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Calleja JL, Delgado Sánchez O, Fuentes Pradera MÁ, Llop E, López Zárraga F, Lozano ML, Parra R, Turnes J. Recommendations for the future management of thrombocytopenia in patients with liver cirrhosis: A modified RAND/UCLA appropriateness method. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:32-50. [PMID: 37028757 DOI: 10.1016/j.gastrohep.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/14/2023] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE The lack of consensus and specific guidelines, and the introduction of new treatments in thrombocytopenia management in liver cirrhosis patients, required a series of recommendations by experts to improve knowledge on this disease. This study's aim was to improve the knowledge around thrombocytopenia in liver cirrhosis patients, in order to contribute to the generation of future evidence to improve the management of this disease. PATIENTS AND METHODS A modified version of the RAND/UCLA appropriateness method was used. The scientific committee, a multidisciplinary team of 7 experts in managing thrombocytopenia in liver cirrhosis patients, identified the expert panel, and participated in elaborating the questionnaire. Thirty experts from different Spanish institutions were invited to answer a 48-item questionnaire covering 6 areas on a nine-point Likert scale. Two rounds were voted. The consensus was obtained if >77.7% of panelists reached agreement or disagreement. RESULTS A total of 48 statements were developed by the scientific committee and then voted by the experts, resulting in 28 defined as appropriate and completely necessary, relating to evidence generation (10), care circuit, (8), hemorrhagic risk assessment, decision-making and diagnostic tests (14), professionals' role and multidisciplinary coordination (9) and patient education (7). CONCLUSIONS This is the first consensus in Spain on the management of thrombocytopenia in liver cirrhosis patients. Experts indicated several recommendations to be carried out in different areas that could help physicians make better decisions in their clinical practice.
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Affiliation(s)
- José Luis Calleja
- Department of Gastroenterology and Hepatology, Puerta de Hierro University Hospital, IDIPHISA, CIBERehd, Madrid, Spain.
| | | | | | - Elba Llop
- Department of Gastroenterology and Hepatology, Puerta de Hierro University Hospital, IDIPHISA, CIBERehd, Madrid, Spain
| | - Fernando López Zárraga
- Vascular and Interventional Radiology Unit, Álava University Hospital, Vitoria-Gasteiz, Spain
| | - María Luisa Lozano
- Department of Hematology, Morales Meseguer General University Hospital, Murcia, Spain; Biomedical Research Institute of Murcia (IMIB-Pascual Parrilla), CIBERER, Murcia, Spain
| | - Rafael Parra
- Blood and Tissue Bank, Vall d'Hebrón Hospital, Barcelona, Spain
| | - Juan Turnes
- Department of Gastroenterology and Hepatology, Pontevedra University Hospital Complex, IIS Galicia Sur, Pontevedra, Spain; Health Research Institute (IIS) Galicia Sur, Pontevedra, Spain
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Yoshiji H, Suzuki J, Imasaki M, Tsukimura E, Miyano M, Kurosaki M. Safety and effectiveness of lusutrombopag in patients who have chronic liver disease with thrombocytopenia and undergoing invasive procedures: Real-world post-marketing surveillance in Japan. Hepatol Res 2023; 53:1105-1116. [PMID: 37497574 DOI: 10.1111/hepr.13945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/05/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
AIM Lustrombopag has been approved for the treatment of thrombocytopenia in patients with chronic liver diseases who are scheduled to undergo an invasive procedure. Here, we report the final results of a post-marketing surveillance assessing the safety and effectiveness of lusutrombopag in Japan. METHODS This multicenter, prospective, real-world surveillance collected data from case report forms between October 2016 and May 2021. The observation period was 2 months after the first day of lusutrombopag treatment. Safety and effectiveness (proportion of patients avoiding preoperative platelet transfusion and responders who achieved platelet count increase from baseline) were assessed. RESULTS The safety analysis set included 1033 (100.0%), 130 (12.6%), and 14 (1.4%) patients who received one or more, two or more, and three or more treatment cycle(s), and 482 (48.9%), 457 (46.3%), and 43 (4.4%) patients who were Child-Pugh class A, B, and C, respectively. The most common serious adverse drug reactions were portal vein thrombosis, pancytopenia, and white blood cell count decrease, reported in 14 (1.36%), three (0.29%), and two (0.19%) patients, respectively. The incidence of adverse drug reactions was not higher in patients with Child-Pugh class C or those undergoing retreatment cycles compared with other Child-Pugh classes or the first treatment cycle, respectively. During the observation period of the first treatment cycle, 94.7% (889/939) of patients avoided preoperative platelet transfusion and 82.8% (741/895) of the patients met the responder criteria. CONCLUSIONS This surveillance study further supports the safety and effectiveness of lusutrombopag in a broad range of patients with chronic liver diseases undergoing planned invasive procedures. CLINICAL TRIAL REGISTRATION JapicCTI-163432.
