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Mei H, Liu X, Li Y, Zhou H, Feng Y, Gao G, Cheng P, Huang R, Yang L, Hu J, Hou M, Yao Y, Liu L, Wang Y, Wu D, Shen X, Jin J, Luo J, Zeng Y, Zhou X, Xia R, Jiang Z, Bai Y, Niu T, Yang R, Hu Y. Switching from eltrombopag to hetrombopag in patients with primary immune thrombocytopenia: a post-hoc analysis of a multicenter, randomized phase III trial. Ann Hematol 2024; 103:2273-2281. [PMID: 38842566 PMCID: PMC11224074 DOI: 10.1007/s00277-024-05826-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 05/30/2024] [Indexed: 06/07/2024]
Abstract
While studies have explored the feasibility of switching between various thrombopoietin receptor agonists in treating immune thrombocytopenia (ITP), data on the switching from eltrombopag to hetrombopag remains scarce. This post-hoc analysis of a phase III hetrombopag trial aimed to assess the outcomes of ITP patients who switched from eltrombopag to hetrombopag. In the original phase III trial, patients initially randomized to the placebo group were switched to eltrombopag. Those who completed this 14-week eltrombopag were eligible to switch to a 24-week hetrombopag. Treatment response, defined as a platelet count of ≥ 50 × 109/L, and safety were evaluated before and after the switch. Sixty-three patients who completed the 14-week eltrombopag and switched to hetrombopag were included in this post-hoc analysis. Response rates before and after the switch were 66.7% and 88.9%, respectively. Among those with pre-switching platelet counts below 30 × 109/L, eight out of 12 patients (66.7%) responded, while eight out of nine patients (88.9%) with pre-switching platelet counts between 30 × 109/L and 50 × 109/L responded post-switching. Treatment-related adverse events were observed in 50.8% of patients during eltrombopag treatment and 38.1% during hetrombopag treatment. No severe adverse events were noted during hetrombopag treatment. Switching from eltrombopag to hetrombopag in ITP management appears to be effective and well-tolerated. Notably, hetrombopag yielded high response rates, even among patients who had previously shown limited response to eltrombopag. However, these observations need to be confirmed in future trials.
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Affiliation(s)
- Heng Mei
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Avenue, Wuhan, Hubei, China
| | - Xiaofan Liu
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.288 Nanjing Road Heping District, Tianjin, China
| | - Yan Li
- West China Hospital, Sichuan University, No.37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, China
| | - Hu Zhou
- Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Ying Feng
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guangxun Gao
- The First Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Peng Cheng
- The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ruibin Huang
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linhua Yang
- The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Jianda Hu
- Fujian Medical University Union Hospital, Fuzhou, China
| | - Ming Hou
- Qilu Hospital, Shandong University, Jinan, China
| | | | - Li Liu
- The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Yi Wang
- Shaanxi Provincial People's Hospital, Xi'an, China
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xuliang Shen
- Heping Hospital Affiliated to Changzhi Medical College, Changzhi, China
| | - Jie Jin
- The First Affiliated Hospital, Zhejiang University College of Medicine, Hangzhou, China
| | - Jianmin Luo
- The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yun Zeng
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xin Zhou
- Wuxi People's Hospital, Wuxi, China
| | - Ruixiang Xia
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhongxing Jiang
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuansong Bai
- China-Japan Union Hospital of Jilin University, Changchun, China
| | - Ting Niu
- West China Hospital, Sichuan University, No.37 Guoxue Alley, Wuhou District, Chengdu, Sichuan, China.
| | - Renchi Yang
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.288 Nanjing Road Heping District, Tianjin, China.
| | - Yu Hu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Avenue, Wuhan, Hubei, China.
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Jahandar-Lashaki S, Farajnia S, Faraji-Barhagh A, Hosseini Z, Bakhtiyari N, Rahbarnia L. Phage Display as a Medium for Target Therapy Based Drug Discovery, Review and Update. Mol Biotechnol 2024:10.1007/s12033-024-01195-6. [PMID: 38822912 DOI: 10.1007/s12033-024-01195-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 05/07/2024] [Indexed: 06/03/2024]
Abstract
Phage libraries are now amongst the most prominent approaches for the identification of high-affinity antibodies/peptides from billions of displayed phages in a specific library through the biopanning process. Due to its ability to discover potential therapeutic candidates that bind specifically to targets, phage display has gained considerable attention in targeted therapy. Using this approach, peptides with high-affinity and specificity can be identified for potential therapeutic or diagnostic use. Furthermore, phage libraries can be used to rapidly screen and identify novel antibodies to develop immunotherapeutics. The Food and Drug Administration (FDA) has approved several phage display-derived peptides and antibodies for the treatment of different diseases. In the current review, we provided a comprehensive insight into the role of phage display-derived peptides and antibodies in the treatment of different diseases including cancers, infectious diseases and neurological disorders. We also explored the applications of phage display in targeted drug delivery, gene therapy, and CAR T-cell.
