology, Miyagi Cancer Center, Natori, Japan
| | - Tetsuo Maeda
- Department of Hematology, Suita Municipal Hospital, Suita, Japan
| | | | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | | | - Kenji Imajo
- Department of Hematology, Okayama City Hospital, Okayama, Japan
| | | | | | - Shinji Nakao
- Kanazawa University Institute of Medical Pharmaceutical and Health Sciences, Kanazawa, Japan
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She P, Li S, Zhou L, Liu Y, Xu L, Hussain Z, Li Y, Li Z, Liu S, Wu Y. Repurposing Eltrombopag as an Antimicrobial Agent Against Methicillin-Resistant Staphylococcus aureus. Front Microbiol 2022; 12:790686. [PMID: 35140693 PMCID: PMC8819062 DOI: 10.3389/fmicb.2021.790686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/20/2021] [Indexed: 11/16/2022] Open
Abstract
Because of the excessive use of antibiotics, methicillin-resistant Staphylococcus aureus (MRSA) has become prevalent worldwide. Moreover, the formation of S. aureus biofilms often cause persistence and relapse of infections. Thus, the discovery of antibiotics with excellent antimicrobial and anti-biofilm activities is urgently needed. In the present study, eltrombopag (EP), a classic thrombopoietin receptor agonist, exhibited potential antimicrobial activity against S. aureus and its biofilms. Through our mechanistic studies, EP was found to interfere with proton motive force in S. aureus. The in vivo anti-infective efficacy of EP was further confirmed in the wound infection model, thigh infection model and peritonitis model by MRSA infection. In addition, the cytotoxicity of EP against mammalian cells and the in vivo toxicity of EP in animal models were not observed at the tested concentrations. Collectively, these results indicate that EP could be considered a potential novel antimicrobial agent against recalcitrant infections caused by MRSA.
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Affiliation(s)
- Pengfei She
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Shijia Li
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Linying Zhou
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Yaqian Liu
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Lanlan Xu
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Zubair Hussain
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Yimin Li
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Zehao Li
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Shasha Liu
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
| | - Yong Wu
- Department of Laboratory Medicine, Third Xiangya Hospital of Central South University, Changsha, China
- Department of Laboratory Medicine, The First Hospital of Changsha, Changsha, China
- *Correspondence: Yong Wu,
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3
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Imada K, Obara N, Iida H, Imajo K, Maeda T, Usuki K, Fanghong Z, Hombo Y, Tajima T, Kumagai A, Matsuda A, Nakao S. Eltrombopag in Combination with Rabbit Anti-thymocyte Globulin/Cyclosporine A in Immunosuppressive Therapy-naïve Patients with Aplastic Anemia in Japan. Intern Med 2021; 60:1159-1168. [PMID: 33229810 PMCID: PMC8112980 DOI: 10.2169/internalmedicine.6063-20] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective In Japan, immunosuppressive therapy (IST) with anti-thymocyte globulin (ATG), and cyclosporine A (CsA) is the standard of care in patients with aplastic anemia (AA) who are not indicated for stem-cell transplantation, although some patients may experience relapse. This study assessed the efficacy and safety of eltrombopag in combination with rabbit-ATG/CsA in IST-naïve patients with non-severe or severe AA in Japan. Methods In this non-randomized, open-label, single-arm, phase II study, rabbit-ATG/CsA and eltrombopag were initiated on Days 1 and 15 (±3 days), respectively, and continued for ≥26 weeks; rabbit-ATG was given for 5 days (Days 1 to 5). The primary endpoint was the overall response rate (ORR) at Week 26. Patients Patients with AA who were IST-naïve and ≤70 years old or between 71 and 75 years old based on the recommendation of the investigator were enrolled in Japan. Results Of the 11 enrolled patients, 10 started treatment with eltrombopag. The ORRs at Weeks 26 and 52 were 70.0% and 60.0%, respectively. The ORR at Week 26 was 100% (all 3 patients) in patients with non-severe AA and 57.1% (4/7) in patients with severe AA. Among transfusion-dependent patients, 66.7% (4/6) and 62.5% (5/8) became red blood cell- and platelet-transfusion independent, respectively. The most common adverse events were nausea and headache. No deaths or hematologic malignancies were reported. A cytogenetic abnormality was reported in one patient. Conclusion This study confirmed the clinical benefit of eltrombopag plus rabbit-ATG/CsA in IST-naïve patients with non-severe or severe AA in Japan.
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Affiliation(s)
- Kazunori Imada
- Department of Hematology, Japanese Red Cross Osaka Hospital, Japan
| | - Naoshi Obara
- Department of Hematology, University of Tsukuba, Japan
| | - Hiroatsu Iida
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Japan
| | - Kenji Imajo
- Department of Hematology, Okayama City Hospital, Japan
| | - Tetsuo Maeda
- Department of Hematology, Suita City Hospital, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Japan
| | | | | | | | | | - Akira Matsuda
- Department of Hemato-Oncology, International Medical Center, Saitama Medical University, Japan
| | - Shinji Nakao
- Department of Hematology, Kanazawa University Institute of Medical Pharmaceutical and Health Sciences, Japan
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Zhu J, She P, Fu J, Peng C, Wu Y. Identification of Eltrombopag as a Repurposing Drug Against Staphylococcus epidermidis and its Biofilms. Curr Microbiol 2021; 78:1159-1167. [PMID: 33611618 DOI: 10.1007/s00284-021-02386-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 02/07/2021] [Indexed: 10/22/2022]
Abstract
Staphylococcus epidermidis is a common cause of nosocomial infections, and readily adheres to medical apparatus to form biofilms consisting of highly resistant persister cells. Owing to the refractory infections caused by S. epidermidis biofilms and persisters in immunosuppressed patients, it is crucial to develop new antimicrobials. In the present study, we analyzed the antimicrobial effects of the thrombopoietin receptor agonist eltrombopag (EP) against S. epidermidis planktonic cells, biofilms, and persister cells. EP was significantly toxic to S. epidermidis with the minimal inhibitory concentration of 8 μg/ml, and effectively inhibited the biofilms and persisters in a strain-dependent manner. In addition, EP was only mildly toxic to mammalian cells after 12 to 24 h treatment. It also partially synergized with vancomycin against S. epidermidis, which enhanced its antimicrobial effects and reduced its toxicity to mammalian cells. Taken together, EP is a potential antibiotic for treating refractory infections caused by S. epidermidis.
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Affiliation(s)
- Juan Zhu
- Department of Clinical Laboratory, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, People's Republic of China
| | - Pengfei She
- Department of Clinical Laboratory, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, People's Republic of China.
| | - Juhua Fu
- Department of Human Resources, The Third Xiangya Hospital of Central South University, Changsha, 410013, People's Republic of China
| | - Canhui Peng
- Department of Clinical Laboratory, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, People's Republic of China
| | - Yong Wu
- Department of Clinical Laboratory, The Third Xiangya Hospital of Central South University, Changsha, 410013, Hunan, People's Republic of China.
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5
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Discovery of the anti-angiogenesis effect of eltrombopag in breast cancer through targeting of HuR protein. Acta Pharm Sin B 2020; 10:1414-1425. [PMID: 32963940 PMCID: PMC7488360 DOI: 10.1016/j.apsb.2020.02.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/04/2020] [Accepted: 01/07/2020] [Indexed: 01/26/2023] Open
Abstract
HuR (human antigen R), an mRNA-binding protein responsible for poor prognosis in nearly all kinds of malignancies, is a potential anti-tumor target for drug development. While screening HuR inhibitors with a fluorescence polarization (FP) based high-throughput screening (HTS) system, the clinically used drug eltrombopag was identified. Activity of eltrombopag on molecular level was verified with FP, electrophoretic mobility shift assay (EMSA), simulation docking and surface plasmon resonance (SPR). Further, we showed that eltrombopag inhibited in vitro cell proliferation of multiple cancer cell lines and macrophages, and the in vivo anti-tumor activity was also demonstrated in a 4T1 tumor-bearing mouse model. The in vivo data showed that eltrombopag was efficient in reducing microvessels in tumor tissues. We then confirmed the HuR-dependent anti-angiogenesis effect of eltrombopag in 4T1 cells and RAW264.7 macrophages with qRT-PCR, HuR-overexpression and HuR-silencing assays, RNA stability assays, RNA immunoprecipitation and luciferase assays. Finally, we analyzed the in vitro anti-angiogenesis effect of eltrombopag on human umbilical vein endothelial cells (HUVECs) mediated by macrophages with cell scratch assay and in vitro Matrigel angiogenesis assay. With these data, we revealed the HuR-dependent anti-angiogenesis effect of eltrombopag in breast tumor, suggesting that the existing drug eltrombopag may be used as an anti-cancer drug.
