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Mei H, Liu X, Li Y, Zhou H, Feng Y, Gao G, Cheng P, Huang R, Yang L, Hu J, Hou M, Yao Y, Liu L, Wang Y, Wu D, Shen X, Jin J, Luo J, Zeng Y, Zhou X, Xia R, Jiang Z, Bai Y, Niu T, Yang R, Hu Y. Switching from eltrombopag to hetrombopag in patients with primary immune thrombocytopenia: a post-hoc analysis of a multicenter, randomized phase III trial. Ann Hematol 2024; 103:2273-2281. [PMID: 38842566 PMCID: PMC11224074 DOI: 10.1007/s00277-024-05826-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 05/30/2024] [Indexed: 06/07/2024]
Abstract
While studies have explored the feasibility of switching between various thrombopoietin receptor agonists in treating immune thrombocytopenia (ITP), data on the switching from eltrombopag to hetrombopag remains scarce. This post-hoc analysis of a phase III hetrombopag trial aimed to assess the outcomes of ITP patients who switched from eltrombopag to hetrombopag. In the original phase III trial, patients initially randomized to the placebo group were switched to eltrombopag. Those who completed this 14-week eltrombopag were eligible to switch to a 24-week hetrombopag. Treatment response, defined as a platelet count of ≥ 50 × 109/L, and safety were evaluated before and after the switch. Sixty-three patients who completed the 14-week eltrombopag and switched to hetrombopag were included in this post-hoc analysis. Response rates before and after the switch were 66.7% and 88.9%, respectively. Among those with pre-switching platelet counts below 30 × 109/L, eight out of 12 patients (66.7%) responded, while eight out of nine patients (88.9%) with pre-switching platelet counts between 30 × 109/L and 50 × 109/L responded post-switching. Treatment-related adverse events were observed in 50.8% of patients during eltrombopag treatment and 38.1% during hetrombopag treatment. No severe adverse events were noted during hetrombopag treatment. Switching from eltrombopag to hetrombopag in ITP management appears to be effective and well-tolerated. Notably, hetrombopag yielded high response rates, even among patients who had previously shown limited response to eltrombopag. However, these observations need to be confirmed in future trials.
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Affiliation(s)
- Heng Mei
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Avenue, Wuhan, Hubei, China
| | - Xiaofan Liu
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.288 Nanjing Road Heping District, Tianjin, China
| | - Yan Li
- West China Hospital, Sichuan University, No.37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, China
| | - Hu Zhou
- Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Feng
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guangxun Gao
- The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Peng Cheng
- The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ruibin Huang
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linhua Yang
- The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Jianda Hu
- Fujian Medical University Union Hospital, Fuzhou, China
| | - Ming Hou
- Qilu Hospital, Shandong University, Jinan, China
| | | | - Li Liu
- The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Yi Wang
- Shaanxi Provincial People's Hospital, Xi'an, China
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xuliang Shen
- Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Jie Jin
- The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Jianmin Luo
- The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yun Zeng
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xin Zhou
- Wuxi People's Hospital, Wuxi, China
| | - Ruixiang Xia
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhongxing Jiang
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuansong Bai
- China-Japan Union Hospital of Jilin University, Changchun, China
| | - Ting Niu
- West China Hospital, Sichuan University, No.37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, China.
| | - Renchi Yang
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.288 Nanjing Road Heping District, Tianjin, China.
| | - Yu Hu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Avenue, Wuhan, Hubei, China.
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Vianelli N, Auteri G, Buccisano F, Carrai V, Baldacci E, Clissa C, Bartoletti D, Giuffrida G, Magro D, Rivolti E, Esposito D, Podda GM, Palandri F. Refractory primary immune thrombocytopenia (ITP): current clinical challenges and therapeutic perspectives. Ann Hematol 2022; 101:963-978. [PMID: 35201417 PMCID: PMC8867457 DOI: 10.1007/s00277-022-04786-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/01/2022] [Indexed: 01/19/2023]
Abstract
Chronic primary immune thrombocytopenia (ITP) can today benefit from multiple therapeutic approaches with proven clinical efficacy, including rituximab, thrombopoietin receptor agonists (TPO-RA), and splenectomy. However, some ITP patients are unresponsive to multiple lines of therapy with prolonged and severe thrombocytopenia. The diagnosis of refractory ITP is mainly performed by exclusion of other disorders and is based on the clinician's expertise. However, it significantly increases the risk of drug-related toxicity and of bleedings, including life-threatening events. The management of refractory ITP remains a major clinical challenge. Here, we provide an overview of the currently available treatment options, and we discuss the emerging rationale of new therapeutic approaches and their strategic combination. Particularly, combination strategies may target multiple pathogenetic mechanisms and trigger additive or synergistic effects. A series of best practices arising both from published studies and from real-life clinical experience is also included, aiming to optimize the management of refractory ITP.