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Affiliation(s)
- Samaneh Jahandar-Lashaki
- Medical Biotechnology Department, Faculty of Advanced Medical Science, Tabriz University of Medical Sciences, Tabriz, Iran
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Safar Farajnia
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Aref Faraji-Barhagh
- Medical Biotechnology Department, Faculty of Advanced Medical Science, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zahra Hosseini
- Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Nasim Bakhtiyari
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Rahbarnia
- Infectious and Tropical Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Shah S, Yadav R, Bhattarai A, Dahal K, Tharu S, Gautam S, Rawal L, Thapa S, Sah SK, Sharma S, Gundabolu K. Safety and efficacy of danazol in immune thrombocytopenia: a systematic review. Res Pract Thromb Haemost 2024; 8:102444. [PMID: 38988949 PMCID: PMC11234045 DOI: 10.1016/j.rpth.2024.102444] [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: 04/04/2024] [Accepted: 05/13/2024] [Indexed: 07/12/2024] Open
Abstract
Background The treatment landscape for relapsed or refractory immune thrombocytopenia (ITP) after corticosteroids is complex. Objectives We aimed to assess the efficacy of danazol in treating ITP and evaluate the safety and adverse events following its administration. Methods We searched the databases PubMed, EMBASE, and ClinicalTrials.gov for all published studies assessing danazol's efficacy and safety in treating ITP. The retrieved studies were screened by title and abstract, followed by full-text screening based on the eligibility requirements. The quality assessment was performed using a set of questionnaires. The data were extracted on the descriptive characteristics of the studies and participants, drug dosage, efficacy measures, and adverse effects, and the data were synthesized. Results A total of 17 studies consisting of 901 participants were included. The overall response rate is around 61% in this analysis. Among the participants, 315 (34.9%) were men. The age of participants ranged from 16 to 86 years. Danazol combined with other pharmacologic interventions, including all-trans-retinoic acid or glucocorticoids, generated better results. The most common side effects appear to be liver injury and elevation of liver enzymes, weight gain, oligomenorrhea, amenorrhea, and myalgia. Conclusion Danazol at low-to-medium doses was well tolerated and succeeded in improving ITP. Danazol therapy may be helpful in the treatment of chronic ITP that is corticosteroid refractory and when corticosteroids or splenectomy (or both) is contraindicated. Danazol can be considered for further research and development in treating primary immune thrombocytopenia.
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Affiliation(s)
- Sangam Shah
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Rukesh Yadav
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | | | - Krishna Dahal
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Sunraj Tharu
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Sandesh Gautam
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Laba Rawal
- Institute of Medicine, Tribhuvan University, Maharajgunj, Nepal
| | - Sangharsha Thapa
- Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | | | - Sumit Sharma
- B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Krishna Gundabolu
- Fred and Pamela Buffett Cancer Center, Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Wong A, Ahuja T, Cirrone F, Xiang E. Antithrombotic and hemostatic stewardship: Evaluation of romiplostim for treatment of thrombocytopenia at a large academic medical center. J Oncol Pharm Pract 2024; 30:246-250. [PMID: 37132025 DOI: 10.1177/10781552231173138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Romiplostim is indicated for immune thrombocytopenia (ITP), though is often used off-label for other indications such as chemotherapy-induced thrombocytopenia (CIT) and thrombocytopenia post hematopoietic stem cell transplantation (HSCT). Although romiplostim is FDA approved at a starting dose of 1 mcg/kg, it is often initiated at 2-4 mcg/kg depending on the severity of thrombocytopenia in clinical practice. Given the limited data, but interest in higher doses of romiplostim for indications other than ITP, we aimed to assess our inpatient romiplostim utilization at NYU Langone Health.This was a single-center, retrospective review of 84 adult patients from January 2019 to July 2021. The top three indications were ITP (51, 60.7%), CIT (13, 15.5%), and HSCT (10, 11.9%). The median initial romiplostim dose was 3.8 mcg/kg (range, 0.9-10.8). 51% of patients achieved a platelet count of ≥50 × 109/L by the end of week 1 of therapy. For patients achieving goal platelets by the end of week 1, the median dose of romiplostim was 2.4 mcg/kg (range, 0.9-10.8). There was 1 episode of thrombosis and 1 episode of stroke.We found that higher than FDA-recommended initial doses should be considered to achieve a platelet response. It appears to be safe to initiate romiplostim as higher doses, and to increase doses by greater increments than 1 mcg/kg in order to achieve a platelet response. Future prospective studies are needed to confirm the safety and efficacy of romiplostim in off-label indications and should evaluate clinical outcomes such as bleeding and need for transfusions.