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Key Words
- ARE, AU-rich element
- Angiogenesis
- Anti-tumor
- ELB, eltrombopag
- ELISA, enzyme linked immune sorbent assay
- EMSA, electrophoretic mobility shift assay
- Eltrombopag
- FP, fluorescence polarization
- HTS, high-throughput screening
- HUVEC, human umbilical vein endothelial cell
- HuR
- HuR, human antigen R
- IHC, immunohistochemistry
- RIP, RNA immunoprecipitation
- SPR, surface plasmon resonance
- mRNAs stability
- qRT-PCR, quantitative real-time PCR
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6
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Strickland SA, Wang XV, Cerny J, Rowe JM, Rybka W, Tallman MS, Litzow M, Lazarus HM. A novel PrECOG (PrE0901) dose-escalation trial using eltrombopag: enhanced platelet recovery during consolidation therapy in acute myeloid leukemia. Leuk Lymphoma 2020; 61:2191-2199. [DOI: 10.1080/10428194.2020.1762878] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Stephen A. Strickland
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Jan Cerny
- University of Massachusetts Medical Center, Worcester, MA, USA
| | - Jacob M. Rowe
- Institute of Hematology, Rambam Medical Center, Haifa, Israel
| | | | - Martin S. Tallman
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Hillard M. Lazarus
- Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
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7
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Duong VH, Al Ali N, Zhang L, Padron E, Sallman D, Lancet JE, List AF, Komrokji RS. A sequential two-stage dose escalation study of eltrombopag in patients with myelodysplastic syndrome and thrombocytopenia after hypomethylating agent failure. Leuk Lymphoma 2020; 61:1901-1907. [PMID: 32306798 DOI: 10.1080/10428194.2020.1751841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Thrombocytopenia occurs frequently in patients with myelodysplastic syndromes (MDS), and the survival of patients after failure of hypomethylating agents (HMAs) is poor. We conducted a trial of eltrombopag in patients with MDS, MDS/myeloproliferative neoplasm (MPN) or acute myeloid leukemia (AML) with 20-30% myeloblasts after HMA failure and mean baseline platelet count ≤ 50 × 109/L. Eltrombopag was escalated from 50 mg daily up to 200 mg daily. The primary objective was to determine the maximally tolerated dose (MTD). 37 patients were enrolled, and MTD was not reached. Responses were observed in 9 patients (24%), 2 achieving marrow CR with hematologic improvement (HI), 1 marrow CR without HI, and 6 HI. Median overall survival was 7.5 months. Eltrombopag was well-tolerated and yielded modest responses in heavily treated, predominantly higher-risk MDS patients after HMA failure. Future studies should focus on determining characteristics that predict response.
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Affiliation(s)
- Vu H Duong
- Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Najla Al Ali
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ling Zhang
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Eric Padron
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - David Sallman
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jeffrey E Lancet
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Alan F List
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rami S Komrokji
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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8
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Bussel J, Kulasekararaj A, Cooper N, Verma A, Steidl U, Semple JW, Will B. Mechanisms and therapeutic prospects of thrombopoietin receptor agonists. Semin Hematol 2019; 56:262-278. [PMID: 31836033 DOI: 10.1053/j.seminhematol.2019.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
The second-generation thrombopoietin (TPO) receptor agonists eltrombopag and romiplostim are potent activators of megakaryopoiesis and represent a growing treatment option for patients with thrombocytopenic hematological disorders. Both TPO receptor agonists have been approved worldwide for the treatment of children and adults with chronic immune thrombocytopenia. In the EU and USA, eltrombopag is approved for the treatment of patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy and in the USA for the first-line treatment of severe aplastic anemia in combination with immunosuppressive therapy. Eltrombopag has also shown efficacy in several other disease settings, for example, chemotherapy-induced thrombocytopenia, selected inherited thrombocytopenias, and myelodysplastic syndromes. While both TPO receptor agonists stimulate TPO receptor signaling and enhance megakaryopoiesis, their vastly different biochemical structures bestow upon them markedly different molecular and functional properties. Here, we review and discuss results from preclinical and clinical studies on the functional and molecular mechanisms of action of this new class of drug.
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Affiliation(s)
- James Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY.
| | | | | | - Amit Verma
- Albert Einstein College of Medicine, New York, NY
| | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Britta Will
- Albert Einstein College of Medicine, New York, NY.
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9
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Shi M, Xu F, Yang X, Bai Y, Niu J, Drokow EK, Chen M, Chen Y, Sun K. The synergistic antileukemic effects of eltrombopag and decitabine in myeloid leukemia cells. Cancer Manag Res 2019; 11:8229-8238. [PMID: 31564981 PMCID: PMC6735651 DOI: 10.2147/cmar.s213931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/05/2019] [Indexed: 12/18/2022] Open
Abstract
Background Hypomethylating agents (HMAs), such as decitabine (DAC), are currently used as first-line therapy for patients with high-risk myelodysplastic syndromes (MDS) and acute myelogenous leukemia (AML) not eligible for standard chemotherapies. Exacerbation of thrombocytopenia is one of the prevalent complications after HMA treatment. Eltrombopag (EP), an oral thrombopoietin receptor agonist, can efficiently stimulate megakaryopoiesis and elevate platelet counts in MDS/AML patients. However, the significance of combining EP with HMAs in patients with high-risk MDS/AML has not been determined. Purpose To explore the impacts and mechanisms of EP and/or DAC on leukemia cell growth and to explore whether EP exhibits antileukemic effects in the context of DAC treatment in human myeloid leukemia cell lines. Methods In our study, we assessed the anti-leukemic effect of EP in the context of DAC treatment by measuring cell proliferation, apoptosis, cell-cycle distribution, and intracellular reactive oxygen species (ROS) levels. Results Our results showed that the combination of EP and DAC had a more obvious antiproliferative effect than that of DAC as a single agent. EP mainly induced S or G0/G1 phase cell cycle arrest, and DAC arrested the cell cycle in the S or G2/M phase. The combination of EP and DAC had a synergistic effect on cell cycle arrest. Furthermore, single-agent treatment with EP or DAC induced a change in intracellular ROS levels, and the combination of EP and DAC had a synergistic effect on ROS levels, exacerbating leukemia cell death. Conclusion Our study provides in vitro evidence of the synergistic antileukemic effect and potential mechanisms of the combination of DAC and EP on myeloid leukemia cells.
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Affiliation(s)
- Mingyue Shi
- Division of Graduate, Department of Hematology, The Second Clinical Medical School and the Second Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China.,Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China.,Department of Pathology and Laboratory Medicine, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Fangfang Xu
- Department of Research and Discipline Development, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Xiawan Yang
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Yanliang Bai
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Junwei Niu
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Emmanuel Kwateng Drokow
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Mingyi Chen
- Department of Pathology and Laboratory Medicine, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Yuqing Chen
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Kai Sun
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
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10
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Yamazaki H, Ohta K, Iida H, Imada K, Obara N, Tokumine Y, Tomiyama Y, Usuki K, Imajo K, Miyamura K, Sasaki O, Fanghong Z, Hattori T, Tajima T, Matsuda A, Nakao S. Hematologic recovery induced by eltrombopag in Japanese patients with aplastic anemia refractory or intolerant to immunosuppressive therapy. Int J Hematol 2019; 110:187-196. [PMID: 31183813 DOI: 10.1007/s12185-019-02683-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 06/03/2019] [Accepted: 06/04/2019] [Indexed: 11/26/2022]
Abstract
Eltrombopag, an oral thrombopoietin-receptor agonist, stimulates hematopoiesis in patients with acquired aplastic anemia (AA) and has higher exposure in patients of East Asian origin. We evaluated the pharmacokinetics, efficacy, and safety of eltrombopag in Japanese patients with AA refractory or intolerant to immunosuppressive therapy (IST). Twenty-one patients (15 with non-severe AA, six with severe AA) with platelet counts < 30,000/µL received eltrombopag in a dose-escalation fashion (25, 50, 75, or 100 mg once daily) depending on individual platelet responses; the responders continued eltrombopag treatment beyond 6 months. The primary endpoint was hematologic response at 6 months, defined as improvements in blood counts or transfusion requirements. Ten (48%) patients achieved hematologic responses in at least one lineage at 6 months. Six patients achieved tri- and/or bi-lineage responses with continuation of eltrombopag treatment, with two patients no longer requiring eltrombopag treatment. The most common adverse events were nasopharyngitis and abnormal hepatic function, with the majority being grade 1 or 2. Cytogenetic abnormalities were observed in three patients; however, no progression to myelodysplastic syndrome/other malignancy was observed. Eltrombopag can safely restore multi-lineage hematopoiesis in Japanese patients with AA refractory or intolerant to IST.Clinical Trial registration NCT02148133.
