1
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Dong Y, Xia Z, Zhou J, Hu Y, Yue M, Wang Y, Hu M. Risk of thrombotic events in immune thrombocytopenia patients treated with thrombopoietic agents: a systematic review and meta-analysis. Thromb J 2023; 21:69. [PMID: 37353791 DOI: 10.1186/s12959-023-00509-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/01/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Immune thrombocytopenia (ITP), which is a well-known hemorrhagic disorder characterized by low platelet counts, has been shown to be associated with the risk of thrombosis. Thrombopoietic agents (TAs) are extensively used as second-line treatments for ITP, effectively reducing the risk of hemorrhage. However, thrombosis, a potential adverse effect of TAs, raises clinical challenges. METHODS The MEDLINE(PubMed), Embase, and the Cochrane Library databases were systematically searched for relevant studies, including both single-arm trials and randomized controlled trials (RCTs), without language restrictions. RESULTS A total of 17 RCTs comprising 2,105 patients and 29 single-arm trials comprising 3,227 patients were included. In the single-arm meta-analysis, the pooled rate of overall thrombotic events in ITP patients receiving TAs was 2.2% (95% CI 1.0% - 3.7%). In RCTs, a higher incidence of thrombosis (33/1425 vs. 4/680) and higher risk ratios (RR) of overall, arterial, and venous thrombotic events (1.73, 95% CI [0.88, 3.39], P = 0.113; RR 1.98, 95% CI [0.80, 4.92], P = 0.141; RR 1.06, 95% CI [0.46, 2.41], P = 0.895, respectively) were observed in the TAs group than in the control group, although the differences were not significant. Subgroup analysis demonstrated that hetrombopag was the only TA with no increased thrombotic risk (rate 0.3% 95% CI [0.0 - 1.5%]; RR 0.76, 95% CI [0.03, 18.41], P = 0.864) compared to eltrombopag, avatrombopag, romiplostim, and rhTPO. Subgroup analyses also revealed that ITP patients with advanced age (3.7% vs. 1.3%, P = 0.132) or with a thrombotic history (3.0% vs. 1.4%, P = 0.257), and patients who received TAs therapy for a long duration (4.7% vs. 0.1%, P < 0.001) had an increased risk of thrombosis. CONCLUSION Our findings suggest ITP patients treated with TAs have a nonsignificantly higher risk of overall, arterial, and venous thrombotic events. Furthermore, hetrombopag is the recommended TA to avoid thrombophilia. Patients receiving long-term TAs, as well as elderly ITP patients or those with a history of thrombosis, face an increased thrombotic risk. In general, clinicians should consider potential thrombotic risks, address underlying risk factors, and ensure ongoing monitoring and follow-up when treating ITP patients with TAs.
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Affiliation(s)
- Yu Dong
- Department of the Fourth Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Urology, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Zhinan Xia
- Department of Urology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Jie Zhou
- Department of Basic Medicine College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yutao Hu
- Department of the First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ming Yue
- Department of Basic Medicine College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuyong Wang
- Department of Urology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Mengjiao Hu
- Department of Basic Medicine College, Zhejiang Chinese Medical University, Hangzhou, China.
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2
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Casari C, Favier R, Legendre P, Kauskot A, Adam F, Picard V, Lenting PJ, Denis CV, Proulle V. A thrombopoietin receptor agonist to rescue an unusual platelet transfusion-induced reaction in a p.V1316M-associated von Willebrand disease type 2B patient. Ther Adv Hematol 2022; 13:20406207221076812. [PMID: 35186246 PMCID: PMC8855378 DOI: 10.1177/20406207221076812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 01/09/2022] [Indexed: 11/29/2022] Open
Abstract
This report describes the first case of splenic injury in a patient with
p.V1316M-associated von Willebrand disease type 2B (VWD2B) with chronic
thrombocytopenia, successfully treated with nonoperative management including
von Willebrand factor (VWF) replacement therapy, and platelet transfusions
relayed by a thrombopoietin receptor agonist (TPO-RA, Eltrombopag). Eltrombopag
was initially introduced to rescue an unusual post-platelet-transfusion reaction
exacerbating the thrombocytopenia. In-depth analysis of the dramatic platelet
count drop and VWF measurements timeline ruled out an allo-immune reaction and
supported an alternative hypothesis of a sudden platelet clearance as a
consequence of stress-induced release of abnormal VWF. One year later, a second
life-threatening bleeding episode required urgent surgery successfully managed
with VWF replacement therapy and platelet transfusions. Eltrombopag was further
introduced in the post-surgery period to allow bleeding-free and
platelet-transfusion-free successful recovery. Treatment decisions are
particularly challenging in patients with VWD2B, and this case highlights how
such decisions can benefit from understanding the molecular origin of platelet
count fluctuations observed in these patients. Here, we successfully used a new
therapeutic approach combining VWF-replacement therapy and initial
platelet-transfusion relayed by TPO-RA to optimize patient management.