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Affiliation(s)
- Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Junto Suzuki
- Pharmacovigilance Department, Shionogi & Co., Ltd., Chuo-ku, Osaka, Japan
| | - Masafumi Imasaki
- Pharmacovigilance Department, Shionogi & Co., Ltd., Chuo-ku, Osaka, Japan
| | - Eri Tsukimura
- PMS & Pharmacoepidemiology Department, Shionogi Pharmacovigilance Center Co., Ltd., Chuo-ku, Osaka, Japan
| | - Makiko Miyano
- PMS & Pharmacoepidemiology Department, Shionogi Pharmacovigilance Center Co., Ltd., Chuo-ku, Osaka, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
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Orme ME, Bentley R, Marcella S, Peck-Radosavljevic M, Perard R, Wedemeyer H, Yoshiji H, Agarwal K, Dusheiko G. Systematic Review with Meta-Analysis: Efficacy and Safety of Lusutrombopag for Severe Thrombocytopenia in Patients with Chronic Liver Disease Undergoing Invasive Procedures. Adv Ther 2022; 39:4169-4188. [PMID: 35836089 PMCID: PMC9402754 DOI: 10.1007/s12325-022-02235-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 06/17/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Lusutrombopag is an oral thrombopoietin receptor agonist (TPO-RA). Clinical trials have shown lusutrombopag's efficacy in reducing need for preoperative platelet transfusion in patients with chronic liver disease (CLD) and severe thrombocytopenia. This analysis assessed efficacy and safety of lusutrombopag in patients with severe thrombocytopenia and CLD undergoing planned invasive procedures. METHODS An electronic database search (through 1 December 2020) identified three randomised, placebo-controlled, double-blind clinical trials comparing lusutrombopag with placebo in patients with CLD and platelet count below 50 × 109/L scheduled to undergo a procedure with a perioperative bleeding risk. A random-effects meta-analysis examined treatment effect, with Cochrane Collaboration's tool assessing risk of bias. RESULTS The meta-analysis included 343 (lusutrombopag 3 mg, n = 173; placebo, n = 170) patients. More patients met the criteria for treatment response (platelet count at least 50 × 109/L and increase of at least 20 × 109/L from baseline anytime during the study) with lusutrombopag versus placebo (risk ratio [RR] 6.39; 95% confidence interval [CI] 3.69, 11.07; p < 0.0001). The primary efficacy outcome, proportion of patients requiring no platelet transfusion and no rescue therapy for bleeding for at least 7 days post procedure, was achieved by more patients treated with lusutrombopag versus placebo (RR 3.42; 95% CI 1.86, 6.26; p = 0.0001). The risk of any bleeding event was significantly lower with lusutrombopag compared to placebo (RR 0.55; 95% CI 0.32, 0.95; p = 0.03); conversely, thrombosis event rates were similar between lusutrombopag and placebo (RR 0.79; 95% CI 0.19, 3.24; p = 0.74). CONCLUSION This meta-analysis showed that treatment of severe thrombocytopenia with lusutrombopag in patients with CLD prior to a planned invasive procedure was efficacious and safe in increasing platelet counts, avoiding the need for platelet transfusions, and reducing risk of bleeding, thereby enhancing the certainty of evidence supporting the efficacy and safety of lusutrombopag.
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Affiliation(s)
- Michelle E Orme
- ICERA Consulting Ltd., 17 Redbridge Close, Swindon, Wiltshire, UK.
| | | | | | - Markus Peck-Radosavljevic
- Abteilung Innere Medizin und Gastroenterologie (IMuG), mit Zentrale Aufnahme und Erstversorgung (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | | | - Heiner Wedemeyer
- Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Kosh Agarwal
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Geoffrey Dusheiko
- University College London Medical School and King's College Hospital, London, UK
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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Yoshiji H, Ueno Y, Kurosaki M, Torimura T, Hatano E, Yatsuhashi H, Yamakado K. Treatment algorithm for thrombocytopenia in patients with chronic liver disease undergoing planned invasive procedures. Hepatol Res 2021; 51:1181-1195. [PMID: 34555262 DOI: 10.1111/hepr.13715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/01/2021] [Accepted: 09/16/2021] [Indexed: 12/12/2022]
Abstract
Thrombocytopenia is highly prevalent in patients with chronic liver disease (CLD) and these patients often require invasive procedures that carry a risk of bleeding. To prevent bleeding, guidelines recommend increasing platelet counts in patients with CLD who have thrombocytopenia and are planned to undergo invasive procedures. There are currently two options to increase platelet counts in patients in this setting: platelet transfusion or thrombopoietin receptor agonists (TPORAs). Several treatment algorithms have been developed in the US to help physicians choose the best course of treatment for each patient; however, to date, no such algorithm has been proposed in other countries, where the choice of treatment has been based on each physician's judgment and experience. Here, we discuss the pathogenesis and treatment of thrombocytopenia in patients with CLD, we review and present current evidence of the efficacy of TPORAs for the treatment of thrombocytopenia in patients with CLD, and we present our expert opinion on a Japanese treatment algorithm for thrombocytopenia in patients with CLD who are planned to undergo invasive procedures. This algorithm aims to provide guidance for optimal decision making in the selection of TPORA therapy or platelet transfusion based on the latest evidence and according to actual clinical practice.
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Affiliation(s)
- Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Nara, Japan
| | - Yoshiyuki Ueno
- Department of Gastroenterology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Masayuki Kurosaki
- Department of Gastroenterology and Hepatology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Takuji Torimura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Etsuro Hatano
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Yatsuhashi
- Department of Gastroenterology, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Koichiro Yamakado
- Department of Radiology, Hyogo College of Medicine, Nishinomiya, Japan
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Giannini EG, Kano T, Ochiai T, Bentley R, Shrestha P, Afdhal N. Bleeding events in lusutrombopag-treated thrombocytopenic patients. Eur J Clin Invest 2021; 51:e13503. [PMID: 33523482 PMCID: PMC8243945 DOI: 10.1111/eci.13503] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/22/2021] [Accepted: 01/26/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Edoardo Giovanni Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Takeshi Kano
- Global Project Management Department, Shionogi & Co., Ltd., Osaka, Japan
| | | | - Roy Bentley
- US Global Market Access, Shionogi Inc., Florham Park, NJ, USA
| | - Pomy Shrestha
- Product Safety and Pharmacovigilance, Shionogi Inc., Florham Park, NJ, USA
| | - Nezam Afdhal
- Liver Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
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