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Affiliation(s)
- Hirohito Yamazaki
- Division of Transfusion Medicine, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | | | - Hiroatsu Iida
- National Hospital Organization Nagoya Medical Center, Nagoya, Aichi, Japan
| | | | | | | | | | | | | | - Koichi Miyamura
- Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Aichi, Japan
| | | | | | | | | | - Akira Matsuda
- International Medical Center, Saitama Medical University, Saitama, Japan
| | - Shinji Nakao
- Kanazawa University Institute of Medical Pharmaceutical and Health Sciences, Kanazawa, Ishikawa, Japan
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11
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Swaminathan M, Borthakur G, Kadia TM, Ferrajoli A, Alvarado Y, Pemmaraju N, Bodden K, Yearby B, Konopleva M, Khoury J, Bueso-Ramos C, Garcia-Manero G, DiNardo CD. A phase 2 clinical trial of eltrombopag for treatment of patients with myelodysplastic syndromes after hypomethylating-agent failure. Leuk Lymphoma 2019; 60:2207-2213. [DOI: 10.1080/10428194.2019.1576873] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Mahesh Swaminathan
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M. Kadia
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Yesid Alvarado
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Kristy Bodden
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Brittany Yearby
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Khoury
- Department of Hematopathology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos Bueso-Ramos
- Department of Hematopathology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Courtney D. DiNardo
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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12
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Frey N, Jang JH, Szer J, Illés Á, Kim HJ, Ram R, Chong BH, Rowe JM, Borisenkova E, Liesveld J, Winer ES, Cherfi A, Aslanis V, Ghaznawi F, Strickland S. Eltrombopag treatment during induction chemotherapy for acute myeloid leukaemia: a randomised, double-blind, phase 2 study. LANCET HAEMATOLOGY 2019; 6:e122-e131. [PMID: 30704923 DOI: 10.1016/s2352-3026(18)30231-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with acute myeloid leukaemia frequently have thrombocytopenia during induction chemotherapy. Eltrombopag, an oral thrombopoietin receptor agonist, stimulates platelet production by a similar mechanism to endogenous thrombopoietin. This study investigated safety and efficacy of eltrombopag versus placebo during anthracycline-based induction treatment of patients with acute myeloid leukaemia. METHODS In this randomised, double-blind, phase 2 study, treatment-naive patients were recruited from clinical centres across 10 countries (Australia, Belgium, Canada, Greece, Hungary, Israel, South Korea, Poland, Russia, and the USA). Patients with acute myeloid leukaemia of any subtype except M3 and M7 were stratified by antecedent malignant haematological disorder (yes or no) and age (18-60 years or >60 years) and were then randomly assigned (1:1) using an automated interactive voice-response system randomisation schedule. Investigators and patients were blinded to study treatment. Starting on day 4, patients received standard induction chemotherapy (daunorubicin bolus intravenous infusion on days 1-3 [90 mg/m2 for patients aged 18-60 years or 60 mg/m2 for patients aged >60 years], plus cytarabine continuous intravenous infusion on days 1-7 [100 mg/m2]), with eltrombopag 200 mg (100 mg for east Asians) or placebo once daily, until platelet counts were 200 × 109/L or higher, until remission, or after 42 days from the start of induction chemotherapy. The primary objective of the study was safety and tolerability assessed by adverse events, changes in left ventricular ejection fraction (LVEF), and clinical laboratory parameters in all treated patients. This study has been completed and is registered with ClinicalTrials.gov, number NCT01890746. FINDINGS Between Sept 7, 2013, and Jan 30, 2015, 149 patients were assessed for eligibility and 148 were then randomly assigned to receive eltrombopag (n=74) and placebo (n=74). Groups were matched in mean (SD) age (56·7 years [12·3] in the eltrombopag group vs 56·6 years [11·6] in the placebo group), mean (SD) initial platelet count (59·5 × 109/L [43·3] vs 63·7 × 109/L [48·0]), and poor-risk karyotype (16 [22%] of 74 patients in both groups). The most common grade 3-4 adverse events (≥10% in either group) were febrile neutropenia (31 [42%] vs 28 [39%]), decreased white blood cell count (8 [11%] vs 5 [7%]), and hypophosphataemia (3 [4%] vs 9 [13%]). Serious adverse events occurred in 24 (32%) patients in the eltrombopag group compared with 14 (20%) patients in the placebo group. 39 (53%) patients in the eltrombopag group died versus 29 (41%) patients in the placebo group. Thromboembolic events (5 [7%] vs 4 [6%]) and mean (SD) change in LVEF (-2·5% [7·8] vs -4·3% [8·5]) were similar. INTERPRETATION Data from this trial do not support combining eltrombopag with induction chemotherapy in patients with acute myeloid leukaemia. FUNDING Novartis Pharma AG.
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Affiliation(s)
- Noelle Frey
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jun Ho Jang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeff Szer
- The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Árpád Illés
- Faculty of Medicine, Department of Hematology, University of Debrecen, Debrecen, Hungary
| | - Hee-Je Kim
- Seoul St Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ron Ram
- Tel-Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Beng H Chong
- St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | | | | | - Jane Liesveld
- University of Rochester Medical Center, Rochester, NY, USA
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13
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Thrombopoietin Receptor Agonists. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00061-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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14
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Mittelman M, Platzbecker U, Afanasyev B, Grosicki S, Wong RSM, Anagnostopoulos A, Brenner B, Denzlinger C, Rossi G, Nagler A, Garcia-Delgado R, Portella MSO, Zhu Z, Selleslag D. Eltrombopag for advanced myelodysplastic syndromes or acute myeloid leukaemia and severe thrombocytopenia (ASPIRE): a randomised, placebo-controlled, phase 2 trial. LANCET HAEMATOLOGY 2017; 5:e34-e43. [PMID: 29241762 DOI: 10.1016/s2352-3026(17)30228-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/09/2017] [Accepted: 11/10/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Thrombocytopenia is a life-threatening complication in patients with advanced myelodysplastic syndromes (MDS) and acute myeloid leukaemia (AML). In this study (ASPIRE), we aimed to assess eltrombopag, an oral thrombopoietin receptor agonist, for thrombocytopenia (grade 4) treatment in adult patients with advanced MDS or AML. METHODS ASPIRE consisted of an open-label, double-blind phase for 8 weeks and a randomised, double-blind phase (parts 1 and 2, reported here) for 12 weeks, and an open-label extension (part 3). Eligible patients were men and women aged 18 years or older, with intermediate-2 or high-risk MDS or AML, with bone marrow blasts of 50% or less, and had either grade 4 thrombocytopenia due to bone marrow insufficiency (platelet counts <25 × 109 per L) or grade 4 thrombocytopenia before platelet transfusion, with 25 × 109 platelets per L or greater after transfusion. Additionally, eligible patients had at least one of the following within the screening period of 4 weeks: platelet transfusion, symptomatic bleeding, or platelet count of less than 10 × 109 per L. During part 1, patients received eltrombopag, and dose-escalation criteria for part 2 were determined. In part 2, we randomly allocated patients 2:1 using an interactive voice-response system to eltrombopag or placebo, stratified by baseline platelet count (<10 × 109 platelets per L vs ≥10 × 109 platelets per L) and disease (MDS vs AML). In parts 1 and 2, patients received supportive standard of care and initiated eltrombopag or placebo at 100 mg per day (50 mg per day for patients of east-Asian heritage) to a maximum of 300 mg per day (150 mg per day for patients of east-Asian heritage). The part 2 primary objective was assessed by a composite primary endpoint of clinically relevant thrombocytopenic events (CRTE) during weeks 5-12, defined as one of the following events, either alone or in combination: grade 3 or worse haemorrhagic adverse events; platelet counts of less than 10 × 109 per L; or platelet transfusions. Efficacy analyses were based on intention to treat; clinically meaningful efficacy was defined as 30% absolute difference between groups. This trial is registered with ClinicalTrials.gov, number NCT01440374. FINDINGS In part 1, 17 patients received eltrombopag and 11 patients completed treatment; four experienced significantly increased platelet counts, and ten had reduced platelet transfusion requirements. In part 2 we randomly allocated 145 patients to receive supportive care plus eltrombopag (n=98) or placebo (n=47); similar proportions had MDS (50 [51%] patients to eltrombopag, 22 (47%) patients to placebo) or AML (48 [49%] patients to eltrombopag, 25 [53%] patients to placebo). Average weekly CRTE proportions from weeks 5-12 were significantly lower with eltrombopag (54% [95% CI 43-64]) than with placebo (69% [57-80], odds ratio [OR] 0·20, 95% CI 0·05-0·87; p=0·032) although the difference between treatment groups was less than 30%. The most common grade 3 and grade 4 adverse events were fatigue (six [6%] in the eltrombopag group and one [2%] in the placebo group), hypokalaemia (six [6%] and two [4%]), pneumonia (five [5%] and five [11%]), and febrile neutropenia (five [5%] and six [13%]). Serious adverse events were reported in 56 (58%) eltrombopag-treated patients and 32 (68%) placebo-treated patients. Seven eltrombopag recipients and two placebo recipients had serious adverse events that were suspected to be study drug-related (eltrombopag: acute kidney injury, arterial thrombosis, bone pain, diarrhoea, myocardial infarction, pyrexia, retinal vein occlusion, n=1 each; placebo: vomiting, white blood cell count increased, n=1 each). Two eltrombopag recipients (arterial thrombosis n=1; myocardial infarction n=1) and no placebo recipients experienced fatal serious adverse events suspected to be study drug-related. INTERPRETATION No new safety concerns were noted with eltrombopag and the trial met the primary objective of a reduction in CRTEs; eltrombopag might be a treatment option for thrombocytopenic patients with AML or MDS who are ineligible for other treatment and who are not receiving disease-modifying treatment. FUNDING Novartis Pharma AG.
