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Yu J, Miao P, Qian S. Application of recombinant human thrombopoietin in pregnant women with immune thrombocytopenia: a single-center experience of four patients and literature review. J Int Med Res 2023; 51:3000605231187950. [PMID: 37548331 PMCID: PMC10408329 DOI: 10.1177/03000605231187950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023] Open
Abstract
The management of pregnant women with immune thrombocytopenia who fail to respond to corticosteroids and intravenous immunoglobulin is an intractable clinical challenge because of the limited availability of evidence-based information. Recombinant human thrombopoietin (rhTPO) is recommended for refractory immune thrombocytopenia (ITP). To date, however, few studies have investigated rhTPO treatment during pregnancy. We retrospectively reviewed four cases who were diagnosed with ITP and treated with rhTPO during pregnancy in our center from January 2015 to June 2020. Of the four cases, two (50%) responded to rhTPO treatment. No adverse events were noted in the newborns. Our findings indicate that rhTPO treatment is safe for patients with refractory gestational ITP, and that subcutaneous injection is a convenient delivery method that does not lead to adverse events. Thus, rhTPO may be a viable alternative treatment option for patients with refractory gestational ITP who do not respond to first-line therapies.
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Affiliation(s)
- Jingdi Yu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Peiwen Miao
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang Chinese Medical University, Hangzhou, China
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2
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Lu J, Jamieson BD, Hui AM. Avatrombopag ethnic sensitivity analysis in chronic liver disease and thrombocytopenia patients: individual-level pooled analysis. Therap Adv Gastroenterol 2022; 15:17562848221105976. [PMID: 35795378 PMCID: PMC9252017 DOI: 10.1177/17562848221105976] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/19/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Few data have been published on the ethnic sensitivity of effectiveness, pharmacokinetics (PK), and pharmacodynamics (PD) of avatrombopag for the management of thrombocytopenia in patients with chronic liver disease (CLD). METHODS An ethnic sensitivity analysis was performed based on the results from two phase III studies (ADAPT-1 and ADAPT-2), with a primary endpoint of the proportion of patients without the requirement of platelet transfusion or rescue treatment for bleeding after randomization to 7 days following a scheduled procedure, and three phase I studies in healthy subjects. Cochran-Mantel-Haenszel and Fisher's exact tests were used to compare the differences in effectiveness in different ethnicities and overall population. RESULTS In total, 435 patients (placebo, n = 158; avatrombopag, n = 277) were stratified into various ethnic groups: 121 East Asians, including the subgroup of 27 Chinese, and 259 Caucasians. The proportion of patients who did not receive a platelet transfusion and those with a platelet count ⩾50 × 109/L in the avatrombopag 40 and 60 mg groups were higher than that of placebo for all ethnicities and in the overall population. Statistical significance was obtained in the overall population and for all ethnicities other than Chinese patients, a group with a very small sample size. No significant difference was observed in the proportion of responders in each ethnic group compared to overall population (p > 0.05). The incidence of adverse events in East Asians was similar to that in both Caucasians and the overall population. CONCLUSION Avatrombopag was effective and safe in the management of thrombocytopenia in Chinese patients with CLD. Ethnicity does not appear to influence the efficacy, safety, PK, or PD of avatrombopag.
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Affiliation(s)
- Jun Lu
- Clinical Research Department, Shanghai Fosun Pharmaceutical Development, Co., Ltd, Shanghai, China
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3
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van Dijk WEM, van Es RJJ, Correa MEP, Schutgens REG, van Galen KPM. Dentoalveolar Procedures in Immune Thrombocytopenia; Systematic Review and an Institutional Guideline. TH OPEN 2021; 5:e489-e502. [PMID: 34805736 PMCID: PMC8595053 DOI: 10.1055/a-1641-7770] [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: 02/18/2021] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background
Dentoalveolar procedures in immune thrombocytopenia (ITP) pose a risk of bleeding due to thrombocytopenia and infection due to immunosuppressive treatments. We aimed to systematically review the safety and management of dentoalveolar procedures in ITP patients to create practical recommendations.
Methods
PubMed, Embase, Cochrane, and Cinahl were searched for original studies on dentoalveolar procedures in primary ITP patients. We recorded bleeding- and infection-related outcomes and therapeutic strategies. Clinically relevant bleeding was defined as needing medical attention.