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Affiliation(s)
- Caterina Casari
- INSERM_UMR S 1176, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Remi Favier
- Service Hématologie Biologique, Hôpital Trousseau, APHP, CRPP, Paris, France
| | - Paulette Legendre
- INSERM_UMR S 1176, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Alexandre Kauskot
- INSERM_UMR S 1176, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Frederic Adam
- INSERM_UMR S 1176, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Veronique Picard
- Service Hématologie Biologique, Hôpital Bicêtre, APHP, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Peter J. Lenting
- INSERM_UMR S 1176, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Cecile V. Denis
- INSERM_UMR S 1176, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Valerie Proulle
- Service Hématologie Biologique et Unité Fonctionnelle d’Hémostase Clinique, Hôpital Cochin, APHP Centre–Université de Paris, 27 rue du Faubourg Saint Jacques, 75014 Paris, France
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3
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Tjepkema M, Amini S, Schipperus M. Risk of thrombosis with thrombopoietin receptor agonists for ITP patients: a systematic review and meta-analysis. Crit Rev Oncol Hematol 2022; 171:103581. [PMID: 35007700 DOI: 10.1016/j.critrevonc.2022.103581] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 12/09/2021] [Accepted: 01/05/2022] [Indexed: 11/25/2022] Open
Abstract
One possible side effect of thrombopoietin receptor agonists in immune thrombocytopenia is thrombosis. Our aim is to systematically review whether patients with ITP that were treated with a TPO-RA have an increased risk for thrombosis as compared to ITP patients without TPO-RA. Patients in the intervention group were required to receive TPO-RA therapy. The primary outcome was the incidence of thromboembolic events. Eleven studies were included in the pooled analysis. More thromboembolic events were noted in the TPO-RA group than in the control group: 25 compared to 4. Ten out of 11 studies showed a relative risk greater than 1. However, none of these individual risk ratios was statistically significant. The meta-analysis showed a RR of 1.82 [95% CI 0.78-4.24]. Our findings indicate there is a non-significant higher chance of thrombosis in ITP patients with TPO-RA treatments versus ITP patients without TPO-RA treatment.
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Affiliation(s)
- Mathilde Tjepkema
- University Medical Center Groningen, Department of Hematology, the Netherlands
| | - Sufia Amini
- Haga Teaching Hospital, Department of Hematology, the Netherlands.
| | - Martin Schipperus
- University Medical Center Groningen, Department of Hematology, the Netherlands
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4
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Özgünoğlu EC, Bayar N, Arslan Ş, Ersoysal MR, Avcı R. Is the increase in eltrombopag dose cause of myocardial infarction? Anatol J Cardiol 2021; 25:520-521. [PMID: 34236330 DOI: 10.5152/anatoljcardiol.2021.45605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Edip Can Özgünoğlu
- Department of Cardiology, University of Health Sciences, Antalya Training and Research Hospital; Antalya-Turkey
| | - Nermin Bayar
- Department of Cardiology, University of Health Sciences, Antalya Training and Research Hospital; Antalya-Turkey
| | - Şakir Arslan
- Department of Cardiology, University of Health Sciences, Antalya Training and Research Hospital; Antalya-Turkey
| | - Muhammed Rıdvan Ersoysal
- Department of Cardiology, University of Health Sciences, Antalya Training and Research Hospital; Antalya-Turkey
| | - Rauf Avcı
- Department of Cardiology, University of Health Sciences, Antalya Training and Research Hospital; Antalya-Turkey
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5
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Swan D, Newland A, Rodegheiro F, Thachil J. Thrombosis in immune thrombocytopenia - current status and future perspectives. Br J Haematol 2021; 194:822-834. [PMID: 33822358 DOI: 10.1111/bjh.17390] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder in which a combination of defective platelet production and enhanced clearance leads to thrombocytopenia. The primary aim for therapy in patients with this condition is the prevention of bleeding. However, more recently, increased rates of venous and arterial thrombotic events have been reported in ITP, even in the context of marked thrombocytopenia. In this review we discuss the epidemiology, aetiology and management of thrombotic events in these patients. We consider the impact of ITP therapies on the increased thrombotic risk, in particular the use of thrombopoietin-receptor agonists (TPO-RAs), as well as factors inherent to ITP itself. We also discuss the limited evidence available to guide clinicians in the treatment of these complex cases.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, University Hospital Galway, Galway, Republic of Ireland
| | - Adrian Newland
- Department of Haematology, The Royal London Hospital, London, UK
| | | | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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6
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van Dijk WEM, Brandwijk ON, Heitink-Polle KMJ, Schutgens REG, van Galen KPM, Urbanus RT. Hemostatic changes by thrombopoietin-receptor agonists in immune thrombocytopenia patients. Blood Rev 2020; 47:100774. [PMID: 33213987 DOI: 10.1016/j.blre.2020.100774] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/02/2020] [Accepted: 11/04/2020] [Indexed: 01/08/2023]
Abstract
Thrombopoietin receptor agonist (TPO-RA) treatment increases the thrombosis rate in immune thrombocytopenia (ITP). We hypothesize that TPO-RAs influence platelet function, global and secondary hemostasis and/or fibrinolysis. A systematic review was performed. If possible, data were compared between responders (relevant increase in platelet count), and non-responders. Twelve observational studies with 305 patients were included (responders (127/150 (85%))). There were indications that TPO-RA treatment enhanced platelet function, with respect to platelet-monocyte aggregates, soluble P-selectin, GPVI expression, and adhesion under flow. Studies addressing global and secondary hemostasis and fibrinolysis were scarce. Overall, no changes were found during TPO-RA treatment, apart from an accelerated clot formation and conflicting data on levels of plasminogen activator inhibitor (PAI)-1. The parameters that increased have previously been associated with thrombosis in other patient groups, and might contribute to the increased rate of thrombosis observed in TPO-RA-treated ITP patients.