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Affiliation(s)
- Moshe Mittelman
- Tel Aviv Sourasky Medical Center, Sackler Medical Faculty, Tel Aviv University, Tel Aviv, Israel.
| | | | | | | | - Raymond S M Wong
- Sir YK Pao Centre for Cancer & Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | | | - Benjamin Brenner
- Rambam Medical Center, Technion, Israel Institute of Technology, Haifa, Israel
| | | | | | - Arnon Nagler
- Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Zewen Zhu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Kurokawa T, Ohkohchi N. Platelets in liver disease, cancer and regeneration. World J Gastroenterol 2017; 23:3228-3239. [PMID: 28566882 PMCID: PMC5434428 DOI: 10.3748/wjg.v23.i18.3228] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 11/17/2016] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
Although viral hepatitis treatments have evolved over the years, the resultant liver cirrhosis still does not completely heal. Platelets contain proteins required for hemostasis, as well as many growth factors required for organ development, tissue regeneration and repair. Thrombocytopenia, which is frequently observed in patients with chronic liver disease (CLD) and cirrhosis, can manifest from decreased thrombopoietin production and accelerated platelet destruction caused by hypersplenism; however, the relationship between thrombocytopenia and hepatic pathogenesis, as well as the role of platelets in CLD, is poorly understood. In this paper, experimental evidence of platelets improving liver fibrosis and accelerating liver regeneration is summarized and addressed based on studies conducted in our laboratory and current progress reports from other investigators. In addition, we describe our current perspective based on the results of these studies. Platelets improve liver fibrosis by inactivating hepatic stellate cells, which decreases collagen production. The regenerative effect of platelets in the liver involves a direct effect on hepatocytes, a cooperative effect with liver sinusoidal endothelial cells, and a collaborative effect with Kupffer cells. Based on these observations, we ascertained the direct effect of platelet transfusion on improving several indicators of liver function in patients with CLD and liver cirrhosis. However, unlike the results of our previous clinical study, the smaller incremental changes in liver function in patients with CLD who received eltrombopag for 6 mo were due to patient selection from a heterogeneous population. We highlight the current knowledge concerning the role of platelets in CLD and cancer and anticipate a novel application of platelet-based clinical therapies to treat liver disease.
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16
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Gill H, Wong RSM, Kwong YL. From chronic immune thrombocytopenia to severe aplastic anemia: recent insights into the evolution of eltrombopag. Ther Adv Hematol 2017; 8:159-174. [PMID: 28473904 DOI: 10.1177/2040620717693573] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Thrombopoietin (TPO) is the most potent cytokine stimulating thrombopoiesis. Therapy with exogenous TPO is limited by the formation of antibodies cross-reacting with endogenous TPO. Mimetics of TPO are compounds with no antigenic similarity to TPO. Eltrombopag is an orally-active nonpeptide small molecule that binds to the transmembrane portion of the TPO receptor MPL. Initial trials of eltrombopag have centered on immune thrombocytopenia (ITP), which is due to both increased destruction and decreased production of platelets. Eltrombopag at 25-75 mg/day has been shown to be highly effective in raising the platelet count in ITP with suboptimal response to immunosuppression and splenectomy. These successful results led to the exploration of eltrombopag in other thrombocytopenic disorders. In hepatitis C viral infection, eltrombopag raises the platelet count sufficiently enough to allow treatment with ribavirin and pegylated interferon. Because MPL is expressed on hematopoietic cells, eltrombopag use in myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) might enhance leukemic proliferation. Clinical trials of eltrombopag in MDS and AML, however, have shown amelioration of thrombocytopenia without promoting disease progression. In severe aplastic anemia (SAA) not responding to immunosuppression with anti-thymocyte globulin (ATG) and cyclosporine, eltrombopag as a single agent at 150-300 mg/day results in an overall response rate of 40-70%. At high doses, adverse effects including pigmentation, gastrointestinal upset and hepatic derangement have become evident. Current studies have examined the first-line use of eltrombopag in combination with ATG in SAA. In a recent study, eltrombopag used at 150 mg/day with horse ATG resulted in an overall response rate of 90% in newly diagnosed SAA patients, with a complete response rate of about 50%. Clonal karyotypic aberrations are, however, found in 10-20% of SAA patients treated with eltrombopag. The safety and efficacy of eltrombopag in SAA require further evaluation, particularly when it is used with less intensive immunosuppression.
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Affiliation(s)
- Harinder Gill
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | - Raymond S M Wong
- Sir Y.K. Pao Centre for Cancer and Department of Medicine and Therapeutics, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China
| | - Yok-Lam Kwong
- Department of Medicine, Queen Mary Hospital, Pokfulam Road, Hong Kong, China
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17
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Kuter DJ. What is the role of novel thrombopoietic agents in the management of acute leukemia? Best Pract Res Clin Haematol 2016; 29:372-378. [PMID: 27890262 DOI: 10.1016/j.beha.2016.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The role of novel thrombopoietic agents in the management of acute leukemia is a tale of two molecules, romiplostim and eltrombopag. Both are thrombopoietin (TPO) receptor agonists with somewhat different mechanisms of action. Romiplostim is a peptide TPO receptor agonist that activates the TPO receptor by binding to it just like TPO. Eltrombopag is a nonpeptide TPO receptor agonist that activates the TPO receptor by binding to the transmembrane domain. Both TPO receptor agonists increase platelet counts in healthy humans and in those with immune thrombocytopenia. This review focuses on the potential these agents may have in supportive care of patients with acute leukemia.
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Affiliation(s)
- David J Kuter
- Massachusetts General Hospital, Boston, MA 02114, USA; Harvard Medical School, Boston, MA 02114, USA.
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18
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Simultaneous Manifestation of Chronic Myelomonocytic Leukemia and Multiple Myeloma during Treatment by Prednisolone and Eltrombopag for Immune-Mediated Thrombocytopenic Purpura. Case Rep Hematol 2016; 2016:4342820. [PMID: 27597907 PMCID: PMC5002293 DOI: 10.1155/2016/4342820] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/09/2016] [Accepted: 07/10/2016] [Indexed: 11/17/2022] Open
Abstract
An 80-year-old man was admitted to our hospital because of severe thrombocytopenia. He was diagnosed with idiopathic thrombocytopenia, and prednisolone together with eltrombopag was started, leading to significant improvement of platelet counts. Four years later, there was a prominent increase of peripheral blood monocytes, which was accompanied by recurrence of thrombocytopenia. Bone marrow aspirates and serum electrophoresis revealed coexistence of chronic myelomonocytic leukemia (CMML) and multiple myeloma (MM). The patient received lenalidomide plus dexamethasone therapy but died due to exacerbation of the disorder. It was supposed that thrombocytopenia was secondarily caused by CMML and MM developed at a later period.
