1
|
Li Y, Kong F, Bai G, Jiang Y, Zhang W, Sun X, Sui X, Li Y, Ding M, Yuan D, Wang X, Fang X. Eltrombopag can promote platelet implantation after allogeneic hematopoietic stem cell transplantation as safely and similarly to thrombopoietin. Front Immunol 2024; 15:1340908. [PMID: 38650933 PMCID: PMC11033304 DOI: 10.3389/fimmu.2024.1340908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/25/2024] [Indexed: 04/25/2024] Open
Abstract
Background Eltrombopag has demonstrated efficacy in treating low platelet (PLT) levels, but it remains unclear whether eltrombopag can promote PLT engraftment after hematopoietic stem cell transplantation (HSCT). Methods Forty-one HSCT patients received eltrombopag 50 mg/d from +1 day until PLT >50 × 109/L or 1 month after HSCT. Fifty-one patients in the same period received thrombopoietin (TPO) to promote PLT graft after HSCT and served as a control group. Results A total of 51 patients who applied TPO during the same period were treated as a control. In the eltrombopag group, the median time to white blood cells (WBC) graft was 12 days (range, 10-17 days) and the PLT graft was 15 days (range, 10-30 days), whereas for the patients in the TPO group, the median time to WBC and PLT graft was 12 days (range, 9-23 days) and 15.5 days (range, 9-41 days), respectively. In the first month after HSCT, the median WBC count in the eltrombopag group was 4.41 × 109/L (range, 0.87-40.01 × 109/L) and the median PLT was 89x109/L (range, 30-401 × 109/L); the median WBC and PLT \counts in the TPO group were 4.65 × 109/L (range, 0.99-23.63 × 109/L) and 86 × 109/L (range, 5-512 × 109/L), respectively. Patients in the TPO or eltrombopag group did not experience serious side effects after drug administration, and the difference in side effects on liver and kidney function between the two groups was not statistically significant. Conclusion Eltrombopag is safe and similarly promotes platelet engraftment to thrombopoietin after allogeneic HSCT.
Collapse
Affiliation(s)
- Yahan Li
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Fansheng Kong
- Department of Hematology, The Affiliated Hospital of Shandong University of Traditional Chinese Medical, Jinan, Shandong, China
| | - Guanchen Bai
- Department of Hematology, The Affiliated Taian City Centeral Hospital of Qingdao University, Taian, Shandong, China
| | - Yujie Jiang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Wenlu Zhang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xue Sun
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiaohui Sui
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Ying Li
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Mei Ding
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Dai Yuan
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Department of Hematology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
- Branch of National Clinical Research Center for Hematologic Diseases, Jinan, Shandong, China
- National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaosheng Fang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| |
Collapse
|
2
|
Soff G, Leader A, Al-Samkari H, Falanga A, Maraveyas A, Sanfilippo K, Wang TF, Zwicker J. Management of chemotherapy-induced thrombocytopenia: guidance from the ISTH Subcommittee on Hemostasis and Malignancy. J Thromb Haemost 2024; 22:53-60. [PMID: 37827380 DOI: 10.1016/j.jtha.2023.09.031] [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: 06/14/2023] [Revised: 09/08/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
Thrombocytopenia is a common adverse effect of chemotherapy. The development of chemotherapy-induced thrombocytopenia (CIT) is influenced by cancer type and therapy, occurring in approximately one-third of patients with a solid tumor diagnosis and half of all patients with a hematologic malignancy. CIT may complicate the administration of chemotherapy, leading to therapeutic delays or dose reductions. This guidance document, presented by the International Society on Thrombosis and Haemostasis (ISTH) Subcommittee on Hemostasis and Malignancy, provides a comprehensive summary of the evidence and offers direction on the use of thrombopoietin receptor agonists (TPO-RAs) in various settings of CIT, including solid tumors, acute myeloid leukemia, stem cell transplant, and lymphoma. Studies have shown that TPO-RAs can improve platelet counts in CIT, but the clinical benefits of TPO-RA in terms of reducing bleeding, limiting platelet transfusion, avoiding chemotherapy delay, or dose reduction are uncertain. Further research is needed to optimize the selection of appropriate indications and study design to manage thrombocytopenia following chemotherapy.
Collapse
Affiliation(s)
- Gerald Soff
- Department of Medicine, University of Miami Health System/Sylvester Comprehensive Cancer Center, Miami, Florida, USA.
| | - Avi Leader
- Section of Hematology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Hanny Al-Samkari
- Classical Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Anthony Maraveyas
- Faculty of Health Sciences, Joint Centre for Cancer Studies, The Hull York Medical School, Castle Hill Hospital, Hull, UK
| | - Kristen Sanfilippo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA. https://twitter.com/sanfilippomd
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. https://twitter.com/tzufeiwang
| | - Jeffrey Zwicker
- Section of Hematology, Memorial Sloan Kettering Cancer Center, New York, New York, USA. https://twitter.com/jzbos
| |
Collapse
|
3
|
Wen B, Zhang X, Chen S, Fan J, Yang S, Cai Y, Wang P, Zhang Q, Gu Q, Du X. Oral eltrombopag versus subcutaneous recombinant human thrombopoietin for promoting platelet engraftment after allogeneic stem cell transplantation: A prospective, non-inferiority, randomized controlled trial. Hematol Oncol 2022; 40:777-786. [PMID: 35554955 PMCID: PMC9790607 DOI: 10.1002/hon.3017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/20/2022] [Accepted: 05/04/2022] [Indexed: 12/30/2022]
Abstract
Delayed platelet engraftment (DPE) is associated with poor survival and increased transplantation-related mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Therefore, treatments are needed to improve platelet engraftment and prevent DPE. We performed a phase three, non-inferior, randomized controlled study of eltrombopag or recombinant human thrombopoietin (rhTPO) to promot platelet engraftment after allo-HSCT. Candidates for allo-HSCT were randomly assigned to receive oral eltrombopag (50 mg daily) or subcutaneous rhTPO (15000U daily) from the first-day post-transplantation. The primary endpoint was the cumulative numbers of platelet engraftment (platelet recovery ≥20 × 109 /L, without transfusion, for seven consecutive days) on day 60 after transplantation. We performed intention-to-treat analyses with a non-inferior margin of -15%. A total of 92 participants underwent randomization. 44 and 48 patients were randomized to the eltrombopag and rhTPO groups, respectively. The median duration of follow-up was 360 days (range: 12-960 days). The cumulative incidence of platelet engraftment on day 60 after transplantation in eltrombopag group was 86.4% (38/44) compared with 85.4% (41/48) in the rhTPO group (absolute risk difference [ARD] 1%, one-sided lower limit of 95% confidence interval [CI] -13.28%, Pnon-inferirioty = 0.014). The rate of DPE in the eltrombopag group was 6.8% (3/44) compared with 12.5% (6/48) in the rhTPO group (ARD -5.7%, one-sided higher limit of 95% CI 6.28%, Pnon-inferirioty = 0.063). Approximately, three-fourths of non-hematologic adverse events were not observed in the eltrombopag group but three patients (3/48, 6%) experienecd them in the rhTPO group. In addition, platelet transfusions unite from day 0 to day 21, or from day 22 to day 60, progression-free survival, overall survival were not significantly different between both groups. Eltrombopag was non-inferior to rhTPO in promoting platelet engraftment post allo-HSCT for patients with hematological malignancy. Oral eltrombopag was more convenient for patients than subcutaneous rhTPO (NCT03515096).