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Affiliation(s)
- Wobke E M van Dijk
- Department of Hematology, Van Creveldkliniek, University Medical Centre Utrecht, Postbox 85500, 3508 GA Utrecht, The Netherlands.
| | - Odila N Brandwijk
- Education Centre, University Medical Centre Utrecht, Utrecht University, Universiteitsweg 98, 3584 CG Utrecht, The Netherlands
| | - Katja M J Heitink-Polle
- Department of Hematology, Van Creveldkliniek, University Medical Centre Utrecht, Postbox 85500, 3508 GA Utrecht, The Netherlands
| | - Roger E G Schutgens
- Department of Hematology, Van Creveldkliniek, University Medical Centre Utrecht, Postbox 85500, 3508 GA Utrecht, The Netherlands.
| | - Karin P M van Galen
- Department of Hematology, Van Creveldkliniek, University Medical Centre Utrecht, Postbox 85500, 3508 GA Utrecht, The Netherlands.
| | - Rolf T Urbanus
- Department of Hematology, Van Creveldkliniek, University Medical Centre Utrecht, Postbox 85500, 3508 GA Utrecht, The Netherlands.
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7
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Abstract
Eltrombopag (ELT) is a thrombopoietin receptor activator that has shown efficacy in chronic immune thrombocytopenia. We report the outcome of ELT therapy in 4 children who were treated for rare hematologic disorders, including Pearson syndrome, DiGeorge syndrome, posttransplant allogeneic poor graft function (PGF), and Wiskott-Aldrich syndrome. The ELT tolerance in the analyzed group was good, with the exception of the child with Pearson syndrome, who experienced an exacerbation of cataracts and had to discontinue treatment. Thromboembolic events were observed in one child, who continued ELT therapy despite achieving normalized platelet counts. Independence from PLT transfusions was observed at the 4-week timepoint of therapy in patients with DiGeorge syndrome and PGF who responded to ELT. Discontinuation of therapy was successful in one child, who sustained the normal CBC values afterward. In 2 patients, an increase in neutrophil counts was observed during ELT therapy without additional intervention, and a positive correlation between neutrophil and platelet values during ELT therapy was observed in the child with PGF. ELT is effective in rare pediatric disorders, but response patterns are determined by the underlying disease. ELT shows promising results in patients, but constitutional hematopoiesis defects reduce the chances of a response.
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8
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Nishiura N, Kashiwagi H, Akuta K, Hayashi S, Kato H, Kanakura Y, Tomiyama Y. Reevaluation of platelet function in chronic immune thrombocytopenia: impacts of platelet size, platelet‐associated anti‐αIIbβ3 antibodies and thrombopoietin receptor agonists. Br J Haematol 2020; 189:760-771. [DOI: 10.1111/bjh.16439] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/11/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Nobuko Nishiura
- Department of Hematology and Oncology Graduate School of Medicine Osaka University Suita Japan
| | - Hirokazu Kashiwagi
- Department of Hematology and Oncology Graduate School of Medicine Osaka University Suita Japan
| | - Keigo Akuta
- Department of Hematology and Oncology Graduate School of Medicine Osaka University Suita Japan
| | - Satoru Hayashi
- Department of Hematology and Oncology Graduate School of Medicine Osaka University Suita Japan
| | - Hisashi Kato
- Department of Hematology and Oncology Graduate School of Medicine Osaka University Suita Japan
| | - Yuzuru Kanakura
- Department of Hematology and Oncology Graduate School of Medicine Osaka University Suita Japan
| | - Yoshiaki Tomiyama
- Department of Hematology and Oncology Graduate School of Medicine Osaka University Suita Japan
- Department of Blood Transfusion Osaka University Hospital Suita Japan
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9
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Lozano ML, Garabet L, Fernandez-Perez MP, De Los Reyes-García AM, Diaz-Lozano P, Garcia-Barbera N, Aguila S, Vicente V, Ghanima W, Martinez C, Gonzalez-Conejero R. Platelet activation and neutrophil extracellular trap (NET) formation in immune thrombocytopenia: is there an association? Platelets 2019; 31:906-912. [PMID: 31762368 DOI: 10.1080/09537104.2019.1696456] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
No biological predictors for the increased risk of thrombosis in patients with immune thrombocytopenia (ITP) have been identified. The aim of the study was to investigate platelet and neutrophil activation as well neutrophil extracellular trap (NET) formation in 63 ITP patients and 30 healthy volunteers. Platelet and neutrophil activation was assessed during steady state using flow cytometry analysis, and NETs were evaluated by quantitation of cell free DNA (cfDNA), and citrullinated histone-3-DNA (CitH3-DNA). Patient platelets and neutrophils showed increased CD62 and CD11b expression compared to controls (p = .038, and p = .022, respectively). In patients, platelet activation inversely correlated with platelet count and platelet size (p < .001), and positively correlated with neutrophil degranulation (p = .024). More NET formation, both CitH3-DNA (p = .025) and cfDNA(p < .001), were present in ITP patients compared to controls. CitH3-DNA inversely correlated with CD62 expression on platelets (p = .042), but higher levels of cfDNA were observed in individuals with classical cardiovascular risk factors for thrombosis, and in those with a previous history of thrombotic events. In this disease, the increased platelet activation and plasma NET levels seem to be separable processes that associate (either positively or inversely in the case of CitH3-DNA or platelet degranulation, respectively) to platelet mass.