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19
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Tanaka T, Inamoto Y, Yamashita T, Fuji S, Okinaka K, Kurosawa S, Kim SW, Tanosaki R, Fukuda T. Eltrombopag for Treatment of Thrombocytopenia after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:919-24. [DOI: 10.1016/j.bbmt.2016.01.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 01/11/2016] [Indexed: 11/25/2022]
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20
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Kurokawa T, Zheng YW, Ohkohchi N. Novel functions of platelets in the liver. J Gastroenterol Hepatol 2016; 31:745-51. [PMID: 26632220 DOI: 10.1111/jgh.13244] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 10/18/2015] [Accepted: 11/06/2015] [Indexed: 12/12/2022]
Abstract
Platelets contain not only proteins needed for hemostasis but also many growth factors that are required for organ development, tissue regeneration, and repair. Thrombocytopenia, which is frequently observed in patients with chronic liver disease (CLD) and cirrhosis, is due to various causes, such as decreased thrombopoietin production and accelerated platelet destruction caused by hypersplenism; however, the relationship between thrombocytopenia and hepatic pathogenesis and the role of platelets in CLD are poorly understood. Thus, in this paper, the experimental evidence for platelets improving liver fibrosis and accelerating liver regeneration is summarized and addressed based on studies conducted in our laboratory and current progress reports from other investigators. Platelets improve liver fibrosis by inactivating hepatic stellate cells to decrease collagen production. The level of intracellular cAMP is increased by adenosine through its receptors on hepatic stellate cells, thereby resulting in inactivation of these cells. Adenosine is produced by degradation of adenine nucleotides, which are stored in abundance within the dense granules of platelets. The regenerative effect of platelets in the liver consists of three mechanisms: a direct effect on hepatocytes, a cooperative effect with liver sinusoidal endothelial cells, and a collaborative effect with Kupffer cells. Based on these experiments, a clinical trial suggested that the increase in platelets induced by platelet transfusion improved liver function in patients with CLD in a clinical setting.We highlight the current knowledge concerning the role of platelets in CLD and expect to open a novel avenue for application of these clinical therapies to treat liver disease.
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Affiliation(s)
- Tomohiro Kurokawa
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yun-Wen Zheng
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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21
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Li W, Morrone K, Kambhampati S, Will B, Steidl U, Verma A. Thrombocytopenia in MDS: epidemiology, mechanisms, clinical consequences and novel therapeutic strategies. Leukemia 2015; 30:536-44. [PMID: 26500138 DOI: 10.1038/leu.2015.297] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/03/2015] [Indexed: 12/14/2022]
Abstract
Thrombocytopenia is commonly seen in myelodysplastic syndrome (MDS) patients, and bleeding complications are a major cause of morbidity and mortality. Thrombocytopenia is an independent factor for decreased survival and has been incorporated in newer prognostic scoring systems. The mechanisms of thrombocytopenia are multifactorial and involve a differentiation block of megakaryocytic progenitor cells, leading to dysplastic, hypolobated and microscopic appearing megakaryocytes or increased apoptosis of megakaryocytes and their precursors. Dysregulated thrombopoietin (TPO) signaling and increased platelet destruction through immune or nonimmune mechanisms are frequently observed in MDS. The clinical management of patients with low platelet counts remains challenging and approved chemotherapeutic agents such as lenalidomide and azacytidine can also lead to a transient worsening of thrombocytopenia. Platelet transfusion is the only supportive treatment option currently available for clinically significant thrombocytopenia. The TPO receptor agonists romiplostim and eltrombopag have shown clinical activity in clinical trials in MDS. In addition to thrombopoietic effects, eltrombopag can inhibit leukemic cell proliferation via TPO receptor-independent effects. Other approaches such as treatment with cytokines, immunomodulating drugs and signal transduction inhibitors have shown limited activity in selected groups of MDS patients. Combination trials of approved agents with TPO agonists are ongoing and hold promise for this important clinical problem.
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Affiliation(s)
- W Li
- Department of Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, NY, USA
| | - K Morrone
- Department of Pediatrics, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - S Kambhampati
- Department of Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - B Will
- Division of Hemato-Oncology, Department of Oncology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - U Steidl
- Division of Hemato-Oncology, Department of Oncology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - A Verma
- Division of Hemato-Oncology, Department of Oncology, Albert Einstein College of Medicine, Bronx, NY, USA
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22
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Platzbecker U, Wong RSM, Verma A, Abboud C, Araujo S, Chiou TJ, Feigert J, Yeh SP, Götze K, Gorin NC, Greenberg P, Kambhampati S, Kim YJ, Lee JH, Lyons R, Ruggeri M, Santini V, Cheng G, Jang JH, Chen CY, Johnson B, Bennett J, Mannino F, Kamel YM, Stone N, Dougherty S, Chan G, Giagounidis A. Safety and tolerability of eltrombopag versus placebo for treatment of thrombocytopenia in patients with advanced myelodysplastic syndromes or acute myeloid leukaemia: a multicentre, randomised, placebo-controlled, double-blind, phase 1/2 trial. LANCET HAEMATOLOGY 2015; 2:e417-26. [PMID: 26686043 DOI: 10.1016/s2352-3026(15)00149-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients with myelodysplastic syndrome or acute myeloid leukaemia who are thrombocytopenic and unable to receive disease-modifying therapy have few treatment options. Platelet transfusions provide transient benefit and are limited by alloimmunisation. Eltrombopag, an oral thrombopoietin receptor agonist, increases platelet counts and has preclinical antileukaemic activity. We aimed to assess the safety and tolerability of eltrombopag for the treatment of thrombocytopenia in adult patients with advanced myelodysplastic syndrome, secondary acute myeloid leukaemia after myelodysplastic syndrome, or de-novo acute myeloid leukaemia. METHODS We did this multicentre, randomised, placebo-controlled, double-blind, phase 1/2 trial at 37 centres in ten countries in Europe, east Asia, and the Americas. Patients aged 18 years or older who had relapsed or refractory disease or were ineligible for standard treatments; had platelet counts of less than 30 × 10(9) platelets per L; had 10-50% bone-marrow blasts; or were platelet transfusion dependent were randomly assigned (2:1), via a telephone-based interactive voice-response system (GlaxoSmithKline Registration and Medication Ordering System) with a permuted-block randomisation schedule (block size of three), to receive once-daily eltrombopag or matching placebo dose adjusted from 50 mg to a maximum dose of 300 mg. Randomisation was stratified by presence of poor-prognosis (complex) karyotype (presence of at least three abnormalities, or chromosome 7 abnormalities, vs absence) and bone-marrow blast count (<20% vs ≥20%). Patients and study personnel were masked to treatment allocation. The primary endpoint was safety and tolerability, including adverse events, non-haematological laboratory grade 3-4 toxic effects, and changes in bone-marrow blast counts from baseline. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCT00903422. FINDINGS Between May 14, 2009, and May 9, 2013, we randomly assigned 98 patients to receive either eltrombopag (n=64) or placebo (n=34). 63 (98%) patients in the eltrombopag group and 32 (94%) patients in the placebo group had adverse events. The most common adverse events were pyrexia (27 [42%] vs 11 [32%]), nausea (20 [31%] vs 7 [21%]), diarrhoea (19 [30%] vs 6 [18%]), fatigue (16 [25%] vs 6 [18%]), decreased appetite (15 [23%] vs 5 [15%]), and pneumonia (14 [22%] vs 8 [24%]). Drug-related adverse events of grade 3 or higher were reported in six (9%) patients in the eltrombopag group and four (12%) patients in the placebo group. Increases in the proportion of peripheral blasts did not differ significantly between groups. Haemorrhage of grade 3 or higher was reported in ten (16%) patients given eltrombopag and nine (26%) patients given placebo. 21 (33%) patients receiving eltrombopag and 16 (47%) patients receiving placebo died while on treatment. No deaths in patients receiving eltrombopag and two deaths in patients receiving placebo were regarded as treatment related. Post-baseline bone-marrow examinations were done in 40 (63%) patients in the eltrombopag group and 17 (50%) patients in the placebo group. The most common reason for no examination was death before the scheduled 3 month assessment. There were no differences between median bone-marrow blast counts or proportions of peripheral blasts between groups. INTERPRETATION Eltrombopag doses up to 300 mg daily had an acceptable safety profile in patients with advanced myelodysplastic syndrome or acute myeloid leukaemia. The role of eltrombopag in these patients warrants further investigation. FUNDING GlaxoSmithKline.