Collapse
Affiliation(s)
- Bingbing Wen
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| | - Xiaohan Zhang
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| | - Shiyu Chen
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| | - Jingchao Fan
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| | - Sitian Yang
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| | - Yun Cai
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| | - Pengcheng Wang
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| | - Qiaoxia Zhang
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| | - Qingli Gu
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| | - Xin Du
- Department of HematologyThe First Affiliated Hospital of Shenzhen UniversityShenzhen Second People's HospitalShenzhenChina
| |
Collapse
|
4
|
Bostankolu Değirmenci B, Yegin ZA, Dikyar A, Aydın Kaynar L, Özkurt ZN, Uyar Göçün P, Akyürek N. Eltrombopag may induce bone marrow fibrosis in allogeneic hematopoietic stem cell transplant recipients with prolonged thrombocytopenia. Leuk Res 2022; 118:106870. [PMID: 35665626 DOI: 10.1016/j.leukres.2022.106870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 01/05/2023]
Abstract
Poor graft function (PGF) and secondary failure of platelet recovery (SFPR) are significant causes of transplant related morbidity and mortality. Although thrombopoietin receptor agonists (TPO-RA), particularly Eltrombopag (EPAG), have been reported to be efficacious in the treatment of prolonged thrombocytopenia, potential long term adverse effects remain to be elucidated. This retrospective study was performed to determine the efficacy and toxicity profile of TPO-RAs in allogeneic hematopoietic stem cell transplant (alloHCT) recipients. Medical records of 27 patients [median age: 55(21-73) years; male/female: 15/12] who received posttransplant EPAG for SFPR or PGF were analysed. Eltrombopag was started on day 110(33-670) after transplant. Median initial dose was 25(25-50) mg/day which was properly escalated to a maximum dose of 75(50-100) mg/day. Duration of the treatment was median 120(31-377) days. Overall response rate (ORR) was 59.3% in the study population. Time-to-treatment response was 42(3-170) days. Mild-to-moderate bone marrow fibrosis was detected in the posttreatment biopsies of 12/22 patients (54.5%), 9 of whom did not represent any grade of myelofibrosis in their inital biopsies. The grade of posttreatment fibrosis was significantly increased when time-to-treatment response was longer (p = 0.008). Long term use of TPO-RAs may be considered as a potential cause of myelofibrosis in alloHCT recipients.
Collapse
Affiliation(s)
| | - Zeynep Arzu Yegin
- Gazi University Faculty of Medicine, Department of Hematology, Ankara, Turkey.
| | - Asena Dikyar
- Gazi University Faculty of Medicine, Department of Hematology, Ankara, Turkey.
| | - Lale Aydın Kaynar
- Gazi University Faculty of Medicine, Department of Hematology, Ankara, Turkey.
| | - Zübeyde Nur Özkurt
- Gazi University Faculty of Medicine, Department of Hematology, Ankara, Turkey.
| | - Pınar Uyar Göçün
- Gazi University Faculty of Medicine, Department of Pathology, Ankara, Turkey.
| | - Nalan Akyürek
- Gazi University Faculty of Medicine, Department of Pathology, Ankara, Turkey.
| |
Collapse
|
5
|
Tarantini F, Cumbo C, Anelli L, Zagaria A, Conserva MR, Redavid I, Specchia G, Musto P, Albano F. Exploring the Potential of Eltrombopag: Room for More? Front Pharmacol 2022; 13:906036. [PMID: 35677428 PMCID: PMC9168361 DOI: 10.3389/fphar.2022.906036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/06/2022] [Indexed: 11/26/2022] Open
Abstract
Since its introduction in clinical practice, eltrombopag (ELT) has demonstrated efficacy in heterogeneous clinical contexts, encompassing both benign and malignant diseases, thus leading researchers to make a more in-depth study of its mechanism of action. As a result, a growing body of evidence demonstrates that ELT displays many effects ranging from native thrombopoietin agonism to immunomodulation, anti-inflammatory, and metabolic properties. These features collectively explain ELT effectiveness in a broad spectrum of indications; moreover, they suggest that ELT could be effective in different, challenging clinical scenarios. We reviewed the extended ELT mechanism of action in various diseases, with the aim of further exploring its full potential and hypothesize new, fascinating indications.
Collapse
Affiliation(s)
- Francesco Tarantini
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Cosimo Cumbo
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Luisa Anelli
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Antonella Zagaria
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Maria Rosa Conserva
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Immacolata Redavid
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | | | - Pellegrino Musto
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesco Albano
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
- *Correspondence: Francesco Albano,
| |
Collapse
|
6
|
Efficacy and Immunomodulating Properties of Eltrombopag in Aplastic Anemia following Autologous Stem Cell Transplant: Case Report and Review of the Literature. Pharmaceuticals (Basel) 2022; 15:ph15040419. [PMID: 35455416 PMCID: PMC9032708 DOI: 10.3390/ph15040419] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 12/20/2022] Open
Abstract
Thrombopoietin receptor agonists (TPO-RA) are currently indicated for the treatment of chronic immune thrombocytopenia and relapsed refractory aplastic anemia. However, the off-label use of these drugs is more and more frequent, including in the setting of aplasia secondary to chemotherapy and hemopoietic stem cell transplant (SCT). Growing evidence suggests that mechanisms of action of TPO-RA go beyond the TPO-receptor stimulation and point at the immunomodulating properties of these drugs. Here, we present a case of prolonged bone marrow aplasia secondary to autologous SCT treated with eltrombopag. We describe the clinical efficacy and the immunomodulating effect of this drug on inflammatory cytokine profile and bone marrow histology. Furthermore, we provide a review of the most recent literature highlighting the efficacy and safety of TPO-RA after SCT and chemotherapy for hematologic conditions.