Results
Seventeen articles were included, of which 12 case reports/series. Overall, the quality of the available evidence was poor. Outcomes and administered therapies (including hemostatic therapies and prophylactic antibiotics) were not systematically reported. At least 73 dentoalveolar procedures in 49 ITP patients were described. The range of the preoperative platelet count was 2 to 412 × 10
9
/L. Two clinically relevant bleedings (2%) were reported in the same patient of which one was life-threatening. Strategies used to minimize the risk of bleeding were heterogeneous and included therapies to increase platelet count, antifibrinolytics, local measures, and minimally invasive techniques. Reports on the occurrence of bleedings due to anesthetics or infection were lacking.
Conclusion
Based on alarmingly limited data, clinically relevant bleedings and infections after dentoalveolar procedures in ITP patients seem rare. Awaiting prospective and controlled studies to further evaluate these risks and the efficacy of therapeutic interventions, we provided our institutional guideline to guide the management of dentoalveolar procedures in ITP patients.
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Affiliation(s)
- Wobke E M van Dijk
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert J J van Es
- Department of Oral and Maxillofacial Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maria E P Correa
- Oral Medicine Ambulatory, Hematology and Hemotherapy Center, University of Campinas, Campinas, Sao Paulo, Brazil
| | - Roger E G Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karin P M van Galen
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
PURPOSE OF REVIEW In this review, we discuss recent developments and trends in the perioperative management of thrombocytopenia. RECENT FINDINGS Large contemporary data base studies show that preoperative thrombocytopenia is present in about 8% of asymptomatic patients, and is associated with increased risks for bleeding and 30-day mortality. Traditionally specific threshold platelet counts were recommended for specific procedures. However, the risk of bleeding may not correlate well with platelet counts and varies with platelet function depending on the underlying etiology. Evidence to support prophylactic platelet transfusion is limited and refractoriness to platelet transfusion is common. A number of options exist to optimize platelet counts prior to procedures, which include steroids, intravenous immunoglobulin, thrombopoietin receptor agonists, and monoclonal antibodies. In addition, intraoperative alternatives and adjuncts to transfusion should be considered. It appears reasonable to use prophylactic desmopressin and antifibrinolytic agents, whereas activated recombinant factor VII could be considered in severe bleeding. Other options include enhancing thrombin generation with prothrombin complex concentrate or increasing fibrinogen levels with fibrinogen concentrate or cryoprecipitate. SUMMARY Given the lack of good quality evidence, much research remains to be done. However, with a multidisciplinary multimodal perioperative strategy, the risk of bleeding can be decreased effectively.
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Kuter DJ, Tarantino MD, Lawrence T. Clinical overview and practical considerations for optimizing romiplostim therapy in patients with immune thrombocytopenia. Blood Rev 2021; 49:100811. [PMID: 33781612 DOI: 10.1016/j.blre.2021.100811] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/23/2020] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
The fundamental treatment goal for patients with immune thrombocytopenia (ITP) is reduced or ameliorated bleeding. Although various treatment options exist for the management of ITP, recent advances have led to the approval of three thrombopoietin receptor agonists (TPO-RAs; romiplostim, eltrombopag, and avatrombopag) in the United States and European Union. Current treatment guidelines for ITP indicate that medical therapy is preferred over surgical therapy and support the use of TPO-RAs as early as 3 months after disease onset. More recent data are available on the use of romiplostim in patients who have had ITP for <1 year, and romiplostim is now indicated for the treatment of adults who have not responded adequately to initial treatment, as well as children aged ≥1 year who have had ITP for ≥6 months. Here we review the role of romiplostim in the management of ITP, with a focus on efficacy and safety data, emerging data on early use (beginning within 3 months of disease onset) and treatment-free remission, and practical considerations for optimal management of ITP.
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Affiliation(s)
- David J Kuter
- Hematology Division, Massachusetts General Hospital, Suite 118, Room 110, Zero Emerson Place, Boston, MA 02114, USA.
| | - Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, 9128 North Lindbergh Drive, Peoria, IL 61615, USA.
| | - Tatiana Lawrence
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 91320, USA.