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Affiliation(s)
- Uwe Platzbecker
- Department of Internal Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - Raymond S M Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Amit Verma
- Division of Hematologic Malignancies, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Camille Abboud
- Division of Oncology, Bone Marrow Transplantation and Leukemia Section, Washington University Medical School, St Louis, MO, USA
| | - Sergio Araujo
- Hematology Unit, Hospital das Clínicas-UFMG, Belo Horizonte, Minas Gerais, Brazil
| | - Tzeon-Jye Chiou
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - John Feigert
- Georgetown University Department of Medicine, Virginia Cancer Specialists, Arlington, VA, USA
| | - Su-Peng Yeh
- Department of Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Katharina Götze
- Department of Medicine, Technical University of Munich, Munich, Germany
| | | | - Peter Greenberg
- Hematology Division, Stanford University Cancer Center, Stanford, CA, USA
| | - Suman Kambhampati
- Department of Internal Medicine, Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Yoo-Jin Kim
- Division of Hematology, Department of Internal Medicine, Seoul St Mary's Hospital, Seocho-Gu, Seoul, South Korea
| | - Je-Hwan Lee
- Internal Medicine, Asan Medical Center, Songpa-Gu, Seoul, South Korea
| | - Roger Lyons
- Department of Hematology, Cancer Care Centers of South Texas-US Oncology Network, San Antonio, TX, USA
| | - Marco Ruggeri
- Hematology Department, San Bortolo Hospital, Vicenza, Italy
| | - Valeria Santini
- Department of Experimental and Clinical Medicine, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
| | - Gregory Cheng
- Faculty of Health Science, Macau University of Science and Technology Hospital, Taipa, Macau, China
| | - Jun Ho Jang
- Division of Hematology Oncology, Samsung Medical Center, Seoul, South Korea
| | - Chien-Yuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Brendan Johnson
- Clinical Pharmacology Modeling and Simulation, GlaxoSmithKline, Research Triangle Park, NC, USA
| | - John Bennett
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Frank Mannino
- Oncology R&D, Projects Clinical Platforms and Sciences, GlaxoSmithKline, Collegeville, PA, USA
| | | | - Nicole Stone
- Oncology R&D, Projects Clinical Platforms and Sciences, GlaxoSmithKline, Collegeville, PA, USA
| | - Souria Dougherty
- Oncology R&D, Projects Clinical Platforms and Sciences, GlaxoSmithKline, Collegeville, PA, USA
| | - Geoffrey Chan
- Oncology R&D, Projects Clinical Platforms and Sciences, GlaxoSmithKline, Collegeville, PA, USA
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Kurokawa T, Murata S, Zheng YW, Iwasaki K, Kohno K, Fukunaga K, Ohkohchi N. The Eltrombopag antitumor effect on hepatocellular carcinoma. Int J Oncol 2015; 47:1696-702. [PMID: 26397763 PMCID: PMC4599203 DOI: 10.3892/ijo.2015.3180] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/21/2015] [Indexed: 12/13/2022] Open
Abstract
Currently, sorafenib is the only available chemotherapeutic agent for advanced hepatocellular carcinoma (HCC), but it cannot be used in patients with liver cirrhosis (LC) or thrombocytopenia. In these cases, sorafenib is likely effective if given in combination with treatments that increase the number of platelets, such as thrombopoietin (TPO) receptor agonists. Increasing the platelet count via TPO treatment resulted in reduction of LC. Eltrombopag (EP), a TPO receptor agonist, has been reported to have antitumor effects against certain cancers, despite their lack of TPO receptor expression. We hypothesized that EP may possess antitumor activity against HCC in addition to its ability to suppress hepatic fibrosis by increasing the platelet count. In the present study, the antitumor activity of EP was examined by assessing the inhibition of cell proliferation and then ascertaining the ability of iron supplementation to reverse these effects in HepG2, Hep3B and Huh7 cells. In addition, a cell cycle assay was performed using flow cytometry, and signal transduction was evaluated by analyzing cell cycle-related protein expression. The results of EP were compared with those of the most common iron chelator, deferoxamine (DFO). The combined effect of EP and sorafenib was also assessed. The results revealed that EP exerts antitumor activity in HCC that is mediated by the modulation of intracellular iron content. EP suppressed the expression of the cell cycle-related protein cyclin D1 and elicited cell cycle arrest in the G0/G1 phase. The activity of EP was comparable to that of DFO in HCC, and EP did not compete with sorafenib at low concentrations. In conclusion, our findings suggest that EP is a good candidate chemotherapeutic agent for the treatment of HCC in patients with LC and thrombocytopenia.
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Affiliation(s)
- Tomohiro Kurokawa
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
| | - Soichiro Murata
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
| | - Yun-Wen Zheng
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
| | - Kenichi Iwasaki
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
| | - Keisuke Kohno
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
| | - Kiyoshi Fukunaga
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
| | - Nobuhiro Ohkohchi
- Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery, and Organ Transplantation, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan
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The non-peptide thrombopoietin receptor agonist eltrombopag stimulates megakaryopoiesis in bone marrow cells from patients with relapsed multiple myeloma. J Hematol Oncol 2015; 8:37. [PMID: 25886818 PMCID: PMC4405817 DOI: 10.1186/s13045-015-0136-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 04/04/2015] [Indexed: 01/04/2023] Open
Abstract
Background Thrombocytopenia is a significant problem in patients with relapsed or refractory multiple myeloma, precipitating a need for supportive platelet transfusions and necessitating decreases in delivered doses of chemotherapy. Eltrombopag is a non-peptide, small molecule thrombopoietin (TPO) receptor agonist that promotes megakaryopoiesis similar to endogenous human TPO and may be an effective agent for thrombocytopenia in this patient population. Methods We examined the effects of eltrombopag on megakaryocyte colony-forming capacity in CD34+ cells in patients with multiple myeloma and investigated its impact on proliferation, viability, and apoptosis in primary CD138+ human myeloma cells and myeloma cell lines. Results Eltrombopag at doses of 0.1 to 100 μM did not enhance proliferation of primary human CD138+ multiple myeloma cells from patients with relapsed disease or myeloma cell lines when used alone or in combination with erythropoietin (EPO) and granulocyte colony-stimulating factor (G-CSF) and did not alter cell viability nor apoptosis of human myeloma cells exposed to bortezomib and lenalidomide. Eltrombopag stimulated megakaryopoiesis in human CD34+ cells from normal individuals and from patients with relapsed multiple myeloma via activation of Akt signaling pathways. Conclusions These results provide proof-of-principle supporting the design of future clinical studies examining eltrombopag for the treatment of thrombocytopenia in patients with advanced multiple myeloma.