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Affiliation(s)
- Maria L Lozano
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Servicio de Hematología y Oncología Médica, Universidad de Murcia , Murcia, Spain.,Grupo de investigación CB15/00055 del Centro de Investigacion Biomedica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII) , Madrid, Spain
| | - Lamya Garabet
- Multidisciplinary Laboratory Medicine and Medical Biochemistry, Akershus University Hospital , Lørenskog, Norway.,Center for Laboratory Medicine, Østfold Hospital Trust , Grålum, Norway.,Institute of Clinical Medicine, University of Oslo , Oslo, Norway
| | - Maria Piedad Fernandez-Perez
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Servicio de Hematología y Oncología Médica, Universidad de Murcia , Murcia, Spain
| | - Ascension M De Los Reyes-García
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Servicio de Hematología y Oncología Médica, Universidad de Murcia , Murcia, Spain
| | - Pedro Diaz-Lozano
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Servicio de Hematología y Oncología Médica, Universidad de Murcia , Murcia, Spain
| | - Nuria Garcia-Barbera
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Servicio de Hematología y Oncología Médica, Universidad de Murcia , Murcia, Spain
| | - Sonia Aguila
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Servicio de Hematología y Oncología Médica, Universidad de Murcia , Murcia, Spain
| | - Vicente Vicente
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Servicio de Hematología y Oncología Médica, Universidad de Murcia , Murcia, Spain.,Grupo de investigación CB15/00055 del Centro de Investigacion Biomedica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII) , Madrid, Spain
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo , Oslo, Norway.,Department of Research, Østfold Hospital Trust , Grålum, Norway.,Department of Medicine, Østfold Hospital Trus , Grålum, Norway
| | - Constantino Martinez
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Servicio de Hematología y Oncología Médica, Universidad de Murcia , Murcia, Spain
| | - Rocio Gonzalez-Conejero
- Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Servicio de Hematología y Oncología Médica, Universidad de Murcia , Murcia, Spain
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10
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Bussel J, Kulasekararaj A, Cooper N, Verma A, Steidl U, Semple JW, Will B. Mechanisms and therapeutic prospects of thrombopoietin receptor agonists. Semin Hematol 2019; 56:262-278. [PMID: 31836033 DOI: 10.1053/j.seminhematol.2019.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
The second-generation thrombopoietin (TPO) receptor agonists eltrombopag and romiplostim are potent activators of megakaryopoiesis and represent a growing treatment option for patients with thrombocytopenic hematological disorders. Both TPO receptor agonists have been approved worldwide for the treatment of children and adults with chronic immune thrombocytopenia. In the EU and USA, eltrombopag is approved for the treatment of patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy and in the USA for the first-line treatment of severe aplastic anemia in combination with immunosuppressive therapy. Eltrombopag has also shown efficacy in several other disease settings, for example, chemotherapy-induced thrombocytopenia, selected inherited thrombocytopenias, and myelodysplastic syndromes. While both TPO receptor agonists stimulate TPO receptor signaling and enhance megakaryopoiesis, their vastly different biochemical structures bestow upon them markedly different molecular and functional properties. Here, we review and discuss results from preclinical and clinical studies on the functional and molecular mechanisms of action of this new class of drug.
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Affiliation(s)
- James Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY.
| | | | | | - Amit Verma
- Albert Einstein College of Medicine, New York, NY
| | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Britta Will
- Albert Einstein College of Medicine, New York, NY.