Collapse
|
7
|
Güven ZT, Çelik S, Eser B, Çetin M, Ünal A, Kaynar L. Eltrombopag for Treatment of Thrombocytopenia After Hematopoietic Stem Cell Transplantation. Turk J Haematol 2022; 39:103-108. [PMID: 35297243 PMCID: PMC9160700 DOI: 10.4274/tjh.galenos.2022.2021.0675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective: This study aimed to evaluate the efficacy and safety of eltrombopag (ELT) in the treatment of thrombocytopenia following hematopoietic stem cell transplantation (HSCT). Materials and Methods: Forty-eight patients treated with ELT for thrombocytopenia after allogeneic or autologous transplantation at the Erciyes University Bone Marrow Transplantation Center between July 2017 and July 2021 were evaluated retrospectively. Results: Forty-eight HSCT recipients were included in this study. Thirty (62.5%) patients were evaluated as having experienced delayed platelet recovery (DPR) and 18 (37.5%) patients as having experienced secondary failure of platelet recovery (SFPR). The median platelet count before ELT treatment was 13x109/L (range: 3-20x109/L). Twenty-three patients responded to treatment and the cumulative incidence of successful platelet recovery was 48%. Patients with both DPR and SFPR responded, but patients with DPR had a higher response rate (50% vs. 44%). The median platelet count of the 23 responding patients was 12x109/L (5-19x109/L) before treatment and 68x109/L (52-266x109/L) after treatment (p<0.0001). While the number of bone marrow megakaryocytes before treatment was adequate in 22 (46%) cases, it was decreased in 26 (54%) cases. Patients with adequate bone marrow megakaryocytes had a better response rate than those without (77% vs. 23%, p<0.0001). The group with adequate megakaryocytes responded to treatment at a median of 33 days (range: 9-174 days). Patients with decreased megakaryocytes responded at a median of 55 days (30-164 days) (p=0.002). No drug-related side effects were observed in any patients. Conclusion: This real-life experience demonstrates that ELT is an effective and safe treatment option for thrombocytopenia after HSCT. The adequacy of bone marrow megakaryocytes before ELT treatment was an important factor affecting response to treatment.
Collapse
Affiliation(s)
- Zeynep Tuğba Güven
- Erciyes University Faculty of Medicine, Department of Hematology, Kayseri, Turkey
| | - Serhat Çelik
- Erciyes University Faculty of Medicine, Department of Hematology, Kayseri, Turkey
| | | | - Mustafa Çetin
- Erciyes University Faculty of Medicine, Department of Hematology, Kayseri, Turkey
| | - Ali Ünal
- Erciyes University Faculty of Medicine, Department of Hematology, Kayseri, Turkey
| | - Leylagül Kaynar
- Erciyes University Faculty of Medicine, Department of Hematology, Kayseri, Turkey
| |
Collapse
|
8
|
Güven ZT, Çelik S, Eser B, Çetin M, Ünal A, Kaynar L. Eltrombopag for Treatment of Thrombocytopenia After Hematopoietic Stem Cell Transplantation. Turk J Haematol 2022. [DOI: doi10.4274/tjh.galenos.2022.2021.0675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
|
9
|
Eltrombopag in the treatment of patients with persistent thrombocytopenia after haploidentical peripheral blood stem cell transplantation: a single-center experience. Ann Hematol 2021; 101:397-408. [PMID: 34735613 DOI: 10.1007/s00277-021-04706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
Persistent thrombocytopenia (PT) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is associated with an increased risk of bleeding and poor survival. The exact pathogenesis underlying PT remains unclear, and its management is difficult. Here we conducted a retrospective study to evaluate the efficacy and safety of eltrombopag (EPAG) in 34 patients with PT after allo-HSCT. Seven patients suffered from prolonged isolated thrombocytopenia (PIT), and 27 had secondary failure of platelet recovery (SFPR). For most patients, the initial dose was 25 mg or 50 mg daily, then adjusted to the maximum dose of 50-100 mg per day according to the response of platelet recovery and toleration of patients. The cumulative incidence (CI) of platelet recovery to at least 20 × 109/L and 50 × 109/L without transfusion support for at least 7 days was 72.1% and 60.7%, respectively. Nineteen (86.4%) of 22 responders were able to taper off the medication; furthermore, the platelet counts remained stable 1 month after withdrawal of EPAG. Although two patients discontinued EPAG during treatment due to headache and nausea, no patients developed grade 3 or 4 toxicities. Hypoplasia of bone marrow and decreased megakaryocytes (MKs) were found to be risk factors for overall response (OR) and complete response (CR) in multivariate analysis, respectively. Overall, our results indicated that EPAG can be used in the treatment of PT and that continuous exposure to EPAG may not be necessary.
Collapse
|
10
|
Lv WR, Zhou Y, Xu J, Fan ZP, Huang F, Xu N, Xuan L, Shi PC, Liu H, Wang ZX, Sun J, Liu QF. Haploidentical donor transplant is associated with secondary poor graft function after allogeneic stem cell transplantation: A single-center retrospective study. Cancer Med 2021; 10:8497-8506. [PMID: 34668661 PMCID: PMC8633248 DOI: 10.1002/cam4.4353] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 02/05/2023] Open
Abstract
Background Secondary poor graft function (sPGF) is a serious complication after allogeneic hematopoietic stem cell transplantation (allo‐HSCT) related to poor outcome. We aimed to retrospectively evaluate the morbidity and hazard elements of sPGF after allo‐HSCT. Methods Eight hundred and sixty‐three patients who achieved initial engraftment of both neutrophils and platelets were retrospectively reviewed in this study. Results Fifty‐two patients developed sPGF within 180 days post‐transplants, with the median onset time was 62 days (range, 34–121 days) post‐transplants. The overall cumulative incidence of sPGF within 180 days post‐transplantation was 6.0%, with 3.4%, 3.4%, and 10.1%, respectively, in matched sibling donor (MSD), matched unrelated donor (MUD), and haploidentical donor (HID) transplant (p < 0.0001). Multivariable analysis showed that HID (HID vs. MSD: hazard ratio [HR] 2.525, p = 0.004; HID vs. MUD: [HR] 3.531, p = 0.017), acute graft versus host disease (aGVHD) within +30 days ([HR] 2.323, p = 0.003), and cytomegalovirus (CMV) reactivation ([HR] 8.915, p < 0.0001) within +30 days post‐transplants were hazard elements of sPGF. The patients with sPGF had poorer survival than good graft function (51.7±8.1% vs. 62.9±1.9%, p < 0.0001). Our results also showed that only CMV reactivation was the hazard element for the development of PGF in HID transplant ([HR] 12.521 p < 0.0001). Conclusion HID transplant is also an independent hazard element of sPGF except for aGVHD and CMV reactivation.