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6
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Arnold DM, Heddle NM, Cook RJ, Hsia C, Blostein M, Jamula E, Sholzberg M, Lin Y, Kassis J, Larratt L, Tinmouth A, Amini S, Schipperus M, Lim W, Vishnu P, Warner M, Carruthers J, Li N, Lane S, Kelton JG. Perioperative oral eltrombopag versus intravenous immunoglobulin in patients with immune thrombocytopenia: a non-inferiority, multicentre, randomised trial. LANCET HAEMATOLOGY 2020; 7:e640-e648. [PMID: 32853584 DOI: 10.1016/s2352-3026(20)30227-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Patients with immune thrombocytopenia are at risk of bleeding during surgery, and intravenous immunoglobulin is commonly used to increase the platelet count. We aimed to establish whether perioperative eltrombopag was non-inferior to intravenous immunoglobulin. METHODS We did a randomised, open-label trial in eight academic hospitals in Canada. Patients were aged at least 18 years, with primary or secondary immune thrombocytopenia and platelet counts less than 100 × 109 cells per L before major surgery or less than 50 × 109 cells per L before minor surgery. Previous intravenous immunoglobulin within 2 weeks or thrombopoietin receptor agonists within 4 weeks before randomisation were not permitted. Patients were randomly assigned to receive oral daily eltrombopag 50 mg from 21 days preoperatively to postoperative day 7 or intravenous immunoglobulin 1 g/kg or 2 g/kg 7 days before surgery. Eltrombopag dose adjustments were allowed weekly based on platelet counts. The randomisation sequence was generated by a computerised random number generator, concealed and stratified by centre and surgery type (major or minor). The central study statistician was masked to treatment allocation. The primary outcome was achievement of perioperative platelet count targets (90 × 109 cells per L before major surgery or 45 × 109 cells per L before minor surgery) without rescue treatment. We did intention-to-treat and per-protocol analyses using an absolute non-inferiority margin of -10%. This trial is registered with ClinicalTrials.gov, NCT01621204. FINDINGS Between June 5, 2013, and March 7, 2019, 92 patients with immune thrombocytopenia were screened, of whom 74 (80%) were randomly assigned: 38 to eltrombopag and 36 to intravenous immunoglobulin. Median follow-up was 50 days (IQR 49-55). By intention-to-treat analysis, perioperative platelet targets were achieved for 30 (79%) of 38 patients assigned to eltrombopag and 22 (61%) of 36 patients assigned to intravenous immunoglobulin (absolute risk difference 17·8%, one-sided lower limit of the 95% CI 0·4%; pnon-inferiority=0·005). In the per-protocol analysis, perioperative platelet targets were achieved for 29 (78%) of 37 patients in the eltrombopag group and 20 (63%) of 32 in the intravenous immunoglobulin group (absolute risk difference 15·9%, one-sided lower limit of the 95% CI -2·1%; pnon-inferiority=0·009). Two serious adverse events occurred in the eltrombopag group: one treatment-related pulmonary embolism and one vertigo. Five serious adverse events occurred in the intravenous immunoglobulin group (atrial fibrillation, pancreatitis, vulvar pain, chest tube malfunction and conversion to open splenectomy); all were related to complications of surgery. No treatment-related deaths occurred. INTERPRETATION Eltrombopag is an effective alternative to intravenous immunoglobulin for perioperative treatment of immune thrombocytopenia. However, treatment with eltrombopag might increase risk of thrombosis. The decision to choose one treatment over the other will depend on patient preference, resource limitations, cost, and individual risk profiles. FUNDING GlaxoSmithKline and Novartis.