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11
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Ignatova AA, Demina IA, Ptushkin VV, Khaspekova SG, Shustova ON, Pankrashkina MM, Ryabykh AA, Obydennyi SI, Strelkova OS, Polokhov DM, Seregina EA, Poletaev AV, Ataullakhanov FI, Kireev II, Mazurov AV, Maschan AA, Novichkova GA, Panteleev MA. Evolution of platelet function in adult patients with chronic immune thrombocytopenia on romiplostim treatment. Br J Haematol 2019; 187:e38-e42. [DOI: 10.1111/bjh.16164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Anastasia A. Ignatova
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
| | - Irina A. Demina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
| | | | | | | | | | - Aleksandr A. Ryabykh
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
- Lomonosov Moscow State UniversityMoscow Russia
| | - Sergei I. Obydennyi
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
- Center for Theoretical Problems of Physicochemical Pharmacology MoscowRussia
| | | | - Dmitry M. Polokhov
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
| | - Elena A. Seregina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
| | - Aleksandr V. Poletaev
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
| | - Fazoil I. Ataullakhanov
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
- Lomonosov Moscow State UniversityMoscow Russia
- Center for Theoretical Problems of Physicochemical Pharmacology MoscowRussia
| | | | | | - Alexei A. Maschan
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
| | - Galina A. Novichkova
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
| | - Mikhail A. Panteleev
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and ImmunologyMoscow Russia
- Lomonosov Moscow State UniversityMoscow Russia
- Center for Theoretical Problems of Physicochemical Pharmacology MoscowRussia
- Moscow Institute of Physics and Technology Dolgoprudny Russia
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12
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Ghanima W, Cooper N, Rodeghiero F, Godeau B, Bussel JB. Thrombopoietin receptor agonists: ten years later. Haematologica 2019; 104:1112-1123. [PMID: 31073079 PMCID: PMC6545830 DOI: 10.3324/haematol.2018.212845] [Citation(s) in RCA: 212] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/11/2019] [Indexed: 01/19/2023] Open
Abstract
The two thrombopoietin receptor agonists (TPO-RA), eltrombopag and romiplostim, were licensed in the US for treatment of immune thrombocytopenia (ITP) in 2008 and, since then, their use has progressively increased around the world; they are currently used in more than 100 countries. The six largest randomized controlled trials conducted in ITP have used one of these two agents. All studies have demonstrated a platelet response rate between 50-90%, depending on the criteria used, with good safety and tolerability. TPO-RA were shown to be effective in reducing bleeding and the need for concomitant or rescue medication. Many other investigations of their mechanism of effect, prospective and retrospective trials, and studies focusing on toxicity have been performed widening our knowledge of these two agents. Initial concerns on issues such as myelofibrosis have not been confirmed. Only a small number of patients develop moderate-severe reticulin fibrosis and/or collagen fibrosis; however, these are usually reversed after discontinuation of TPO-RA. Studies indicate, however, that TPO-RA may increase the risk of venous thromboembolism. Both TPO-RA are currently approved in patients with chronic ITP aged >1-year who are refractory to at least one other treatment. Eltrombopag has acquired two additional indications: severe aplastic anemia refractory to first-line treatment and hepatitis C patients undergoing treatment with interferon-ribavirin. Despite these wide-ranging studies, important questions still need to be answered. This summary review on TPO-RA will summarize what is known regarding efficacy in ITP, evaluate safety concerns in more depth, and focus on the questions that remain.
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MESH Headings
- Animals
- Benzoates/chemistry
- Benzoates/pharmacology
- Benzoates/therapeutic use
- Biomarkers
- Blood Coagulation/drug effects
- Clinical Trials as Topic
- Disease Susceptibility
- Humans
- Hydrazines/chemistry
- Hydrazines/pharmacology
- Hydrazines/therapeutic use
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Pyrazoles/chemistry
- Pyrazoles/pharmacology
- Pyrazoles/therapeutic use
- Receptors, Fc/chemistry
- Receptors, Fc/therapeutic use
- Receptors, Thrombopoietin/agonists
- Receptors, Thrombopoietin/chemistry
- Receptors, Thrombopoietin/metabolism
- Recombinant Fusion Proteins/chemistry
- Recombinant Fusion Proteins/pharmacology
- Recombinant Fusion Proteins/therapeutic use
- Signal Transduction/drug effects
- Thrombopoietin/chemistry
- Thrombopoietin/pharmacology
- Thrombopoietin/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Waleed Ghanima
- Departments of Medicine, Hematology-Oncology and Research, Østfold Hospital Trust, Norway
- Department of Hematology, Institute of Clinical Medicine, University of Oslo, Norway
| | - Nichola Cooper