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Affiliation(s)
- Nicola Vianelli
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Francesco Buccisano
- Dipartimento Di Biomedicina E Prevenzione, Università Tor Vergata, Rome, Italy
| | | | | | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | | | | | - Elena Rivolti
- Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniela Esposito
- Presidio Ospedaliero San G. Moscati Di Aversa - ASL Caserta, Caserta, Italy
| | - Gian Marco Podda
- Medicina III, Ospedale San Paolo, ASST Santi Paolo E Carlo, Dipartimento Di Scienze Della Salute, Università Degli Studi Di Milano, Milano, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.
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3
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Morales LF, Miyara SJ, Guevara S, Metz CN, Shoaib M, Watt S, Zafeiropoulos S, McCann-Molmenti A, Hayashida K, Takegawa R, Shinozaki K, Choudhary RC, Brindley EC, Nishikimi M, Kressel AM, Alsalmay YM, Mazzotta EA, Cho YM, Aranalde GI, Grande DA, Zanos S, Becker LB, Molmenti EP. Sequential Use of Romiplostim after Eltrombopag for Refractory Thrombocytopenia in Hydrocarbon-Induced Myelodysplasia. Int J Angiol 2021. [DOI: 10.1055/s-0041-1726366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractWe describe the clinical course of a 65-year-old male patient who suffered from hydrocarbon-induced myelodysplasia and was successfully treated with the thrombopoietin receptor agonist (TPO-RA), romiplostim. Myelodysplastic syndromes (MDS) are characterized by ineffective hematopoiesis, cytopenias, and increased risk of leukemic transformation. Here, we present a clinical vignette of MDS-associated thrombocytopenia refractory to first-line drugs as well as the TPO-RA, eltrombopag. To date, romiplostim is an U.S. Food and Drug Administration (FDA)-approved drug for idiopathic thrombocytopenic purpura and thrombocytopenia secondary to liver disease. Of note, currently the FDA advises against its use in MDS based on previous long-term safety concerns. Since the therapeutic options for thrombocytopenia in MDS patients are sparse, repurposing and reassessing romiplostim in this setting have been the focus of recent studies. At the time of writing, no published double-blind randomized clinical trials have conducted a head-to-head comparison between romiplostim and eltrombopag in thrombocytopenic MDS patients. To the best of our knowledge, for a thrombocytopenic patient in the setting of MDS, this is the first documented report of refractory clinical response after a 2-year use of eltrombopag in which replacement of treatment with romiplostim resulted in sustained physiological counts of thrombocytes within four weeks.