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Li C, Zheng L. The pharmacology and clinical application of thrombopoietin receptor agonists. Int J Hematol 2014; 100:529-39. [DOI: 10.1007/s12185-014-1660-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 08/14/2014] [Accepted: 08/20/2014] [Indexed: 12/17/2022]
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Svensson T, Chowdhury O, Garelius H, Lorenz F, Saft L, Jacobsen SE, Hellström-Lindberg E, Cherif H. A pilot phase I dose finding safety study of the thrombopoietin-receptor agonist, eltrombopag, in patients with myelodysplastic syndrome treated with azacitidine. Eur J Haematol 2014; 93:439-45. [DOI: 10.1111/ejh.12383] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2014] [Indexed: 01/03/2023]
Affiliation(s)
- Tobias Svensson
- Department of Medical Sciences; Section of Hematology; Uppsala University Hospital; Uppsala Sweden
| | - Onima Chowdhury
- Haematopoietic Stem Cell Laboratory and MRC Molecular Haematology Unit; Weatherall Institute of Molecular Medicine; Oxford University; Oxford UK
| | - Hege Garelius
- Department of Medicine; Section of Hematology and Coagulation; Sahlgrenska University Hospital; Gothenburg Sweden
| | - Fryderyk Lorenz
- Department of Hematology; Umeå University Hospital; Umeå Sweden
| | - Leonie Saft
- Department of Pathology; Division of Hematopathology; Karolinska University Hospital; Solna Sweden
| | - Sten-Eirik Jacobsen
- Haematopoietic Stem Cell Laboratory and MRC Molecular Haematology Unit; Weatherall Institute of Molecular Medicine; Oxford University; Oxford UK
| | - Eva Hellström-Lindberg
- Center for Hematology and Regenerative Medicine; Karolinska Institutet; Karolinska University Hospital; Huddinge Sweden
| | - Honar Cherif
- Department of Medical Sciences; Section of Hematology; Uppsala University Hospital; Uppsala Sweden
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Tamari R, Schinke C, Bhagat T, Roth M, Braunschweig I, Will B, Steidl U, Verma A. Eltrombopag can overcome the anti-megakaryopoietic effects of lenalidomide without increasing proliferation of the malignant myelodysplastic syndrome/acute myelogenous leukemia clone. Leuk Lymphoma 2014; 55:2901-6. [DOI: 10.3109/10428194.2014.894186] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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28
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Pathak S, Roth M, Verma A, Steidl U. Eltrombopag for the treatment of thrombocytopenia in patients with malignant and non-malignant hematologic disorders. Expert Opin Drug Metab Toxicol 2013; 9:1667-75. [DOI: 10.1517/17425255.2013.858119] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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29
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Nozaki R, Murata S, Nowatari T, Maruyama T, Ikeda N, Kawasaki T, Fukunaga K, Ohkohchi N. Effects of thrombopoietin on growth of hepatocellular carcinoma: Is thrombopoietin therapy for liver disease safe or not? Hepatol Res 2013; 43:610-20. [PMID: 23157389 DOI: 10.1111/hepr.12006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 09/19/2012] [Accepted: 10/15/2012] [Indexed: 12/13/2022]
Abstract
AIM Liver cirrhosis (LC) is the end stage of chronic liver disease. No definitive pharmacological treatment is currently available. We previously reported that thrombopoietin (TPO) promoted liver regeneration and improved liver cirrhosis by increasing platelet count. TPO is therefore considered to be a therapeutic agent for LC; however, it is unclear whether TPO has proliferative effects on hepatocellular carcinoma (HCC), which arises frequently in cirrhotic livers. In this study, we examined the effects of TPO on growth of HCC. METHODS Expression of the TPO receptor, myeloproliferative leukemia virus oncogene (MPL) was examined in various liver tumor cell lines and liver cell types. In an in vitro study, the effects of TPO on signal transduction, cell proliferation, migration and invasion were examined in Huh7 cells, in which MPL is highly expressed. In an in vivo study, we subcutaneously transplanted Huh7 cells into nude mice that were divided into a TPO-treated group and a control group, and the tumor volume of each group was measured. RESULTS MPL was expressed strongly in hepatocytes but not in other cell types. Among liver tumor cell lines, Huh7 showed the highest expression of MPL. In Huh7, the addition of TPO activated Akt phosphorylation but not cell proliferation, migration or invasion. In the mouse experiment, there was no significant difference in tumor volume between the two groups. CONCLUSION TPO had no proliferative effect on HCC in vitro or in vivo, and could therefore be useful in the treatment of liver cirrhosis.
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Affiliation(s)
- Reiji Nozaki
- Department of Surgery, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Deutsch VR, Tomer A. Advances in megakaryocytopoiesis and thrombopoiesis: from bench to bedside. Br J Haematol 2013; 161:778-93. [PMID: 23594368 DOI: 10.1111/bjh.12328] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Megakaryocytopoiesis involves the commitment of haematopoietic stem cells, proliferation and terminal differentiation of megakaryocytic progenitors (MK-p) and maturation of megakaryocytes (MKs) to produce functional platelets. This complex process occurs in specialized niches in the bone marrow where MKs align adjacent to vascular endothelial cells, form proplatelet projections and release platelets into the circulation. Thrombopoietin (THPO, TPO) is the primary growth factor for the MK lineage and necessary at all stages of development. THPO is constitutively produced in the liver, and binds to MPL (c-Mpl) receptor on platelets and MKs. This activates a cascade of signalling molecules, which induce transcription factors to drive MK development and thrombopoiesis. Decreased turnover rate and platelet number result in increased levels of free THPO, which induces a concentration-dependent compensatory response of marrow-MKs to enhance platelet production. Newly developed thrombopoietic agents operating via MPL receptor facilitate platelet production in thrombocytopenic states, primarily immune thrombocytopenia. Other drugs are available for attenuating malignant thrombocytosis. Herein, we review the regulation of megakaryocytopoiesis and platelet production in normal and disease states, and the innovative drugs and therapeutic modalities to stimulate or decrease thrombopoiesis.
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Affiliation(s)
- Varda R Deutsch
- The Haematology Institute, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel.
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31
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Dickinson M. Supportive care for thrombocytopenia in patients receiving treatment for myelodysplasia: a challenge for the future. Leuk Lymphoma 2013; 54:221-3. [DOI: 10.3109/10428194.2012.738817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Erickson-Miller CL, Pillarisetti K, Kirchner J, Figueroa DJ, Ottesen L, Martin AM, Liu Y, Kamel YM, Messam C. Low or undetectable TPO receptor expression in malignant tissue and cell lines derived from breast, lung, and ovarian tumors. BMC Cancer 2012; 12:405. [PMID: 22967017 PMCID: PMC3480928 DOI: 10.1186/1471-2407-12-405] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 08/09/2012] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Numerous efficacious chemotherapy regimens may cause thrombocytopenia. Thrombopoietin receptor (TPO-R) agonists, such as eltrombopag, represent a novel approach for the treatment of chemotherapy-induced thrombocytopenia. The TPO-R MPL is expressed on megakaryocytes and megakaryocyte precursors, although little is known about its expression on other tissues. METHODS Breast, lung, and ovarian tumor samples were analyzed for MPL expression by microarray and/or quantitative reverse transcription-polymerase chain reaction (qRT-PCR), and for TPO-R protein expression by immunohistochemistry (IHC). Cell line proliferation assays were used to analyze the in vitro effect of eltrombopag on breast, lung, and ovarian tumor cell proliferation. The lung carcinoma cell lines were also analyzed for TPO-R protein expression by Western blot. RESULTS MPL mRNA was not detectable in 118 breast tumors and was detectable at only very low levels in 48% of 29 lung tumors studied by microarray analysis. By qRT-PCR, low but detectable levels of MPL mRNA were detectable in some normal (14-43%) and malignant (3-17%) breast, lung, and ovarian tissues. A comparison of MPL to EPOR, ERBB2, and IGF1R mRNA demonstrates that MPL mRNA levels were far lower than those of EPOR and ERBB2 mRNA in the same tissues. IHC analysis showed negligible TPO-R protein expression in tumor tissues, confirming mRNA analysis. Culture of breast, lung, and ovarian carcinoma cell lines showed no increase, and in fact, showed a decrease in proliferation following incubation with eltrombopag. Western blot analyses revealed no detectable TPO-R protein expression in the lung carcinoma cell lines. CONCLUSIONS Multiple analyses of breast, lung, and ovarian tumor samples and/or cell lines show no evidence of MPL mRNA or TPO-R protein expression. Eltrombopag does not stimulate growth of breast, lung, or ovarian tumor cell lines at doses likely to exert their actions on megakaryocytes and megakaryocyte precursors.