Collapse
Affiliation(s)
- Wei-Ran Lv
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ya Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi-Ping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Peng-Cheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhi-Xiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qi-Fa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| |
Collapse
|
11
|
Yaman Y, Elli M, Şahin Ş, Özdilli K, Bilgen H, Bayram N, Nepesov S, Anak S. Eltrombopag for treatment of thrombocytopenia after allogeneic hematopoietic cell transplantation in children: Single-centre experience. Pediatr Transplant 2021; 25:e13962. [PMID: 33452850 DOI: 10.1111/petr.13962] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/26/2020] [Accepted: 11/24/2020] [Indexed: 12/17/2022]
Abstract
Delayed recovery of thrombocytopenia is a well-known complication after allogeneic HSCT. Eltrombopag (ELT), a thrombopoietin receptor agonist (TRAs), induces platelet maturation and release. Mostly conducted in adults, some of the previous studies have shown that ELT seems to enhance platelet recovery for post-allogeneic HSCT thrombocytopenia, appears efficacious, and offers transfusion independence. To evaluate the safety and efficacy of ELT in pediatric patients with prolonged isolated thrombocytopenia (PIT) or secondary failure of platelet recovery (SFPR) after alloHSCT. Retrospective analysis of childhood patients who received treatment with ELT for persistent thrombocytopenia after alloHSCT between May 2016 and August 2019. We evaluated the safety and efficacy of ELT in 18 childhood patients with PIT or SFPR after alloHSCT. Eltrombopag (50 mg/d) treatment was started in all patients, above 6 years of age and 20 kg weight, who had thrombocytopenia despite neutrophil engraftment on the 30th day of HSCT. Our objective was to decrease the need for platelet transfusion and have a platelet count of more than 50 000/µL. The overall response rate was 77.7%. The median time to achieve a platelet level above 30 000/µL and 50 000/µL was 21 and 44 days, respectively. In four patients, platelet count never reached 30 000/mm3 . In two patients, the treatment was discontinued due to grade 3 hepatotoxicity. Our study supports the efficacy and relative safety of ELT use for the treatment of PIT and SFPR seen after alloHSCT in children.
Collapse
Affiliation(s)
- Yöntem Yaman
- Pediatric BMT Unit, Istanbul Medipol Universitesi, Istanbul, Turkey
| | - Murat Elli
- Pediatric Oncology, Istanbul Medipol Universitesi, Istanbul, Turkey
| | - Şifa Şahin
- Pediatric Hematology Oncology, İstanbul Üniversitesi, Istanbul, Turkey
| | - Kürşat Özdilli
- Pediatric BMT Unit, Istanbul Medipol Universitesi, Istanbul, Turkey
| | - Hülya Bilgen
- Hematology, Istanbul Medipol Universitesi, Istanbul, Turkey
| | - Nihan Bayram
- Pediatric Hematology Oncology, Istanbul Medipol Universitesi, Istanbul, Turkey
| | - Serdar Nepesov
- Pediatric Immunology, Istanbul Medipol Universitesi, Istanbul, Turkey
| | - Sema Anak
- Pediatric BMT Unit, Istanbul Medipol Universitesi, Istanbul, Turkey
| |
Collapse
|
12
|
Gilreath J, Lo M, Bubalo J. Thrombopoietin Receptor Agonists (TPO-RAs): Drug Class Considerations for Pharmacists. Drugs 2021; 81:1285-1305. [PMID: 34160821 PMCID: PMC8318934 DOI: 10.1007/s40265-021-01553-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 12/11/2022]
Abstract
The thrombopoietin receptor agonists (TPO-RAs) romiplostim, eltrombopag, avatrombopag, and lusutrombopag carry unique US Food and Drug Administration (US FDA)- and European Medicines Agency (EMA)-approved indications and may be used to increase platelet counts in a variety of conditions. Current indications for available TPO-RAs include treatment of chronic immune thrombocytopenia (ITP) in cases of insufficient response to prior treatment (avatrombopag, eltrombopag, romiplostim), management of thrombocytopenia in adult patients with chronic liver disease who are scheduled to undergo a procedure (avatrombopag, lusutrombopag), management of severe aplastic anemia (eltrombopag), and management of thrombocytopenia associated with interferon-based therapy for hepatitis C (eltrombopag). Across current indications, pharmacists can assist in stabilizing platelet counts and help to reduce large undulations commonly seen when starting, stopping, or transitioning between these agents. If therapy modifications may benefit the patient, pharmacists should discuss possible changes with the patient's treatment team or treating physician. When used for ITP, romiplostim, eltrombopag, and avatrombopag stimulate TPO receptors on hematopoietic stem cells (also known as c-Mpl, or CD110) to promote platelet production; however, romiplostim is the only TPO-RA that binds at the same site as endogenous TPO. These subtle mechanistic differences may explain why switching TPO-RA may be clinically advantageous in some situations. As pharmacists are called to counsel patients on TPO-RA use, a deep understanding of potential adverse events and management strategies, as well as appropriate monitoring, will increase the likelihood that patients meet their goals of therapy in the shortest timeframe. Other uses of TPO-RAs are also discussed in this review, including use following hematopoietic stem cell transplant, use in myelodysplastic syndrome, and use in chemotherapy-induced thrombocytopenia.