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Affiliation(s)
- Luis F. Morales
- Department of Surgery, North Shore University Hospital, Manhasset, New York
| | - Santiago J. Miyara
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | - Sara Guevara
- Department of Surgery, North Shore University Hospital, Manhasset, New York
| | - Christine N. Metz
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | - Muhammad Shoaib
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Stacey Watt
- Jacobs School of Medicine and Biomedical Sciences, Buffalo, University at Buffalo, Buffalo, New York
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | | | - Kei Hayashida
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Ryosuke Takegawa
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Koichiro Shinozaki
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Rishabh C. Choudhary
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Elena C. Brindley
- Feinstein Institutes for Medical Research, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Mitsuaki Nishikimi
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Adam M. Kressel
- Department of Surgery, North Shore University Hospital, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | - Yaser M. Alsalmay
- Department of Surgery, North Shore University Hospital, Manhasset, New York
| | - Elvio A. Mazzotta
- Department of Anesthesiology, The Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Young Min Cho
- Department of Surgery, North Shore University Hospital, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | | | - Daniel A. Grande
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Stavros Zanos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
| | - Lance B. Becker
- Department of Surgery, North Shore University Hospital, Manhasset, New York
- Elmezzi Graduate School of Molecular Medicine, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Ernesto P. Molmenti
- Department of Surgery, North Shore University Hospital, Manhasset, New York
- Feinstein Institutes for Medical Research, Manhasset, New York
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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4
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González-Porras JR, Godeau B, Carpenedo M. Switching thrombopoietin receptor agonist treatments in patients with primary immune thrombocytopenia. Ther Adv Hematol 2019; 10:2040620719837906. [PMID: 31156798 PMCID: PMC6515841 DOI: 10.1177/2040620719837906] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/05/2019] [Indexed: 12/17/2022] Open
Abstract
Primary immune thrombocytopenia (ITP) is a bleeding disorder that conventionally has been treated with steroids or other immunosuppressive treatments. The introduction of thrombopoietin receptor agonists (TPO-RAs), which increase platelet production, dramatically changed the treatment landscape for ITP by providing patients with well-tolerated, long-term treatment options. Two TPO-RAs, eltrombopag and romiplostim, have been approved in the United States and European Union for the treatment of ITP. Some patients do not benefit from the first TPO-RA they receive, so it is assumed that the alternate TPO-RA would have the same outcome. However, eltrombopag and romiplostim have distinct pharmacodynamic and pharmacokinetic properties and may have different tolerability and efficacy in individual patients with ITP. Published retrospective studies showed that >75% of patients who switched to the alternate TPO-RA maintained or achieved a response with the new treatment. Notably, most patients who switched due to lack of efficacy with the first TPO-RA responded to the alternate TPO-RA, which demonstrates an absence of cross-resistance between the two drugs. Therefore, switching to the alternate TPO-RA if the first TPO-RA fails to demonstrate a response should be considered before the use of a less-preferable option.
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Affiliation(s)
- José R González-Porras
- Department of Hematology, IBSAL-Hospital Universitario de Salamanca, 1ª Planta. Paseo de San Vicente, 58-182, 37007, Salamanca, Spain
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5
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Cantoni S, Carpenedo M, Mazzucconi MG, De Stefano V, Carrai V, Ruggeri M, Specchia G, Vianelli N, Pane F, Consoli U, Artoni A, Zaja F, D'adda M, Visentin A, Ferrara F, Barcellini W, Caramazza D, Baldacci E, Rossi E, Ricco A, Ciminello A, Rodeghiero F, Nichelatti M, Cairoli R. Alternate use of thrombopoietin receptor agonists in adult primary immune thrombocytopenia patients: A retrospective collaborative survey from Italian hematology centers. Am J Hematol 2018; 93:58-64. [PMID: 28983953 DOI: 10.1002/ajh.24935] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 09/29/2017] [Accepted: 10/02/2017] [Indexed: 01/09/2023]
Abstract
Sequential use of the TPO-RAs romiplostim and eltrombopag in ITP patients failing either agent was retrospectively evaluated to assess efficacy and impact of clinical characteristics on outcome. Patients were grouped into 5 categories: efficacy issues: 1st TPO-RA failure; loss of response; non-efficacy issues: platelet fluctuations; patient's preference; adverse event development. Either one TPO-RA sequence was analyzed at 3 month and at last follow-up. 106/546 patients on TPO-RA underwent switch and 65% achieved, regained or maintained a short- term response independent of switch sequence, gender or age; lower response rates were associated with lines of previous therapy; disease duration lowers probability to respond. Clinically, patients switched for efficacy issue did not differ from those switched for non-efficacy issues. Response was achieved/regained in 57.8% of patients switched for efficacy issues, the lowest response rates were observed in non-responders to 1st TPO-RA; 80% of patients switched for non-efficacy issues maintained a response. Platelet fluctuation resolved in 44.4%. Of the 49 patients evaluable for long-term outcome, 27 were in response on therapy; 16 discontinued the TPO-RA for reasons other than efficacy, while only 6 were non responders. We confirm the efficacy of TPO-RA switch; once achieved, response to the 2nd TPO-RA seems durable.