- Department of Medicine, Hammersmith Hospital, Imperial College, London, UK
| | - Francesco Rodeghiero
- Hematology Project Foundation and Department of Cell Therapy and Hematology, S. Bortolo Hospital, Vicenza, Italy
| | - Bertrand Godeau
- Department of Internal Medicine, Henri Mondor University Hospital, Assistance Publique-Hopitaux de Paris, UPEC, Créteil, France
| | - James B Bussel
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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13
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Garabet L, Ghanima W, Monceyron Jonassen C, Skov V, Holst R, Mowinckel MC, C Hasselbalch H, A Kruse T, Thomassen M, Liebman H, Bussel JB, Sandset PM. Effect of thrombopoietin receptor agonists on markers of coagulation and P-selectin in patients with immune thrombocytopenia. Platelets 2017; 30:206-212. [PMID: 29215956 DOI: 10.1080/09537104.2017.1394451] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Thrombopoietin-receptor-agonists (TPO-RA) are effective treatments of immune thrombocytopenia (ITP). Previous long-term TPO-RA clinical trials have shown that thrombotic events occurred in 6% of TPO-RA-treated ITP patients. To explore the increased risk of thrombosis, the effects of TPO-RA on markers of coagulation and P-selectin were studied. The study comprised two ITP cohorts and controls. Cohort 1 included 26 patients with sequential samples acquired before and during treatment with TPO-RA. Cohort 2 included a single sample in 18 patients on TPO-RA for more than one year. Thrombin generation (endogenous thrombin potential (ETP)) prothrombin fragments 1 + 2 (F1+2), D-dimer, and plasminogen-activator-inhibitor-1 (PAI-1) were measured as well as soluble P-selectin (sP-selectin). Sequential expression of encoding genes for P-selectin (SELP) and PAI-1 (SERPINE1) was determined in four patients in cohort 1. Significantly higher levels of F1+2, D-dimer, and PAI-1 were found in ITP patients before TPO-RA treatment and in patients on long-term TPO-RA treatment than in controls. Pre-treatment levels of sP-selectin did not differ from controls. Analysis of longitudinal trends showed an increase in platelet count, sP-selectin, and PAI-1 after initiation of TPO-RA, followed by gradual decline. Platelet count and sP-selectin remained at higher levels throughout the study, whereas PAI-1 did not. Levels of other studied parameters did not show significant changes after initiation of treatment. Expression of SELP was up-regulated after initiation of TPO-RA, while the expression of SERPINE1 showed no significant changes. In conclusion, elevated pre-treatment levels of F1+2, D-dimer and PAI-1 are compatible with ITP being an intrinsically pro-thrombotic condition. After TPO-RA treatment, there were no significant changes in markers of coagulation activation or fibrinolysis, except for an initial increase in PAI-1 and a significant increase in sP-selectin both of which may contribute to increased thrombotic risk associated with TPO-RA treatment in ITP.
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Affiliation(s)
- Lamya Garabet
- a Center for Laboratory Medicine , Østfold Hospital Trust , Kalnes , Oslo , Norway.,b Institute of Clinical Medicine , University of Oslo , Norway
| | - Waleed Ghanima
- b Institute of Clinical Medicine , University of Oslo , Norway.,c Department of Research , Østfold Hospital Trust , Kalnes , Norway.,d Department of Medicine , Østfold Hospital Trust , Kalnes , Norway
| | | | - Vibe Skov
- e Department of Hematology , Zealand University Hospital , Roskilde , Denmark
| | - René Holst
- c Department of Research , Østfold Hospital Trust , Kalnes , Norway.,f Oslo Centre for Biostatistics and Epidemiology , University of Oslo and Oslo University Hospital , Oslo , Norway
| | - Marie-Christine Mowinckel
- g Department of Haematology , Oslo University Hospital , Oslo , Norway.,h Research Institute of Internal Medicine , Oslo University Hospital , Oslo , Norway
| | - Hans C Hasselbalch
- i Department of Hematology , Copenhagen University Hospital , Roskilde , Denmark
| | - Torben A Kruse
- j Department of Clinical Genetics , Odense University Hospital , Odense , Denmark
| | - Mads Thomassen
- j Department of Clinical Genetics , Odense University Hospital , Odense , Denmark
| | - Howard Liebman
- k Department of Medicine , University of California-Keck School of Medicine , Los Angeles , CA , USA
| | - James B Bussel
- l Department of Pediatrics, Division of Hematology , New York Presbyterian Hospital, Weill Cornell Medicine , New York , USA
| | - Per Morten Sandset
- b Institute of Clinical Medicine , University of Oslo , Norway.,g Department of Haematology , Oslo University Hospital , Oslo , Norway.,h Research Institute of Internal Medicine , Oslo University Hospital , Oslo , Norway
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14
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Panzer S, Pabinger I. Is oral all-trans retinoic acid plus danazol a refinement of second-line therapy for primary immune thrombocytopenia in adults? LANCET HAEMATOLOGY 2017; 4:e457-e458. [PMID: 28917656 DOI: 10.1016/s2352-3026(17)30167-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 08/22/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna 1090, Austria.