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Affiliation(s)
- Adrian Wong
- NYU Langone Health - Department of Pharmacy, New York, NY, USA
| | - Tania Ahuja
- NYU Langone Health - Department of Pharmacy, New York, NY, USA
| | - Frank Cirrone
- Perlmutter Cancer Center - Department of Pharmacy, New York, NY, USA
| | - Elaine Xiang
- NYU Langone Health - Department of Pharmacy, New York, NY, USA
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Provan D, Thachil J, Álvarez Román MT. Addressing thrombosis concerns in immune thrombocytopenia: the role of fostamatinib in immune thrombocytopenia management. Expert Rev Hematol 2024; 17:55-66. [PMID: 38369947 DOI: 10.1080/17474086.2024.2318345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 02/09/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP), a disease that commonly presents with an increased risk of bleeding, can also paradoxically produce an increased risk of thromboembolic events. The risk of thromboembolism can be associated with patient-related factors (e.g. co-morbidities, age and history of thrombosis), disease-related factors (e.g. a greater proportion of younger, more reactive platelets, and the presence of microparticles and pro-inflammatory cytokines) and treatment-related factors (e.g. splenectomy, thrombopoietin receptor agonists, and IVIg). AREAS COVERED Aspects of the pathophysiology of ITP and the effects of treatment are discussed with emphasis on individualizing treatment based on the patient's thromboembolic risk, treatment options and preferences. EXPERT OPINION An increased understanding of the pathophysiology of ITP has led to the development of new agents such as fostamatinib, a spleen tyrosine kinase inhibitor. Further research into the factors contributing to the risks for bleeding and thromboembolic events can contribute to the development of more specific therapies for ITP and allow greater individualization of therapy based on each patient's medical history and clinical status.
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Affiliation(s)
- Drew Provan
- Department of Haematology, Emeritus Reader in Autoimmune Haematology, Barts & The London School of Medicine, London, UK
| | - Jecko Thachil
- Haemostasis and Thrombosis, Consultant in Haemostasis and Thrombosis, Manchester Royal Infirmary, Manchester, UK
| | - María Teresa Álvarez Román
- Head of the Haemostasis Unit, University Hospital La Paz, Autonomous University of Madrid, Madrid, Spain
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Yassin MA, Al-Rasheed M, Al-Khaboori M, Marashi M, Osman H, Wali Y, Al Kindi S, Alsayegh F, Provan D. Thrombopoietin-receptor agonists for adult patients with immune thrombocytopenia: a narrative review and an approach for managing patients fasting intermittently. Front Cardiovasc Med 2023; 10:1260487. [PMID: 38162126 PMCID: PMC10755910 DOI: 10.3389/fcvm.2023.1260487] [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: 07/20/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Thrombopoietin-receptor agonist (TPO-RAs) currently represent the state of art for treating immune thrombocytopenia. Their different molecular structures contribute to the difference in their pharmacodynamics and pharmacokinetics. This narrative review aims to provide an overview of the current TPO-RAs approved for primary immune thrombocytopenia (romiplostim, eltrombopag, avatrombopag) and the effect of intermittent fasting in adult patients receiving TPO-RAs. Areas covered Literature was searched with no limits on date or language, using various combinations of keywords. Data on the pharmacokinetics, pharmacodynamics, efficacy, and safety of TPO-RAs and the effect of intermittent fasting were summarized. Expert opinion Switching between TPO-RAs is a useful strategy to tackle some associated limitations. Romiplostim and avatrombopag have an advantage over eltrombopag as they do not require any dietary restrictions. In cases where romiplostim and avatrombopag are unavailable, patients should be educated on the appropriate administration, possible interactions, and dietary restrictions before initiating eltrombopag.