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Affiliation(s)
- Silvia Cantoni
- Hematology and Oncology Department; Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda; Milan
| | - Monica Carpenedo
- Hematology and Transplant Unit, ASST San Gerardo Hospital; Monza
| | | | | | | | - Marco Ruggeri
- Hematology Department; San Bortolo Hospital; Vicenza
| | | | - Nicola Vianelli
- “L. e A. Seragnoli” Hematology and Oncology Institute, Sant'Orsola Hospital; Bologna
| | - Fabrizio Pane
- Hematology and Transplant Department; Federico II University; Naples
| | - Ugo Consoli
- Hematology Department; G.Garibaldi Hospital; Catania
| | - Andrea Artoni
- “Angelo Bianchi Bonomi” Haemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan
| | - Francesco Zaja
- Hematology Department; DISM, S. M. Misericordia University Hospital; Udine
| | | | - Andrea Visentin
- Hematology and Clinical Immunology Department; University Hospital; Padua
| | | | - Wilma Barcellini
- Oncohematology Department; Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico; Milan
| | | | - Erminia Baldacci
- Hematology and Cell Biology Department; La Sapienza University; Rome
| | - Elena Rossi
- Hematology Department; Catholic University; Rome
| | - Alessandra Ricco
- Hematology and Transplant Department; Policlinico Consorziale; Bari
| | | | | | - Michele Nichelatti
- Biostatistics, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda; Milan
| | - Roberto Cairoli
- Hematology and Oncology Department; Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda; Milan
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6
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Bidirectional inefficacy or intolerability of thrombopoietin receptor agonists: new data and a concise review. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 16:307-312. [PMID: 28151387 DOI: 10.2450/2017.0258-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/07/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is evidence that the thrombopoietin-receptor agonists romiplostim and eltrombopag may have different therapeutic values and adverse reaction profiles. Here we present new data and provide a review of all studies dealing with switching between these two drugs. MATERIALS AND METHODS A total of 89 patients (38 males and 51 females, aged between 14-87 years) were treated with eltrombopag and/or romiplostim between 2007 and 2016 at our institution. Eltrombopag was switched to romiplostim or vice versa in 32 patients. In addition, all published data concerning patients treated sequentially with different thrombopoietin-receptor agonists were identified via a computer-assisted search and summarised in this article. RESULTS Thirty-two of 89 patients treated with a thrombopoietin-receptor agonist in our institution were given both eltrombopag and romiplostim sequentially. Therapy was switched to the alternate thrombopoietin-receptor agonist 36 times, due to inefficacy (n=21), adverse reactions (n=14), and a patient's preference (n=1). In addition, data from 126 patients who have been treated with both agonists have been published by other groups. In total eltrombopag was replaced by romiplostim in 56 cases due to poor or no response or to adverse reactions. Forty-five patients responded to treatment with romiplostim, 11 patients shared cross-resistance and nine had adverse reactions to romiplostim. In contrast, romiplostim was replaced by eltrombopag in 106 cases. Seventy-eight patients responded to eltrombopag, 27 shared cross-resistance and 19 had adverse reactions to eltrombopag. DISCUSSION Eltrombopag and romiplostim often share bidirectional cross-resistance and/or adverse reactions. Both drugs appear to cause more adverse reactions than have been previously reported.