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna 1090, Austria
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15
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Audia S, Mahévas M, Samson M, Godeau B, Bonnotte B. Pathogenesis of immune thrombocytopenia. Autoimmun Rev 2017; 16:620-632. [DOI: 10.1016/j.autrev.2017.04.012] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 03/17/2017] [Indexed: 01/19/2023]
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16
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Suntsova EV, Demina IM, Ignatova AA, Ershov NM, Trubina NM, Dobrynina J, Serkova IV, Supik ZS, Orekhova EV, Hachatryan LA, Kotskaya NN, Pshonkin AV, Maschan AA, Novichkova GA, Panteleev MA. Bleeding tendency and platelet function during treatment with romiplostim in children with severe immune thrombocytopenic purpura. Int J Hematol 2017; 105:841-848. [DOI: 10.1007/s12185-017-2207-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/21/2017] [Accepted: 02/28/2017] [Indexed: 01/19/2023]
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17
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Rodeghiero F. Is ITP a thrombophilic disorder? Am J Hematol 2016; 91:39-45. [PMID: 26547507 DOI: 10.1002/ajh.24234] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/03/2015] [Indexed: 01/09/2023]
Abstract
Immune thrombocytopenia (ITP) represents the epitome of acquired bleeding diseases for the hematologist. Stemming from the interest for the safety of thrombopoietin-receptor agonists (TPO-ra) romiplostim and eltrombopag, recent data have investigated if thrombotic risk is also increased in this disorder. In patients not treated with TPO-ra, a slightly higher risk of venous thrombosis (VTE) is consistently found in ITP, but not to a rate demanding special attention in the generality of cases. No significant increase of arterial thrombosis (AT) is apparent. However, age, splenectomy, and personal risk factors may put some ITP patient to a particularly higher risk of venous and arterial thrombosis (three to four times higher than the average subject). Patients exposed to TPO-ra present indirect evidence of a much higher risk of both AT and VTE. Unfortunately, no matched control population is available and the prospective and registrative nature of these studies may have emphasized the incidence of thrombosis, which was recorded as adverse event. The clinician should be able to individualize the best treatment for the patient, taking also into account the thrombotic risk, limiting active treatment of ITP to those patients really at risk of bleeding.
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18
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Chiou TJ, Chang YF, Wang MC, Kao CW, Lin HY, Chen TY, Hsueh EJ, Lan YJ, Sung YC, Lin SF, Bai LY, Chen CG. Eltrombopag enhances platelet adhesion by upregulating the expression of glycoprotein VI in patients with chronic immune thrombocytopenic purpura. Transl Res 2015; 166:750-761.e4. [PMID: 26477577 DOI: 10.1016/j.trsl.2015.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/13/2015] [Accepted: 09/14/2015] [Indexed: 10/23/2022]
Abstract
Eltrombopag, a thrombopoietin receptor agonist, has been approved for the treatment of patients with immune thrombocytopenia because of its abilities to enhance platelet production and reduce hemorrhage. Both platelet count and platelet adhesion are crucial to stop bleeding. Although eltrombopag is known to improve platelet counts, its effects on platelet adhesion are not yet known. This study aimed to assess the efficacy of eltrombopag on platelet production and platelet adhesive affinity. To evaluate the efficacy of low-dose eltrombopag (25 mg) for patients with chronic refractory immune thrombocytopenic purpura (ITP) and to determine the ex vivo platelet adhesion ability before and after treatment with eltrombopag, we conducted an open-label, multicenter study in which 25 Taiwanese patients with chronic ITP were enrolled. During the 6-month evaluation, the starting and maximum doses of eltrombopag were 25 and 50 mg, respectively, to maintain the platelet count of ≥50,000 per μL. Flow-based adhesion assay was used to detect the percentage of platelets adhering to immobilized von Willebrand factor-collagen on microslides. Of the enrolled patients, 48% achieved a platelet count of ≥50,000 per μL. Interestingly, 83% of all responders required 25 mg of eltrombopag daily to achieve the target platelet count. In addition, the percentage of bleeding patients was significantly reduced in both responders and nonresponders by 50% from the baseline level throughout the treatment period. The ex vivo platelet adhesion capacity was elevated after the 6-month eltrombopag treatment in both responders and nonresponders. Furthermore, glycoprotein VI (GPVI) expression was significantly upregulated after treatment with eltrombopag. Low-to-intermediate dose of eltrombopag showed good efficacy to expedite platelet production and augment platelet adhesion. These 2 factors might explain the efficacy of eltrombopag in ameliorating hemorrhage in patients with ITP.
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Affiliation(s)
- Tzeon-Jye Chiou
- Department of Hematology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Fang Chang
- Department of Hematology, GCRC Laboratory, Mackay Memorial Hospital, Taipei, Taiwan
| | | | | | - Hsuan-Yu Lin
- National Cheng-Kung University Hospital, Tainan, Taiwan
| | | | | | | | - Yung-Chuan Sung
- Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | | | - Li-Yuan Bai
- Institute Molecular Medicine, National Tsing-Hua University, Hsinchu, Taiwan
| | - Caleb G Chen
- Department of Hematology, Mackay Medical College, New Taipei, Taiwan.