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Affiliation(s)
- Donald M Arnold
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada; Canadian Blood Services, Ancaster, ON, Canada.
| | - Nancy M Heddle
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard J Cook
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON, Canada
| | - Cyrus Hsia
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
| | - Mark Blostein
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Erin Jamula
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jeannine Kassis
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Loree Larratt
- Division of Hematology, University of Alberta, Edmonton, AB, Canada
| | - Alan Tinmouth
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sufia Amini
- Department of Hematology, HagaZiekenhuis, The Hague, Netherlands
| | - Martin Schipperus
- Department of Hematology, HagaZiekenhuis, The Hague, Netherlands; Department of Hematology, University Medical Centre Groningen, Groningen, Netherlands
| | - Wendy Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Prakash Vishnu
- Division of Hematology, Mayo Clinic College of Medicine, Jacksonville, FL, USA
| | | | - Julie Carruthers
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Na Li
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon Lane
- McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John G Kelton
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada; McMaster Centre for Transfusion Research, Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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7
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Bussel JB, Kuter D. Preparing patients with immune thrombocytopenia for surgery: what are the options? LANCET HAEMATOLOGY 2020; 7:e626-e627. [PMID: 32853578 DOI: 10.1016/s2352-3026(20)30253-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Affiliation(s)
| | - David Kuter
- Section of Hematology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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8
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Nakajima S, Kimura N, Nakagawa T, Murata S, Oka H, Shimizu H. Pulmonary valve replacement after tetralogy of Fallot repair in a patient with immune thrombocytopenia. J Card Surg 2020; 35:1711-1713. [PMID: 32445258 DOI: 10.1111/jocs.14640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Marked thrombocytopenia causes significant bleeding in cardiovascular surgery. Herein, we describe the case of a 47-year-old woman with immune thrombocytopenia who underwent successful pulmonary valve replacement for pulmonary valve regurgitation and stenosis after complete repair of tetralogy of Fallot. Her platelet count decreased significantly to less than 5 × 109 /L on postoperative day 3, thus multiple platelet transfusions were given. Pulse steroid therapy with dexamethasone was subsequently administered systemically for 4 days. After the treatment, her platelet count started to recover. There were no significant postoperative bleeding events, and red blood cell transfusion was not required. Other than the platelet event, the postoperative course was uneventful and the patient was discharged on postoperative day 15.
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Affiliation(s)
- Shintaro Nakajima
- Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Naritaka Kimura
- Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tomohiko Nakagawa
- Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoru Murata
- Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hidetoshi Oka
- Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hideyuki Shimizu
- Department of Cardiovascular Surgery, Keio University School of Medicine, Tokyo, Japan
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9
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Xu H, Cai R. Avatrombopag for the treatment of thrombocytopenia in patients with chronic liver disease. Expert Rev Clin Pharmacol 2019; 12:859-865. [PMID: 31352834 DOI: 10.1080/17512433.2019.1649137] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Thrombocytopenia is a common hematological abnormality in patients with chronic liver disease (CLD), occurring in 64%~84% of patients with cirrhosis or fibrosis. Due to the increased risk of bleeding, thrombocytopenia potentially affects management of CLD, such as surgery or liver biopsy. Avatrombopag is a new oral thrombopoietin (TPO) receptor agonist, activating TPO receptor and increasing megakaryocytic proliferation/differentiation and platelet production. Areas covered: This review summarizes the collected data concerning pharmacokinetics, clinical efficacy, safety and tolerability profiles of avatrombopag for the management of thrombocytopenia in patients with CLD. Expert opinion: Avatrombopag is recently approved by Food and Drug Administration (FDA) for the treatment of thrombocytopenia in patients with CLD who are scheduled to undergo a procedure. Based on the available clinical trials, avatrombopag is superior to placebo in reducing the need for platelet transfusions or rescue procedures for bleeding. Avatrombopag is also recommended as alternative to platelet transfusions.