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7
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Reciprocal absence of cross-resistance between eltrombopag and romiplostim in two patients with refractory immune thrombocytopenic purpura. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 12:605-7. [PMID: 25351191 DOI: 10.2450/2014.0246.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 01/16/2014] [Indexed: 11/21/2022]
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8
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Kim YK, Lee SS, Jeong SH, Ahn JS, Yang DH, Lee JJ, Kim HJ. Efficacy and safety of eltrombopag in adult refractory immune thrombocytopenia. Blood Res 2015; 50:19-25. [PMID: 25830126 PMCID: PMC4377333 DOI: 10.5045/br.2015.50.1.19] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 11/13/2014] [Accepted: 02/05/2015] [Indexed: 12/21/2022] Open
Abstract
Background Eltrombopag is a thrombopoietin receptor agonist with excellent treatment outcomes in immune thrombocytopenia (ITP). Here, we analyzed the dose of eltrombopag required to achieve and maintain safe platelet counts in Korean ITP patients. Methods Adult refractory ITP patients (<30,000 platelets/µL) were enrolled. Eltrombopag doses were increased to achieve a target platelet count (≥50,000 cells/µL). After achieving the target platelet count, the dose of concomitant ITP medications and eltrombopag was reduced to identify the lowest effective dose required to maintain the platelet count. Results Among 18 patients, 66.7% achieved complete response, 5.6% achieved platelet counts between 50,000 and 100,000 cells/µL, and 27.8% failed to achieve the target platelet count. The median ITP duration was significantly shorter in patients who achieved the target platelet count. The initial dose required to achieve the target platelet count was 25 mg/d. The adjusted maintenance doses were 25 mg twice per week or 25 mg/d. After discontinuation, 83.3% relapsed, and the median relapse-free survival was 15 days. Two relapsed and 1 failed patient switched to romiplostim. The response to romiplostim was similar to eltrombopag. During eltrombopag treatment, 38.9% showed hepatobiliary laboratory anomalies. Among 9 follow-up bone marrow examinations, 1 revealed fibrosis after 1 year of treatment. Conclusion Eltrombopag was well tolerated with excellent treatment outcomes in refractory adult ITP patients. Low-dose eltrombopag effectively maintained the target platelet count. However, some patients required longer or higher-dose treatment to maintain the target platelet count, especially in heavily pretreated or longer ITP cases.
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Affiliation(s)
- Yeo-Kyeoung Kim
- Department of Hematology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Seung-Sin Lee
- Department of Hematology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sung-Hoon Jeong
- Department of Hematology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jae-Sook Ahn
- Department of Hematology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Deok-Hwan Yang
- Department of Hematology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Je-Jung Lee
- Department of Hematology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Hyeoung-Joon Kim
- Department of Hematology, Chonnam National University Hwasun Hospital, Hwasun, Korea
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9
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Kuter DJ, Macahilig C, Grotzinger KM, Poston SA, Wang PF, Dawson KL, Ward M. Treatment patterns and clinical outcomes in patients with chronic immune thrombocytopenia (ITP) switched to eltrombopag or romiplostim. Int J Hematol 2015; 101:255-63. [PMID: 25586660 DOI: 10.1007/s12185-014-1731-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/16/2014] [Accepted: 12/19/2014] [Indexed: 11/28/2022]
Abstract
This observational study aimed to assess real-world treatment patterns and clinical outcomes for patients with chronic immune thrombocytopenia (ITP) currently being treated with eltrombopag or romiplostim after switching from corticosteroids, rituximab, or the alternate thrombopoietin receptor agonist (TPO-RA). The study examined the rationale for switching to TPO-RA therapy using aided responses. Dosing patterns were also analyzed before and after switching. Treatment outcomes were assessed through platelet counts at multiple time points including treatment initiation and after switching at the last office visit. A total of 280 patients were enrolled whose active therapy for ITP was replaced with either eltrombopag (n = 130) or romiplostim (n = 150). Efficacy-related issues (desired platelet count not achieved and/or lack of response to prior therapy) were the main drivers for therapy switching among all patients (54 % for eltrombopag vs. 57 % for romiplostim). Platelet counts at the last office visit showed improvement compared with counts at the initiation of either eltrombopag or romiplostim treatment. No significant differences were noted when comparing clinical outcomes between the eltrombopag and romiplostim treatment cohorts. Our results suggest that switching to the other TPO-RA may be beneficial if there is inadequate response to treatment with the initial TPO-RA.
