Treatment of severe thrombocytopenia associated with systemic lupus erythematosus in pregnancy with eltrombopag: A case report and literature review

Treatment of immune thrombocytopenia during pregnancy with thrombopoietin receptor agonists

The introduction of thrombopoietin receptor agonists (TPO-RAs) led to a paradigm shift in the management of immune thrombocytopenia (ITP). However, TPO-RAs are not approved for use during pregnancy due to the absence of evidence and concerns for possible effects on the fetus due to their expected transplacental transfer. This comprehensive review examines the safety and efficacy of TPO-RA in 45 pregnancies of women with ITP (romiplostim n = 22; eltrombopag n = 21; both in the same pregnancy n = 2). Mothers experienced failure of the median of three treatment lines during pregnancy prior to TPO-RA administration. A platelet response (>30 × 109 /L) was seen in 86.7% of cases (including a complete response >100 × 109 /L in 66.7%) and was similar between eltrombopag and romiplostim (87.0% and 83.3%, p = 0.99). The maternal safety profile was favourable, with no thromboembolic events encountered. Neonatal thrombocytopenia was noted in one third of cases, with one case of ICH grade 3, and neonatal thrombocytosis was observed in three cases. No other neonatal adverse events attributable to TPO-RAs were seen. This review suggests that the use of TPO-RA during pregnancy is associated with a high response rate and appears safe. Nevertheless, TPO-RA should not be routinely used in pregnancy and should be avoided in the first trimester until further evidence is accumulated.

Eltrombopag in severe immune thrombocytopenia secondary to connective tissue disease: a report of 17 patients and literature review

To assess the remission rate of eltrombopag in the treatment of severe immune thrombocytopenia (ITP) secondary to connective tissue disease (CTD) and to explore factors related to drug efficacy in the context of literature reports, seventeen CTD patients accompanied with severe ITP treated with eltrombopag between June 2019 and February 2021 were included, with their follow-up information recorded. Combined with literature review, patients were divided into two groups depending on whether the treatment was effective or not to determine efficacy-related factors. Totally, 7 patients with systemic lupus erythematosus, 6 with Sjögren's syndrome, and 4 with undifferentiated connective tissue disease were enrolled. The median duration of eltrombopag treatment was 8 weeks, and the median time to response was 4 weeks. Twelve (70.6%) patients responded to eltrombopag. Patients with higher serum white blood cell counts, lower serum triglyceride levels, or previously received multiple immunosuppressants achieved a better efficacy (p < 0.05), while those with megakaryocytopenia in bone marrow tended to have lower remission rate (p = 0.08). By using pooled data including literature reported cases, we demonstrated that evidence of leukopenia, megakaryocytopenia, and being treated with fewer prior immunosuppressants were still associated with poor remission (p < 0.05). Meanwhile, there was a trend indicating the primary disease might affect the treatment efficacy (p = 0.06). Eltrombopag is a viable option for treating severe ITP secondary to CTDs, yet it may be less effective for patients with leukopenia, megakaryocytopenia, and being treated with fewer prior immunosuppressants. Key Points • Eltrombopag provides an alternative to the current treatment of CTD-ITP. • White blood cell levels, bone marrow megakaryocyte counts, and prior use of immunosuppressants may affect the efficacy of eltrombopag.

Aplastic Anemia Treated with Eltrombopag during Pregnancy

Aplastic anemia is a rare blood disorder characterized by pancytopenia and hypocellular bone marrow. In patients with aplastic anemia, pancytopenia sometimes worsens during pregnancy, and relapse of aplastic anemia in pregnancy is common. Nevertheless, only supportive care with blood products is the mainstay of treatment of aplastic anemia in pregnancy. Thus, the obstetric management and treatment of aplastic anemia in pregnancy is extremely challenging. We herein report the first case of a pregnant woman complicated with aplastic anemia who was successfully treated with eltrombopag, a thrombopoietin receptor agonist. A 27-year-old primigravida woman who had a history of aplastic anemia refractory to immunosuppressive therapy and was treated with eltrombopag became pregnant. Eltrombopag treatment was continued after weighing the benefits and potential risks. Throughout pregnancy, the woman's pancytopenia did not progress, and she delivered a 2336 g baby vaginally at 38 weeks of gestation. Her postpartum outcome was uneventful, and the neonate did not develop thrombocytosis. Since the efficacy and safety of eltrombopag in pregnancy has not yet been established, its routine use should be avoided. However, if limited to refractory cases and with adequate maternal and fetal monitoring, including neonatal blood examinations, the use of eltrombopag for patients with aplastic anemia during pregnancy may be acceptable and result in favorable maternal and fetal outcomes.