Collapse
Affiliation(s)
- Jeffrey Gilreath
- Department of Pharmacotherapy, Clinical Hematology/Oncology Pharmacist, University of Utah Hospitals and Clinics Sugar House Clinic, Salt Lake City, UT, USA.
| | - Mimi Lo
- Adult Hematology/Oncology/Blood and Marrow Transplant, University of California, San Francisco Medical Center, San Francisco, CA, USA.,UCSF School of Pharmacy, San Francisco, CA, USA
| | - Joseph Bubalo
- Division of Hematology and Medical Oncology, and Oncology Clinical Pharmacist, OHSU Hospital and Clinics, Portland, OR, USA
| |
Collapse
|
13
|
Efficacy and cost analysis of eltrombopag in thrombocytopenia and poor graft function post allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2021; 56:2471-2476. [PMID: 34108675 DOI: 10.1038/s41409-021-01362-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/09/2021] [Accepted: 05/18/2021] [Indexed: 11/08/2022]
Abstract
Eltrombopag has shown efficacy in the treatment of thrombocytopenia and poor graft function (PGF) after allogeneic hematopoietic cell transplantation (HCT) in retrospective observational studies, but is not approved for this indication. The cost of this drug is also a major concern in publicly funded health care systems. We collected data about patients who received eltrombopag for thrombocytopenia or PGF after HCT. Post-HCT thrombocytopenia, PGF, and eltrombopag response were defined as per previously published criteria. Primary outcome was treatment efficacy and secondary outcome was cost comparison between estimated treatment cost prior to and after initiation of eltrombopag. Seventeen patients (males 70.6%; median age = 58) received eltrombopag. Isolated thrombocytopenia was present in 11.8% (n = 2) patients while PGF was present in 88.2% (n = 15) of patients. After 8 weeks of treatment at the maximum dose of 150 mg orally daily, overall response rate (ORR) was seen in 76.5% (13/17) of patients: complete response (CR) in 10/13 patients and partial response (PR) in 3/13 patients. The use of eltrombopag was associated with an overall decrease in the total weekly care costs (5021 vs 2,524 CA$; P = 0.04). Thus, Eltrombopag is an efficacious and possibly cost-effective therapy for thrombocytopenia and PGF after allogeneic HCT.
Collapse
|
14
|
Uria-Oficialdegui ML, Alonso L, Benitez-Carabante MI, Renedo B, Oliveras M, Diaz-de-Heredia C. Use of eltrombopag for the treatment of poor graft function after hematopoietic stem cell transplantation in children. Pediatr Transplant 2021; 25:e14010. [PMID: 33742757 DOI: 10.1111/petr.14010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/18/2021] [Accepted: 03/02/2021] [Indexed: 01/09/2023]
Abstract
The main objective of this study was to determine whether Eltrombopag, a synthetic thrombopoietin receptor agonist, could improve peripheral blood counts in the three hematopoietic lineages and achieve transfusion independence in children with poor graft function (PGF) after allogenic hematopoietic stem cell transplantation (HSCT). Retrospective study of patients under 18 years who developed PGF post-HSCT in a large tertiary institution between January 2013 and March 2019. Out of 198 allogeneic HSCT, five patients met PGF criteria and were treated with eltrombopag. Median time from HSCT to eltrombopag initiation was 120 days. The median starting dose was 50 mg/day and the maximum dose reached was 75 mg/day. Median treatment duration was 9 months. Three patients achieved complete response and one partial response. The median dose among responders was 75 mg/day and the median time to response 8 weeks. Responses were sustained in three patients and two required a booster dose of CD34+ -selected cells from the original donor. None of the patients had to stop treatment due to adverse effects. The use of eltrombopag in children with PGF achieved responses in 80% of cases and demonstrated to be an effective and safe therapeutic option in pediatric patients with PGF.
Collapse
Affiliation(s)
- M Luz Uria-Oficialdegui
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Laura Alonso
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | | | - Berta Renedo
- Department of Pharmacy, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Maria Oliveras
- Department of Pharmacy, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Cristina Diaz-de-Heredia
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| |
Collapse
|
15
|
Eltrombopag for the treatment of poor graft function following allogeneic stem cell transplant: a retrospective multicenter study. Int J Hematol 2021; 114:228-234. [PMID: 33886103 DOI: 10.1007/s12185-021-03153-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
This retrospective study assessed the effectiveness of eltrombopag (EPAG), a thrombopoietin receptor agonist, in the treatment of poor graft function (PGF) following an allogeneic haemopoietic stem cell transplantation (HSCT). Complete response was defined as normalization of blood counts, whereas partial response was defined as transfusion independence. A total of 48 patients with full donor chimerism after HSCT, received EPAG for a median of 120 days (range 10-591). Patients with uni- bi- or tri-lineage cytopenia started treatment at a median of 95 days (range 17-877) after HSCT. The overall response rate was 75%: 24 patients had a complete response and 12 had a partial response. Positive predictors of response were an HLA-matched donor, a CD34+ dose at transplant > 4 × 106/kg, and starting EPAG treatment at least 90 days after HSCT. Patients with more than one positive predictor had a response rate of 92% for the overall patient cohort and 94% for patients with tri-lineage cytopenia. One-year survival was 89% for complete responders, 60% for partial responders and 20% for non-responders (p = 0.0004). EPAG improves peripheral blood counts in patients with poor graft function following HSCT. Response to EPAG can be predicted and has a significant impact on survival.
Collapse
|
16
|
The Successful Sequential Use of Plerixafor and Eltrombopag For Hematopoietic Cell Transplantation in a Child With High-risk Neuroblastoma. J Pediatr Hematol Oncol 2020; 42:e680-e682. [PMID: 31306338 DOI: 10.1097/mph.0000000000001551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
High-dose chemotherapy with autologous hematopoietic stem cell transplantation improves event-free survival in patients with high-risk neuroblastoma. However, in heavily pretreated patients, poor marrow function can be an obstacle in the successful proceeding of therapy. Priming with plerixafor plus filgrastim is an option for effective mobilization and collection of stem cells. In addition, thrombopoietin agonist eltrombopag can improve the outcome of posttransplantation thrombocytopenia and poor graft function in the posttransplant setting. We describe a case of a child with high-risk neuroblastoma, for whom plerixafor and eltrombopag were used as an effective and safe supportive therapy.