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Affiliation(s)
- David J Kuter
- Hematology Division, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA,
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10
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González-Porras JR, Mingot-Castellano ME, Andrade MM, Alonso R, Caparrós I, Arratibel MC, Fernández-Fuertes F, Cortti MJ, Pascual C, Sánchez-González B, Bernat S, Fuertes-Palacio MA, Vázquez-Paganini JA, Olivera PE, Alvarez-Román MT, Jarque I, Cortés M, Martínez-Robles V, Díaz-Gálvez FJ, Calbacho M, Fernández-Miñano C, Garcia-Frade J, González-López TJ. Use of eltrombopag after romiplostim in primary immune thrombocytopenia. Br J Haematol 2014; 169:111-6. [PMID: 25521630 DOI: 10.1111/bjh.13266] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 11/17/2014] [Indexed: 12/01/2022]
Abstract
The thrombopoietin receptor agonists (THPO-RAs), romiplostim and eltrombopag, are effective and safe in immune thrombocytopenia (ITP). However, the value of their sequential use when no response is achieved or when adverse events occur with one THPO-RA has not been clearly established. Here we retrospectively evaluated 51 primary ITP adult patients treated with romiplostim followed by eltrombopag. The median age of our cohort was 49 (range, 18-83) years. There were 32 women and 19 men. The median duration of romiplostim use before switching to eltrombopag was 12 (interquartile range 5-21) months. The reasons for switching were: lack of efficacy (n = 25), patient preference (n = 16), platelet-count fluctuation (n = 6) and side-effects (n = 4). The response rate to eltrombopag was 80% (41/51), including 67% (n = 35) complete responses. After a median follow-up of 14 months, 31 patients maintained their response. Efficacy was maintained after switching in all patients in the patient preference, platelet-count fluctuation and side-effect groups. 33% of patients experienced one or more adverse events during treatment with eltrombopag. We consider the use of eltrombopag after romiplostim for treating ITP to be effective and safe. Response to eltrombopag was related to the cause of romiplostim discontinuation.
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11
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Kowalczyk M, Rubinstein PG, Aboulafia DM. Initial Experience with the Use of Thrombopoetin Receptor Agonists in Patients with Refractory HIV-Associated Immune Thrombocytopenic Purpura: A Case Series. J Int Assoc Provid AIDS Care 2014; 14:211-6. [PMID: 25504472 DOI: 10.1177/2325957414557266] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
HIV-associated immune thrombocytopenic purpura (ITP) has decreased in incidence 10-fold since the advent of highly active antiretroviral therapy (HAART). For patients with detectable HIV viral loads, first-line treatment approaches involve optimizing HAART followed by standard ITP options used to treat those without HIV infection. In the general population, the thrombopoetin receptor agonists (TRAs), eltrombopag and romiplostim, are effective when used as salvage ITP therapy. In addition, eltrombopag has been used effectively in patients with thrombocytopenia secondary to hepatitis C--a virus seen commonly in HIV-infected patients, especially in those who also have a history of intravenous drug use. There are, however, few reports or studies of TRAs use in those with HIV infection. Herein, we describe 5 cases of refractory HIV-associated ITP managed with TRAs. Although platelet counts improved for all patients, 2 patients succumbed to thromboembolic complications. Our initial experience, as well as our findings from a Medline review, supports the potential utility of TRA as salvage therapy in the treatment of HIV-related ITP; however, we recommend caution in the use of these agents in those who are at highest risk of thrombosis. Additional studies are needed to determine the efficacy and, more importantly, the safety of TRAs in treatment of HIV-associated ITP.