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Affiliation(s)
- Hongming Xu
- Department of emergency, Yuyao People's Hospital , Yuyao , China
| | - Rong Cai
- Department of emergency, Yuyao People's Hospital , Yuyao , China
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10
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Doobaree IU, Newland A, McDonald V, Nandigam R, Mensah L, Leroy S, Seesaghur A, Patel H, Wetten S, Provan D. Primary immune thrombocytopenia (ITP) treated with romiplostim in routine clinical practice: retrospective study from the United Kingdom ITP Registry. Eur J Haematol 2019; 102:416-423. [PMID: 30758874 PMCID: PMC6850028 DOI: 10.1111/ejh.13221] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Romiplostim is a thrombopoietin-mimetic peptibody for adult refractory chronic immune thrombocytopenia (ITP). We aimed to describe ITP patients receiving romiplostim, platelet counts and romiplostim usage in UK clinical practice. METHODS This was a retrospective cohort study of patients in the UKITP Registry who received romiplostim between October 2009 and January 2015, including data up to 6 months before romiplostim initiation through follow-up. RESULTS Of 1440 patients in the UKITP Registry, 118 adults with primary ITP were eligible. Before romiplostim, 22% had splenectomy, 12% received platelet transfusion, 97% received ≥ 1 different ITP medication and 77% received ≥ 3. Most patients (73%) initiated romiplostim ≥ 1 year after ITP diagnosis (chronic phase). The mean duration of romiplostim treatment was 5.7 (SE 0.9) months, and the median was 1.4 months (IQR: 0.2, 6.5). Mean platelet count before romiplostim was 38 × 109 /L, rising to 103 × 109 /L within 1 month, and remaining 50-150 × 109 /L through up to 3 years of follow-up. After romiplostim, 4% of patients had splenectomy, 6% received platelet transfusion, and 57% received just one ITP medication other than romiplostim. CONCLUSION The study provides valuable insights into the real-world use of romiplostim in primary ITP in routine practice and highlighted the timing of romiplostim initiation at different ITP disease phases.
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Affiliation(s)
| | - Adrian Newland
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Vickie McDonald
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Raghava Nandigam
- Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Sandrine Leroy
- Center for Observational Research, Amgen Limited, London, UK
| | | | | | | | - Drew Provan
- Barts and The London School of Medicine and Dentistry, London, UK
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11
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Al-Samkari H, Marshall AL, Goodarzi K, Kuter DJ. Romiplostim for the management of perioperative thrombocytopenia. Br J Haematol 2018; 182:106-113. [DOI: 10.1111/bjh.15280] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/26/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Hanny Al-Samkari
- Center for Hematology; Massachusetts General Hospital Cancer Center; Harvard Medical School; Boston MA USA
| | | | - Katayoon Goodarzi
- Center for Hematology; Massachusetts General Hospital Cancer Center; Harvard Medical School; Boston MA USA
| | - David J. Kuter
- Center for Hematology; Massachusetts General Hospital Cancer Center; Harvard Medical School; Boston MA USA
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12
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Gellens R, Habchi S, Freppel S, Couret D, Iacobelli S. Romiplostim for the Emergency Management of Severe Immune Thrombocytopenia with Intracerebral Hemorrhage. Front Neurol 2018; 8:737. [PMID: 30210422 PMCID: PMC6121195 DOI: 10.3389/fneur.2017.00737] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 12/20/2017] [Indexed: 01/09/2023] Open
Abstract
Currently, we lack well-established guidelines for the emergency management of severe immune thrombocytopenia (ITP) with life-threatening bleeding. We now report the management of two patients with severe ITP, complicated by substantial cerebral hemorrhage, requiring urgent surgery due to refractory intracranial hypertension. To rapidly boost platelet counts (PCs), corticosteroids, intravenous immunoglobulin, and iterative platelet transfusions were given; all were ineffectual. Romiplostim, a thrombopoietin receptor agonist, was then administered as an "on demand therapy," with the result that a rapid and sustained increase of PCs was achieved, thus allowing for postoperative hemostasis. Both patients recovered good neurological condition, suggesting the potential utility of romiplostim, in combined therapy, for the emergency management of severe ITP.