Collapse
|
17
|
Chen J, Wang H, Zhou J, Feng S. Advances in the understanding of poor graft function following allogeneic hematopoietic stem-cell transplantation. Ther Adv Hematol 2020; 11:2040620720948743. [PMID: 32874483 PMCID: PMC7436797 DOI: 10.1177/2040620720948743] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022] Open
Abstract
Poor graft function (PGF) following allogeneic hematopoietic stem-cell transplantation (allo-HSCT) is a life-threatening complication and is characterized by bilineage or trilineage blood cell deficiency and hypoplastic marrow with full chimerism. With the rapid development of allo-HSCT, especially haploidentical-HSCT, PGF has become a growing concern. The most common risk factors illustrated by recent studies include low dose of infused CD34+ cells, donor-specific antibody, cytomegalovirus infection, graft versus host disease (GVHD), iron overload and splenomegaly, among others. Because of the poor prognosis of PGF, it is crucial to uncover the underlying mechanism, which remains elusive. Recent studies have suggested that the bone marrow microenvironment may play an important role in the pathogenesis of PGF. Deficiency and dysfunction of endothelial cells and mesenchymal stem cells, elevated reactive oxygen species (ROS) levels, and immune abnormalities are believed to contribute to PGF. In this review, we also discuss recent clinical trials that evaluate the safety and efficacy of new strategies in patients with PGF. CD34+-selected stem-cell boost (SCB) is effective with an acceptable incidence of GVHD, despite the need for a second donation. Alternative strategies including the applications of mesenchymal stem cells, N-acetyl-l-cysteine (NAC), and eltrombopag have shown favorable outcomes, but further large-scale studies are needed due to the small sample sizes of the recent clinical trials.
Collapse
Affiliation(s)
- Juan Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Department of Stem Cells and Regenerative Medicine, Peking Union Medical College, Tianjin, China
| | - Hongtao Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Department of Stem Cells and Regenerative Medicine, Peking Union Medical College, Tianjin, China
| | - Jiaxi Zhou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
- Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Department of Stem Cells and Regenerative Medicine, Peking Union Medical College, Tianjin, 300020, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
- Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Department of Stem Cells and Regenerative Medicine, Peking Union Medical College, Tianjin, 300020, China
| |
Collapse
|
18
|
Samarkandi H, Al Nahedh M, Alfattani A, Alsharif F, Bakshi N, Rasheed W, Alfraih F, Alhumaid M, Alkhudair N, Alhayli S, Alsaedi H, Shaheen M, Hanbali A, Hashmi SK, Devol E, Alseraihy A, Alzahrani H, Aljurf M. Evaluation of eltrombopag in thrombocytopenia post Hematopoietic cell transplantation: Rertrospective observational trial. Hematol Oncol Stem Cell Ther 2020; 15:285-290. [PMID: 32755559 DOI: 10.1016/j.hemonc.2020.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Thrombocytopenia remains a life-threatening late complication of HCT with an incidence of 5-20%. Currently, there is no approved drug for the treatment of persistent thrombocytopenia post HCT and platelet transfusion is the maintain stay of treatment. Eltrombopag is approved for the treatment of thrombocytopenia associated with different diseases, however; data on eltrombopag treatment post HCT are limited. METHODS This is a retrospective cohort study evaluating the effect of eltrombopag on platelet recovery in patients with persistent thrombocytopenia post HCT. The primary endpoint was platelet recovery to ≥ 20,000/μL for 7 consecutive days without transfusion support after starting eltrombopag. Secondary endpoint was platelet recovery to ≥ 50,000/μL for 7 consecutive days. RESULTS Twenty-one patients were included. Twelve (75%) of 16 patients became independent from platelet transfusions. Median time from starting eltrombopag to last transfusion was 60 days (range, 9-226 days). Ten (63%) of 16 transfusion dependent patients with platelet count < 20,000/μL achieved the primary endpoint. Seven (33%) patients of 21 included had successful platelet recovery (ie, ≥50,000/μL without transfusion support) and the median time to platelet recovery in patients who achieved it was 32 days (range, 13-265 days). Ten patients (48%) were able to successfully discontinue eltrombopag without recurrence of thrombocytopenia. CONCLUSION Our findings demonstrated that eltrombopag appears to have a clinically significant impact on platelet recovery in persistent thrombocytopenic patients post HCT.
Collapse
Affiliation(s)
- H Samarkandi
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Al Nahedh
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - A Alfattani
- Biostatistics Epidemiology and Scientific Computing Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - F Alsharif
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - N Bakshi
- Pathology and Laboratory Medicine Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - W Rasheed
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - F Alfraih
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Alhumaid
- Oncology Centre, King Saud Medical City, Riyadh, Saudi Arabia
| | - Nora Alkhudair
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - S Alhayli
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - H Alsaedi
- Pediatric Hematology/Oncology Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Shaheen
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - A Hanbali
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - S K Hashmi
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - E Devol
- Biostatistics Epidemiology and Scientific Computing Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - A Alseraihy
- Pediatric Hematology/Oncology Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - H Alzahrani
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - M Aljurf
- Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| |
Collapse
|
19
|
Vasudevan Nampoothiri R, Kumar R. Eltrombopag: Role in Cytopenias Following Hematopoietic Stem Cell Transplantation. Indian J Hematol Blood Transfus 2020; 36:238-245. [PMID: 32425372 PMCID: PMC7229069 DOI: 10.1007/s12288-019-01194-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/16/2019] [Indexed: 12/22/2022] Open
Abstract
Eltrombopag is a small molecule oral agonist of the thrombopoietin receptor. Initially used for improving thrombocytopenia in chronic immune thrombocytopenia (ITP), it was later found to be efficacious in various other etiologies of thrombocytopenia as well as inherited marrow failure syndromes. Lately, it has been used for thrombocytopenia and poor graft function after allogeneic hematopoietic stem cell transplantation (HSCT) without any severe adverse events. Although prospective evidence of the efficacy is limited, there are increasing reports on the safety and efficacy with Eltrombopag in post HSCT thrombocytopenia and poor graft function. This provides an exciting opportunity for further research to evaluate both efficacy and cost-effectiveness of the use of Eltrombopag in this scenario. Here we review the current evidence on the indications for the use of Eltrombopag in the post allogeneic hematopoietic stem cell transplant setting.