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Affiliation(s)
- Mark Kowalczyk
- Department of Hematology/Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Paul G Rubinstein
- Section of Hematology/Oncology, Stroger Hospital of Cook County, Ruth M. Rothstein CORE Center, Rush University Medical Center, Chicago, IL, USA
| | - David M Aboulafia
- Department of Hematology/Oncology, Virginia Mason Medical Center, Seattle, WA, USA Division of Hematology, The University of Washington School of Medicine, Seattle WA, USA
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12
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Moulis G, Bagheri H, Sailler L, Jonville-Bera AP, Weber E, Guy C, Petitpain N, Laroche ML, Favrelière S, Béné J, Baldin B, Villeval-Federici L, Tebacher-Alt M, Bres V, Veyrac G, Grandvuillemin A, Mauprivez C, Lapeyre-Mestre M, Montastruc JL. Are adverse drug reaction patterns different between romiplostim and eltrombopag? 2009-2013 French PharmacoVigilance assessment. Eur J Intern Med 2014; 25:777-80. [PMID: 25242516 DOI: 10.1016/j.ejim.2014.09.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Romiplostim and eltrombopag, the two marketed thrombopoietin receptor agonists (TPO-RAs), have distinct binding sites and might have distinct pharmacodynamic mechanisms. The aim of this study was to compare their adverse drug reaction (ADR) patterns. METHODS We selected in the French PharmacoVigilance Database all ADRs associated with TPO-RAs from TPO-RA marketing until the 31st of December 2013. Medical charts were reviewed. We conducted disproportionality analyses comparing romiplostim exposure in the reports of a given ADR pattern (thrombosis, neurological, cutaneous, gastrointestinal or hematological) to romiplostim exposure in all other TPO-RA-related ADR reports. Reporting Odds Ratios (RORs) were adjusted for age and gender. We also compared the number of reports of a given ADR pattern per million daily defined doses (DDDs) dispensed in France during the study period. RESULTS We described 45 reports (53 ADRs) with romiplostim and 26 reports (37 ADRs) with eltrombopag. There were 19 venous thromboses. At least one other risk factor was present in 83.3% of the cases. Ten (55.6%) patients had been splenectomized previously. There were eight arterial thromboses. Another risk factor was noticed in all cases. There was no signal for an excess risk of thrombosis with romiplostim versus eltrombopag (ROR: 1.45, 95% CI [0.48-4.45]). There was a signal for a higher risk of gastrointestinal ADRs with eltrombopag (ROR: 30.28, 95% CI [3.23-383.86]) and of hematological ADRs with romiplostim (ROR: 14.36, 95% CI [1.73-119.08]). Dispensing data-adjusted comparisons led to similar results. CONCLUSIONS This study suggests different ADR patterns between romiplostim and eltrombopag.
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Affiliation(s)
- Guillaume Moulis
- Laboratoire de Pharmacologie Médicale et Clinique, Université Paul Sabatier, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France; Equipe de Pharmacoépidémiologie de l'INSERM U 1027, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France; Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Place du Dr Baylac, TSA 40031, 31059 Toulouse Cedex 9, France.
| | - Haleh Bagheri
- Laboratoire de Pharmacologie Médicale et Clinique, Université Paul Sabatier, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France; Equipe de Pharmacoépidémiologie de l'INSERM U 1027, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France; Service de Pharmacologie Clinique, Centre Midi-Pyrénées de Pharmacovigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire de Toulouse, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France
| | - Laurent Sailler
- Equipe de Pharmacoépidémiologie de l'INSERM U 1027, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France; Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Place du Dr Baylac, TSA 40031, 31059 Toulouse Cedex 9, France
| | - Annie-Pierre Jonville-Bera
- Service de Pharmacologie Clinique, Centre Régional de Pharmacovigilance, Centre Hospitalier Universitaire de Tours, 2 bd Tonnellé, 37044 Tours Cedex 9, France
| | - Emmanuelle Weber
- Service de Médecine Interne, Hôpital Nord, Centre Hospitalier Universitaire de Saint-Etienne, 42055 Saint-Étienne Cedex 02, France
| | - Claire Guy
- Centre Régional de Pharmacovigilance et de Renseignements sur le Médicament, Hôpital Nord, Centre Hospitalier Universitaire de Saint-Etienne, 42055 Saint-Étienne Cedex 02, France
| | - Nadine Petitpain
- Service de Pharmacologie Clinique, Centre Régional de Pharmacovigilance de Lorraine, Centre Hospitalier Universitaire de Nancy, 29 Avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy Cedex, France
| | - Marie-Laure Laroche