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Affiliation(s)
- Romain Gellens
- Neurocritical Care Unit, Centre Hospitalier Universitaire Sud Réunion, Saint-Pierre, France
| | - Sabrina Habchi
- Neurocritical Care Unit, Centre Hospitalier Universitaire Sud Réunion, Saint-Pierre, France
| | - Sebastien Freppel
- Department of Neurosurgery, Centre Hospitalier Universitaire Sud Réunion, Saint-Pierre, France
| | - David Couret
- Neurocritical Care Unit, Centre Hospitalier Universitaire Sud Réunion, Saint-Pierre, France.,INSERM, UMR 1188 Diabète athérothrombose Thérapies Réunion Océan Indien (DéTROI), plateforme CYROI, Sainte Clotilde, France
| | - Silvia Iacobelli
- Centre d'Études Périnatales de l'Océan Indien (CEPOI) - EA 7388, Centre Hospitalier Universitaire Sud Réunion, Saint-Pierre, France.,Pediatric and neonatal intensive care unit, Centre Hospitalier Universitaire Sud Réunion, Saint-Pierre, France
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13
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Zaja F, Barcellini W, Cantoni S, Carpenedo M, Caparrotti G, Carrai V, Di Renzo N, Santoro C, Di Nicola M, Veneri D, Simonetti F, Liberati AM, Ferla V, Paoloni F, Crea E, Volpetti S, Tuniz E, Fanin R. Thrombopoietin receptor agonists for preparing adult patients with immune thrombocytopenia to splenectomy: results of a retrospective, observational GIMEMA study. Am J Hematol 2016; 91:E293-5. [PMID: 26910388 DOI: 10.1002/ajh.24341] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/12/2016] [Accepted: 02/16/2016] [Indexed: 01/09/2023]
Abstract
In patients with immune thrombocytopenia (ITP) refractory to corticosteroids and intravenous immunoglobulins (IVIG), splenectomy may result at higher risk of peri-operative complications and, for this reason, potentially contraindicated. The thrombopoietin receptor agonists (TPO-RAs) romiplostim and eltrombopag have shown high therapeutic activity in primary ITP, but data of efficacy and safety regarding their use in preparation for splenectomy are missing. Thirty-one adult patients, median age 50 years, with corticosteroids and/or IVIG refractory persistent and chronic ITP who were treated with TPO-RAs (romiplostim= 24; eltrombopag= 7) with the aim to increase platelet count and allow a safer execution of splenectomy were retrospectively evaluated. Twenty-four patients (77%) responded to the use of TPO-RAs with a median platelet count that increased from 11 × 10(9) /L before starting TPO-RAs to 114 × 10(9) /L pre-splenectomy, but a concomitant treatment with corticosteroids and/or IVIG was required in 19 patients. Twenty-nine patients underwent splenectomy while two patients who responded to TPO-RAs subsequently refused surgery. Post-splenectomy complications were characterized by two Grade 3 thrombotic events (1 portal vein thrombosis in the patient with previous history of HCV hepatitis and 1 pulmonary embolism), with a platelet count at the time of thrombosis of 260 and 167 × 10(9) /L, respectively and one Grade 3 infectious event. TPO-RAs may represent a therapeutic option to improve platelet count and reduce the risk of peri-operative complications in ITP candidates to splenectomy. An increased risk of post-splenectomy thromboembolic events cannot be ruled out and thromboprophylaxis with low-molecular weight heparin is generally recommended.
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Affiliation(s)
- Francesco Zaja
- Clinica Ematologica, DISM, a O U S. M. Misericordia; Udine Italy
| | - Wilma Barcellini
- UOC Oncoematologia, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Milano Italy
| | - Silvia Cantoni
- S.C. Di Ematologia Ospedale Nigurda Ca' Granda; Milano Italy
| | - Monica Carpenedo
- U.O Ematologia E Trapianto, a.O San Gerardo Di Monza E Università Di Milano Bicocca; Italy
| | | | | | - Nicola Di Renzo
- U.O. Di Ematologia E Trapianto Cellule Staminali; Lecce Italy
| | - Cristina Santoro
- Dipartimento Di Biotecnologie Cellulari Ed Ematologia; , “Sapienza” Università Di Roma; Roma Italy
| | - Massimo Di Nicola
- Unità Di Immunoterapia Clinica E Terapie Innovative, Fondazione IRCCS Istituto Nazionale Tumori; Milano Italy
| | - Dino Veneri
- Clinica Ematologica, Dipartimento Di Medicina; Sezione Di Ematologia, Azienda Ospedaliera Universitaria Integrata Di Verona; Verona Italy
| | | | | | - Valeria Ferla
- UOC Oncoematologia, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico; Milano Italy
| | | | | | - Stefano Volpetti
- Clinica Ematologica, DISM, a O U S. M. Misericordia; Udine Italy
| | - Enrica Tuniz
- Clinica Ematologica, DISM, a O U S. M. Misericordia; Udine Italy
| | - Renato Fanin
- Clinica Ematologica, DISM, a O U S. M. Misericordia; Udine Italy
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