Collapse
Affiliation(s)
- Ram Vasudevan Nampoothiri
- Messner Allogeneic Transplant Program, University of Toronto, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Rajat Kumar
- Messner Allogeneic Transplant Program, University of Toronto, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| |
Collapse
|
20
|
Mahat U, Rotz SJ, Hanna R. Use of Thrombopoietin Receptor Agonists in Prolonged Thrombocytopenia after Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:e65-e73. [DOI: 10.1016/j.bbmt.2019.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 01/09/2023]
|
21
|
Virus reactivation and low dose of CD34+ cell, rather than haploidentical transplantation, were associated with secondary poor graft function within the first 100 days after allogeneic stem cell transplantation. Ann Hematol 2019; 98:1877-1883. [DOI: 10.1007/s00277-019-03715-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/06/2019] [Indexed: 12/17/2022]
|
22
|
Eltrombopag maintains human hematopoietic stem and progenitor cells under inflammatory conditions mediated by IFN-γ. Blood 2019; 133:2043-2055. [PMID: 30803992 DOI: 10.1182/blood-2018-11-884486] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/12/2019] [Indexed: 12/15/2022] Open
Abstract
The proinflammatory cytokine interferon-γ (IFN-γ) has been implicated in human hematopoietic stem and progenitor cell (HSPC) depletion in immune-mediated bone marrow failure syndromes. We show that IFN-γ specifically prevents full engagement of thrombopoietin (TPO), a primary positive regulator of HSPC survival, to its receptor (c-MPL) via steric occlusion of the low-affinity binding site, contributing to perturbation of TPO-induced signaling pathways and decreased survival of human HSPCs. Eltrombopag, a synthetic small molecule mimetic of TPO that interacts with c-MPL at a position distinct from the extracellular binding site of TPO, bypasses this inhibition, providing an explanation for its clinical activity in bone marrow failure, despite already elevated endogenous TPO levels. Thus, IFN-γ-mediated perturbation of TPO:c-MPL complex formation and the resulting inhibition of a critical pathway of growth factor cell signaling may represent a general mechanism by which IFN-γ impairs the function of human HSPCs. This understanding could have broad therapeutic implications for various disorders of chronic inflammation.
Collapse
|
23
|
Yuan C, Boyd AM, Nelson J, Patel RD, Varela JC, Goldstein SC, Ahmad S, Zhu X, Mori S. Eltrombopag for Treating Thrombocytopenia after Allogeneic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1320-1324. [PMID: 30710685 DOI: 10.1016/j.bbmt.2019.01.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/22/2019] [Indexed: 01/18/2023]
Abstract
Thrombocytopenia after allogeneic hematopoietic stem cell transplantation (allo-SCT) can pose significant problems in management of patients. Eltrombopag is a small-molecule thrombopoietin receptor agonist that has been approved for use in immune thrombocytopenic purpura and aplastic anemia; but its use after allo-SCT is limited. Between 2014 and 2017, we treated 13 patients with eltrombopag for poor platelet engraftment without evidence of relapse at the time of initiation, including 6 patients with primary platelet engraftment failure and 7 with secondary platelet engraftment failure. Eltrombopag was started at an initial dose of 25 or 50 mg per day, and dose adjustments were made in accordance with the manufacturer's recommendation. The cumulative incidence of platelet recovery to ≥50,000/μL without the need for transfusion for at least 7 days was defined as response. The overall response rate was 62% (n = 8). Of the 6 patients with primary isolated platelet failure, 3 (50%) responded, and of the 7 patients with secondary platelet failure, 5 (71%) responded. The median time to response was 33 days (range, 11 to 68 days). In addition, no significant differences in platelet recovery were noted in patients with adequate and decreased bone marrow megakaryocytic reserve (60% and 67%, respectively). Although eltrombopag was well tolerated, and no patient discontinued treatment because of adverse events, only 3 patients were alive at the end of the observation period, with relapse and graft-versus-host disease accounting for majority of the deaths. This suggested that despite the relatively good overall response rate to eltrombopag, inadequate platelet engraftment is a harbinger of poor outcome in allo-SCT.
Collapse
Affiliation(s)
- Cai Yuan
- Department of Hematology and Oncology, University of Florida, Gainesville, Florida
| | - Angela M Boyd
- Pharmacy Department, Florida Hospital, Orlando, Florida
| | - Jan Nelson
- Pharmacy Department, Florida Hospital, Orlando, Florida
| | - Rushang D Patel
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida
| | - Juan C Varela
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida
| | - Steven C Goldstein
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Florida Hospital Cancer Institute, Orlando, Florida
| | - Xiang Zhu
- Center for Collaborative Research, Florida Hospital, Orlando, Florida
| | - Shahram Mori
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida.
| |
Collapse
|
24
|
Eltrombopag for post-transplant cytopenias due to poor graft function. Bone Marrow Transplant 2019; 54:1346-1353. [PMID: 30679824 DOI: 10.1038/s41409-019-0442-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 01/06/2023]
Abstract
Persistent cytopenia due to poor graft function (PoGF) is a relatively common complication which may affect up to 20% of patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Treatment options for PoGF remain limited, and reinfusion of additional HSC is often the only way to rescue hematopoiesis. Here we describe a retrospective single-center experience with the thrombopoietin-mimetic agent eltrombopag for the treatment of PoGF. Thirteen patients have received eltrombopag for either PoGF (n = 12) or primary graft failure (n = 1). In the 12 PoGF patients eltrombopag was started at the median time of 79 days after HSCT, due to persistent thrombocytopenia, with concomitant anemia and neutropenia in 7 and 3 patients, respectively. The treatment was started at the dose of 50 mg per day, and eventually increased up to 150 mg in case of lack of response. Hematological response was seen in 7 patients, with 6 complete responses. Hematological responses were seen both in patients with evidence of immune-mediated pathophysiology, and with possible infectious/iatrogenic causes. In responding patients, eltrombopag was discontinued in 6/7 patients without further relapse. These results suggest that eltrombopag is safe and possibly effective in the setting of the treatment of PoGF, and pave the way for future prospective studies.
Collapse
|
25
|
Eltrombopag is an effective and safe therapy for refractory thrombocytopenia after haploidentical hematopoietic stem cell transplantation. Bone Marrow Transplant 2019; 54:1310-1318. [PMID: 30664724 DOI: 10.1038/s41409-019-0435-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/20/2018] [Accepted: 12/23/2018] [Indexed: 12/13/2022]
Abstract
Refractory thrombocytopenia is a frequent and severe complication after haploidentical allogeneic hematopoietic stem cell transplantation (haplo-HSCT) and lacks effective treatment strategies. Eltrombopag has shown promising results in several thrombocytopenia disorders. We report 38 patients treated with eltrombopag for refractory thrombocytopenia after haplo-HSCT. Eight patients had delayed platelet engraftment, 15 patients had secondary failure of platelet recovery, and 15 patients had poor graft function (PGF). Eltrombopag was initiated at 25 or 50 mg daily, and the dosage was adjusted to a maximum of 50-100 mg daily to maintain platelet between 50 × 109/L and 100 × 109/L. The cumulative incidence of platelet recovery to transfusion independence was 63.2% and to ≥50 × 109/L without transfusion support was 52.3%. Furthermore, neutrophil counts and hemoglobin were also increased in the nine responders with PGF. Nineteen (79.2%) of the 24 responders were able to taper off eltrombopag, and the remaining 5 patients were able to begin a taper. The median duration of treatment was 64 (range 14-195) days. The presence of megakaryocyte before initiation was the only independent factor influencing the efficacy of eltrombopag (P = 0.044). Eltrombopag was well tolerated in all patients. In summary, eltrombopag was a safe and effective therapy for refractory thrombocytopenia after haplo-HSCT.