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19
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Merli P, Strocchio L, Vinti L, Palumbo G, Locatelli F. Eltrombopag for treatment of thrombocytopenia-associated disorders. Expert Opin Pharmacother 2015; 16:2243-56. [DOI: 10.1517/14656566.2015.1085512] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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20
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Kawaguchi T, Nakano M, Satani M, Sumie S, Yamada S, Amano K, Kuromatsu R, Sata M. Usefulness of short-term eltrombopag treatment as a supportive treatment in hepatocellular carcinoma patients with cirrhosis and severe thrombocytopenia: A report of two cases. Oncol Lett 2014; 7:2130-2134. [PMID: 24932302 PMCID: PMC4049767 DOI: 10.3892/ol.2014.1976] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 02/11/2014] [Indexed: 12/21/2022] Open
Abstract
Eltrombopag is an oral thrombopoietin (TPO) receptor agonist that increases platelet counts in patients with idiopathic thrombocytopenic purpura and in patients with liver cirrhosis. When cirrhotic patients with thrombocytopenia undergo elective invasive procedures, eltrombopag treatment reduces the requirement for platelet transfusions. However, TPO is known to have proliferative effects on hepatic progenitor cells and hepatic sinusoidal endothelial cells, which indicates that eltrombopag may accelerate tumor progression. Thus, the effect of eltrombopag on hepatocellular carcinoma (HCC) progression is an important issue. The current study describes two cases of HCC with cirrhosis-related thrombocytopenia. A two-week administration of eltrombopag increased platelet counts from 4.8 to 11.3×104 /μl in case 1 and 4.5 to 23.2×104 /μl in case 2. However, no changes were identified in the serum levels of tumor markers or HCC size following eltrombopag administration in the two cases. These HCCs were curatively treated by radiofrequency ablation without platelet transfusions or serious bleeding. Thus, short-term eltrombopag administration may not accelerate HCC proliferation and may be beneficial for invasive HCC treatment in cirrhotic patients with thrombocytopenia.
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Affiliation(s)
- Takumi Kawaguchi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan ; Department of Digestive Disease Information and Research, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Masahito Nakano
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Manabu Satani
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Shuji Sumie
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Shingo Yamada
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Keisuke Amano
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Ryoko Kuromatsu
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
| | - Michio Sata
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan ; Department of Digestive Disease Information and Research, Kurume University School of Medicine, Kurume, Fukuoka 830-0011, Japan
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21
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Giannini EG. Eltrombopag in patients with chronic hepatitis C and thrombocytopenia. Future Virol 2014. [DOI: 10.2217/fvl.13.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT: Eltrombopag is a thrombopoietic drug that acts by interacting with the TPO receptor and stimulates megakaryocytopoiesis and platelet production. Thrombocytopenia is a fairly frequent hematological abnormality in patients with chronic liver disease, and may represent an obstacle to interferon-based antiviral therapy in patients with chronic HCV infection who are otherwise good candidates for treatment. In large, multicenter, randomized, placebo-controlled studies, eltrombopag consistently enabled thrombocytopenic chronic hepatitis C patients to be treated with interferon-based therapy and, as an adjunct to antiviral therapy, has shown to be able to increase the sustained virologic response rate to treatment. The safety profile of the drug, with particular attention to the risk of thromboembolic events and the potential for hepatic decompensation, should be taken into account when planning treatment. The aim of this article is to review the information currently available regarding the pharmacokinetics, clinical efficacy and side-effect profile of eltrombopag, and to assess the role of this drug into the current and future hepatitis C treatment paradigm.
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Affiliation(s)
- Edoardo G Giannini
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV, no.6, 16132, Genoa, Italy
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22
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Abstract
Eltrombopag is a 2nd generation thrombopoietin-receptor agonist. It binds with the thrombopoietin-receptors found on the surfaces of the megakaryocytes & increases platelet production. Many recent studies have suggested a potential role for this novel agent in the treatment of thrombocytopenia associated with hepatitis-C infection. Studies have shown that adjunct treatment with Eltrombopag can help avoid dose reductions/withdrawals of pegylated interferon secondary to thrombocytopenia. It may also have a role in priming up platelet levels to help initiate antiviral therapy. Similarly, chronic liver disease patients with thrombocytopenia who need to undergo an invasive procedure may be potential candidates for short two-week courses of eltrombopag in the periprocedural period to help reduce the risk of bleeding. Besides the price (deemed very expensive and probably not cost-effective), there are some legitimate concerns about the safety profile of this novel agent (most importantly, portal vein thrombosis, bone marrow fibrosis and hepatotoxicity). In this article, the potential role of eltrombopag in the context of hepatitis C virus (HCV)-related thrombocytopenia is reviewed. To write this article, a MEDLINE search was conducted (1990 to November 2012) using the search terms “eltrombopag,” “HCV,” and “thrombocytopenia.”
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