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Affiliation(s)
| | | | - Jennifer Kirchner
- GlaxoSmithKline, 1250 South Collegeville Rd, Collegeville, PA, 19426, USA
| | - David J Figueroa
- GlaxoSmithKline, 1250 South Collegeville Rd, Collegeville, PA, 19426, USA
| | - Lone Ottesen
- GlaxoSmithKline, Stockley Park, Uxbridge, Middlesex UB11 1BT, UK
| | - Anne-Marie Martin
- GlaxoSmithKline, 1250 South Collegeville Rd, Collegeville, PA, 19426, USA
| | - Yuan Liu
- GlaxoSmithKline, 1250 South Collegeville Rd, Collegeville, PA, 19426, USA
| | | | - Conrad Messam
- GlaxoSmithKline, 1250 South Collegeville Rd, Collegeville, PA, 19426, USA
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Eltrombopag inhibits the proliferation of leukemia cells via reduction of intracellular iron and induction of differentiation. Blood 2012; 120:386-94. [PMID: 22627766 DOI: 10.1182/blood-2011-12-399667] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Eltrombopag (EP) is a small-molecule, nonpeptide thrombopoietin receptor (TPO-R) agonist that has been approved recently for the treatment of thrombocytopenia in patients with chronic immune thrombocytopenic purpura. Prior studies have shown that EP stimulates megakaryopoiesis in BM cells from patients with acute myeloid leukemia and myelodysplastic syndrome, and the results also suggested that it may inhibit leukemia cell growth. In the present study, we studied the effects of EP on leukemia cell proliferation and the mechanism of its antiproliferative effects. We found that EP leads to a decreased cell division rate, a block in G(1) phase of cell cycle, and increased differentiation in human and murine leukemia cells. Because EP is species specific in that it can only bind TPO-R in human and primate cells, these findings further suggested that the antileukemic effect is independent of TPO-R. We found that treatment with EP leads to a reduction in free intracellular iron in leukemic cells in a dose-dependent manner. Experimental increase of intracellular iron abrogated the antiproliferative and differentiation-inducing effects of EP, demonstrating that its antileukemic effects are mediated through modulation of intracellular iron content. Finally, determination of EP's antileukemic activity in vivo demonstrated its ability to prolong survival in 2 mouse models of leukemia.
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Zhang Y, Kolesar JM. Eltrombopag: an oral thrombopoietin receptor agonist for the treatment of idiopathic thrombocytopenic purpura. Clin Ther 2011; 33:1560-76. [PMID: 22054810 DOI: 10.1016/j.clinthera.2011.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2011] [Indexed: 12/30/2022]
Abstract
BACKGROUND Idiopathic thrombocytopenic purpura (ITP) is a relatively rare acquired autoimmune disease characterized by either decreased platelet production or increased platelet destruction leading to reduced platelet counts and increased risk of bleeding. Immune modulators have been used in treatment; however, a novel class of thrombopoietin mimetics has recently been developed. Eltrombopag is approved for patients with chronic ITP who have failed initial treatments with traditional immune modulators or splenectomy. OBJECTIVES The goals of this review were to summarize the pharmacology, pharmacokinetic properties, efficacy, and tolerability of eltrombopag and review the approved and investigational uses of this drug. METHODS A search of Cochrane Central Register of Clinical Trials and clinicaltrials.gov was conducted using the terms eltrombopag or SB-497115-GR. In addition, all reviews and preclinical and clinical studies published in English between January 1980 and January 2011 were identified in PubMed and Cochrane Database of Systemic Reviews using the same terms. RESULTS A total of 153 publications and 13 clinical trials were identified; 14 publications were excluded because they were not published in English. A Phase III trial randomized 114 patients with ITP 2:1 to eltrombopag 50 mg or placebo and demonstrated by day 43 a significantly greater proportion of patients responding in the eltrombopag group than in the placebo group (59% vs 16%, odds ratio [OR] = 9.61; 95% CI, 3.31-27.86; P < 0.0001). The mean percentage change of platelets from baseline in the eltrombopag group was double that of the placebo group at day 8 and was sustained several-fold higher throughout the remainder of the treatment period. Another Phase III trial evaluated the efficacy and safety of eltrombopag compared with placebo over 6 months. The odds of responding (defined as a platelet count of 50-400 × 10(9)/L) were 8 times higher in patients receiving eltrombopag than in those in the placebo group (95% CI, 3.59-18.73; P < 0.0001). Bone marrow fibrosis and hepatotoxicity are the most serious adverse effects, and nausea and vomiting are the most common. Eltrombopag is also being evaluated in the treatment of thrombocytopenia secondary to hepatitis C infection, chemotherapy, acute leukemia, and myelodysplasias. CONCLUSION Eltrombopag is well tolerated and effective in raising platelet counts in patients with chronic ITP.
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Affiliation(s)
- Yang Zhang
- School of Pharmacy, University of Wisconsin-Madison, WI, USA
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Matsuki E, Miyakawa Y, Yamane A, Okamoto S. Humanized VB22B minibody for human Mpl stimulates human megakaryopoiesis but does not enhance platelet aggregation. Exp Hematol 2011; 39:829-36. [PMID: 21605620 DOI: 10.1016/j.exphem.2011.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 04/09/2011] [Accepted: 04/30/2011] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Thrombopoietin stimulates megakaryopoiesis and platelet production by binding to its receptor, Mpl, on hematopoietic progenitor cells. Previously, a murine VB22B minibody for Mpl was shown to stimulate megakaryocyte colony formation in vitro and increase the platelet count in cynomolgus monkeys. In this study, we directly compared the effects of a humanized VB22B minibody (huVB22B) with those of thrombopoietin and eltrombopag under the hypothesis that Mpl agonists might have different biological effects on megakaryopoiesis, platelet production, intracellular signal transduction, and platelet function. MATERIALS AND METHODS Human bone marrow-derived CD34(+) cells were used for colony formation assays and proplatelet formation assays in vitro. The DNA ploidy in megakaryocytes was analyzed by flow cytometry. Phosphorylation of signal transducers and activators of transcription and mitogen-activated protein kinase was detected by Western blotting using specific antibodies. The effects of the Mpl agonists on platelet aggregation were analyzed by aggregometry using human platelets. RESULTS HuVB22B was as potent as thrombopoietin and eltrombopag in its ability to form mature megakaryocytes using human CD34(+) cells in vitro. It did not affect granulocyte-macrophage or erythroid colony formation. HuVB22B increased the number of proplatelet-forming megakaryocytes more efficiently than thrombopoietin or eltrombopag. Despite stronger phosphorylation of signal transducers and activators of transcription and mitogen-activated protein kinase compared with thrombopoietin in human platelets, huVB22B did not enhance adenosine diphosphate- or collagen-induced platelet aggregation. Eltrombopag did not enhance agonist-induced platelet aggregation. CONCLUSIONS We found that huVB22B, eltrombopag, and thrombopoietin have different effects on megakaryopoiesis, platelet function, and intracellular signaling. The precise mechanisms for these different biological effects regarding stimulation through the same receptor, Mpl, remain to be elucidated.
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Affiliation(s)
- Eri Matsuki
- Division of Hematology, Department of Internal Medicine, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Mavroudi I, Pyrovolaki K, Pavlaki K, Kozana A, Psyllaki M, Kalpadakis C, Pontikoglou C, Papadaki HA. Effect of the nonpeptide thrombopoietin receptor agonist eltrombopag on megakaryopoiesis of patients with lower risk myelodysplastic syndrome. Leuk Res 2011; 35:323-8. [DOI: 10.1016/j.leukres.2010.06.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Revised: 06/28/2010] [Accepted: 06/29/2010] [Indexed: 12/24/2022]
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Tadmor T, Polliack A. Expanding the use of thrombopoietin mimetic drugs: what about chronic lymphocytic leukemia? Leuk Lymphoma 2011; 52:558-9. [DOI: 10.3109/10428194.2010.547643] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Thrombopoietin receptor levels in tumor cell lines and primary tumors. JOURNAL OF ONCOLOGY 2010; 2010:135354. [PMID: 21318160 PMCID: PMC3026977 DOI: 10.1155/2010/135354] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 09/24/2010] [Indexed: 11/18/2022]
Abstract
Thrombopoietin (TPO) receptor agonists represent a new approach for the treatment of thrombocytopenia, which may develop as a consequence of immune thrombocytopenia, chemotherapy treatment, chronic hepatitis C infection, or myelodysplastic syndromes. There are concerns that use of certain growth factors can hasten disease progression in some types of hematologic malignancies and solid tumors. In this study, expression of MPL (TPO-R) mRNA was examined in tumor cell lines, patient tumor samples (renal cell carcinoma, prostatic carcinoma, soft tissue and bony/cartilage sarcoma, colon cancer, and lymphoma), and normal tissues using microarray analysis and qRT-PCR. MPL mRNA is expressed at very low or undetectable levels compared with erythropoietin receptor (EPOR), human epidermal growth factor (ERBB2; HER2), and insulin-like growth factor-1 receptor (IGF1R) in these patient samples. These data suggest TPO-R agonists will likely preferentially stimulate proliferation and differentiation of cells of megakaryocytic lineage, potentially demonstrating their utility for correcting thrombocytopenia in clinical settings.
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