- Service de Pharmacologie, Toxicologie et Pharmacovigilance, Centre Régional de Pharmacovigilance, de Pharmacoépidémiologie et d'Information sur les Médicaments, Centre Hospitalier Universitaire de Limoges, 2 Avenue Martin-Luther-King, 87042 Limoges Cedex, France
| | - Sylvie Favrelière
- Centre Régional de Pharmacovigilance, Centre Hospitalier Universitaire de Poitiers, BP 577, 86021 Poitiers Cedex, France
| | - Johana Béné
- Centre Régional de Pharmacovigilance, Centre Hospitalier Universitaire de Lille, 1 Place de Verdun, 59045 Lille Cedex, France
| | - Bernadette Baldin
- Centre Régional de Pharmacovigilance, Centre Hospitalier Universitaire de Nice, 4 Avenue Reine Victoria, BP 1179, 06003 Nice Cedex 1, France
| | - Laure Villeval-Federici
- Service de Médecine Interne, Clinique Adassa, 13 Place de Haguenau, 67000 Strasbourg, France
| | - Martine Tebacher-Alt
- Centre Régional de Pharmacovigilance, Centre Hospitalier Universitaire de Strasbourg, 1 Place de l'Hôpital, BP 426, 67091 Strasbourg Cedex, France
| | - Virginie Bres
- Département de Pharmacologie Médicale et Toxicologie, Centre Régional de Pharmacovigilance de Languedoc-Roussillon, Centre Hospitalier Universitaire de Montpellier, 371 Avenue du Doyen-Gaston-Giraud, 34295 Montpellier Cedex 5, France
| | - Gwenaëlle Veyrac
- Service de Pharmacologie Clinique, UF de Pharmacovigilance, Institut de Biologie, Centre Hospitalier Universitaire de Nantes, 9 Quai Moncousu, 44093 Nantes Cedex 01, France
| | - Aurélie Grandvuillemin
- Centre Régional de Pharmacovigilance de Bourgogne, EA 4184, Centre Hospitalier Universitaire de Dijon, 14 rue Paul-Gaffarel, BP 77908, 21079 Dijon Cedex, France
| | - Cédric Mauprivez
- Centre Régional de Pharmacovigilance de Paris-Cochin, Assistance Publique - Hôpitaux de Paris, 27 rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Maryse Lapeyre-Mestre
- Laboratoire de Pharmacologie Médicale et Clinique, Université Paul Sabatier, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France; Equipe de Pharmacoépidémiologie de l'INSERM U 1027, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France; Service de Pharmacologie Clinique, Centre Midi-Pyrénées de Pharmacovigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire de Toulouse, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France
| | - Jean-Louis Montastruc
- Laboratoire de Pharmacologie Médicale et Clinique, Université Paul Sabatier, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France; Equipe de Pharmacoépidémiologie de l'INSERM U 1027, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France; Service de Pharmacologie Clinique, Centre Midi-Pyrénées de Pharmacovigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire de Toulouse, Faculté de Médecine, 37 Allées Jules-Guesde, 31000 Toulouse, France
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13
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Idiopathic thrombocytopenic purpura resistant to eltrombopag, but cured with romiplostim. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 12 Suppl 1:s149-50. [PMID: 23736912 DOI: 10.2450/2013.0289-12] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Accepted: 02/07/2013] [Indexed: 11/21/2022]
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14
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No cross-resistance after sequential use of romiplostim and eltrombopag in chronic immune thrombocytopenic purpura. Blood 2013; 121:1240-2. [DOI: 10.1182/blood-2012-11-465575] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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15
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Polverelli N, Palandri F, Iacobucci I, Catani L, Martinelli G, Vianelli N. Absence of bi-directional cross-resistance of thrombopoietin receptor agonists in chronic refractory immune thrombocytopenia: possible role ofMPLpolymorphisms. Br J Haematol 2012; 161:142-4. [DOI: 10.1111/bjh.12186] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Nicola Polverelli
- Department of Haematology and Clinical Oncology “L. and A. Seràgnoli”, S.Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Francesca Palandri
- Department of Haematology and Clinical Oncology “L. and A. Seràgnoli”, S.Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Ilaria Iacobucci
- Department of Haematology and Clinical Oncology “L. and A. Seràgnoli”, S.Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Lucia Catani
- Department of Haematology and Clinical Oncology “L. and A. Seràgnoli”, S.Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Giovanni Martinelli
- Department of Haematology and Clinical Oncology “L. and A. Seràgnoli”, S.Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
| | - Nicola Vianelli
- Department of Haematology and Clinical Oncology “L. and A. Seràgnoli”, S.Orsola-Malpighi Hospital; University of Bologna; Bologna; Italy
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