Collapse
|
26
|
Bosch-Vilaseca A, García-Cadenas I, Roldán E, Novelli S, Barba P, Esquirol A, Valcárcel D, Martino R, Sierra J. Usefulness of thrombopoietin receptor agonists for persistent clinically relevant thrombocytopenia after allogeneic stem cell transplantation. Eur J Haematol 2018; 101:407-414. [DOI: 10.1111/ejh.13132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/17/2018] [Accepted: 06/18/2018] [Indexed: 01/29/2023]
Affiliation(s)
- Anna Bosch-Vilaseca
- Hematology Department; Hospital de la Santa Creu i Sant Pau; Biomedical Research Institute (IIB Sant-Pau) and José Carreras Leukemia Research Institute; Autonomous University of Barcelona (UAB); Barcelona Spain
| | - Irene García-Cadenas
- Hematology Department; Hospital de la Santa Creu i Sant Pau; Biomedical Research Institute (IIB Sant-Pau) and José Carreras Leukemia Research Institute; Autonomous University of Barcelona (UAB); Barcelona Spain
| | - Elisa Roldán
- Hematology Department; Hospital Vall d'Hebron; Experimental Hematology Unit; Vall d’ Hebron Institute of Oncology (VHIO); Autonomous University of Barcelona (UAB); Barcelona Spain
| | - Silvana Novelli
- Hematology Department; Hospital de la Santa Creu i Sant Pau; Biomedical Research Institute (IIB Sant-Pau) and José Carreras Leukemia Research Institute; Autonomous University of Barcelona (UAB); Barcelona Spain
| | - Pere Barba
- Hematology Department; Hospital Vall d'Hebron; Experimental Hematology Unit; Vall d’ Hebron Institute of Oncology (VHIO); Autonomous University of Barcelona (UAB); Barcelona Spain
| | - Albert Esquirol
- Hematology Department; Hospital de la Santa Creu i Sant Pau; Biomedical Research Institute (IIB Sant-Pau) and José Carreras Leukemia Research Institute; Autonomous University of Barcelona (UAB); Barcelona Spain
| | - David Valcárcel
- Hematology Department; Hospital Vall d'Hebron; Experimental Hematology Unit; Vall d’ Hebron Institute of Oncology (VHIO); Autonomous University of Barcelona (UAB); Barcelona Spain
| | - Rodrigo Martino
- Hematology Department; Hospital de la Santa Creu i Sant Pau; Biomedical Research Institute (IIB Sant-Pau) and José Carreras Leukemia Research Institute; Autonomous University of Barcelona (UAB); Barcelona Spain
| | - Jorge Sierra
- Hematology Department; Hospital de la Santa Creu i Sant Pau; Biomedical Research Institute (IIB Sant-Pau) and José Carreras Leukemia Research Institute; Autonomous University of Barcelona (UAB); Barcelona Spain
| |
Collapse
|
27
|
Master S, Dwary A, Mansour R, Mills GM, Koshy N. Use of Eltrombopag in Improving Poor Graft Function after Allogeneic Hematopoietic Stem Cell Transplantation. Case Rep Oncol 2018; 11:191-195. [PMID: 29681820 PMCID: PMC5903126 DOI: 10.1159/000487229] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 01/29/2018] [Indexed: 02/04/2023] Open
Abstract
Eltrombopag is a thrombopoietin agonist and has been used in aplastic anemia and post-transplantation thrombocytopenia. The c-MPL receptor is present on hematopoietic stem cells. There are no reports of eltrombopag utilization for improving poor graft function in the post-transplant setting. Here were report a case of a young female with post-transplant poor graft function as evident from the low absolute neutrophil count, anemia, and thrombocytopenia on day 60. Eltrombopag was started on day 72 and resulted in improvement in all 3 cell lines. The counts continued to be stable even after eltrombopag was discontinued. The patient tolerated the drug without significant side effects for 1 year.
Collapse
Affiliation(s)
- Samip Master
- Division of Hematology and Oncology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Ashish Dwary
- Division of Hematology and Oncology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Richard Mansour
- Division of Hematology and Oncology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Glenn M Mills
- Division of Hematology and Oncology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Nebu Koshy
- Division of Hematology and Oncology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| |
Collapse
|
28
|
Roberts DJ. Expanding access to Transfusion Medicine and improving practice: guidelines, patient blood management, protocols and products. Transfus Med 2017; 27 Suppl 5:315-317. [PMID: 29076249 DOI: 10.1111/tme.12484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- D J Roberts
- National Health Service Blood and Transplant, University of Oxford, John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
29
|
Ali S, Gassas A, Kirby-Allen M, Krueger J, Ali M, Schechter T. Eltrombopag for secondary failure of platelet recovery post-allogeneic hematopoietic stem cell transplant in children. Pediatr Transplant 2017; 21. [PMID: 28653480 DOI: 10.1111/petr.13017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2017] [Indexed: 01/04/2023]
Abstract
Secondary failure of platelet engraftment occurs in 20% of patients undergoing allogeneic HSCT and is associated with poor outcome. Currently, there are no guidelines for treatment of late thrombocytopenia and platelet transfusion is the mainstay of treatment. Here, we describe the use of Eltrombopag to treat secondary failure of platelet recovery following HSCT in a child with severe aplastic anemia. Eltrombopag resulted in recovery of platelet count with no need for platelet transfusion support with no reported side effects. Eltrombopag may be used successfully in children with secondary failure of platelet recovery post-HSCT for SAA.
Collapse
Affiliation(s)
- Salah Ali
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Adam Gassas
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Melanie Kirby-Allen
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Joerg Krueger
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Ali
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|