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Affiliation(s)
- Mohamed A. Yassin
- National Center for Cancer Care and Research, Hematology Section, Hamad Medical Corporation, Doha, Qatar
| | - Mona Al-Rasheed
- Hematology Unit, Department of Medicine, Al-Adan Hospital, Hadiya, Kuwait
| | | | - Mahmoud Marashi
- Dubai Academic Health Corporation, Dubai, United Arab Emirates
| | - Hani Osman
- Hematology-Oncology Department, Tawam Hospital, Abu Dhabi, United Arab Emirates
| | - Yasser Wali
- Department of Child Health, Sultan Qaboos University, Muscat, Oman
| | - Salam Al Kindi
- Department of Hematology, Sultan Qaboos University, Muscat, Oman
| | - Faisal Alsayegh
- Faculty of Medicine, Department of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
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Zhou H, Han S, Jin J, Huang R, Guo X, Shen X, Wang B, Wang X, Yao H, Du X, Huang M, Ran X, Wang W, Yang T, Zhang F, Zheng C, Zuo X, Fu R, Gao D, Ge Z, Han Y, Li Y, Kang X, Shi Y, Hou M. Efficacy and safety of QL0911 in adult patients with chronic primary immune thrombocytopenia: A multicenter, randomized, double-blind, placebo-controlled, phase III trial. J Transl Int Med 2023; 11:423-432. [PMID: 38130645 PMCID: PMC10732573 DOI: 10.2478/jtim-2023-0106] [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] [Indexed: 12/23/2023] Open
Abstract
Objective QL0911, a recombinant human thrombopoietin mimetic peptide-Fc fusion protein, is a romiplostim (Nplate®) biosimilar used to treat primary immune thrombocytopenia (ITP). This phase III study aimed to assess the efficacy and safety of QL0911 in adult patients with chronic primary ITP over a 24-week treatment period. Methods We conducted a double-blind, placebo-controlled, phase III study in patients diagnosed with primary ITP for at least 12 months who had received at least one first-line ITP treatment with no response or recurrence after treatment, or who relapsed after splenectomy at 44 sites in China. Patients were randomly allocated (2:1 ratio) to QL0911 or placebo injection subcutaneously once weekly at an initial dose of 1 μg/kg for 24 weeks. The doses were adjusted to maintain the target platelet counts from 50 × 109/L to 200 × 109/L. Patients and investigators were blinded to the assignment. The primary endpoints were the proportion of patients who achieved a durable platelet response at week 24 (platelet count, ≥ 50 × 109/L during 6 of the last 8 weeks of treatment) and safety. The study was registered at ClinicalTrials.gov (NCT05621330). Results Between October 2019 and December 2021, 216 patients were randomly assigned (QL0911,144; placebo,72). A durable platelet response was achieved by significantly more patients in the QL0911 group (61.8%, 95% CI: 53.3-69.8; P < 0.0001) than in the placebo group (0%). The mean duration of platelet responses was 15.9 (SE: 0.43) weeks with QL0911, and 1.9 (SE:0.26) week with placebo. Consistent results were achieved in subgroup analyses categorized by baseline splenectomy status (yes/no), concomitant ITP treatment (yes/no), and baseline platelet count (≤ 10 × 109/L, > 10 × 109/L, ≤ 20 × 109/L, > 20 × 109/L, and < 30 × 109/L). The incidence of TEAEs was comparable between the QL0911 and the placebo groups (91.7% and 88.9%, respectively). The most common adverse events overall were ecchymosis (28.5% for QL0911 vs. 37.5% for placebo), upper respiratory tract infections respiratory tract infections (31.9% for QL0911 vs. 27.8% for placebo), and gingival bleeding (17.4% for QL0911 vs. 26.4% for placebo). Conclusion QL0911 was well-tolerated and increased and maintained platelet counts in adults with ITP. QL0911, a biosimilar to romiplostim (Nplate®), may be a novel treatment option for patients with ITP who have failed or relapsed from first-line treatment in China. Ongoing studies will provide further data on long-term efficacy and safety in such patient populations.
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Affiliation(s)
- Hu Zhou
- Department of Hematology, Henan Cancer Hospital, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou450008, Henan Province, China
| | - Shouqing Han
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan250012, Shandong Province, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
| | - Ruibin Huang
- Department of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang330006, Jiangxi Province, China
| | - Xinhong Guo
- Department of Hematology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi830054, Xinjiang Uygur Autonomous Region, China
| | - Xuliang Shen
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi046000, Shanxi Province, China
| | - Binghua Wang
- Department of Hematology, Weihai Central Hospital, Weihai264400, Shandong Province, China
| | - Xin Wang
- Department of Hematology, Suining Central Hospital, Suining629099, Sichuan Province, China
| | - Hongxia Yao
- Department of Hematology, Hainan General Hospital, Haikou570311, Hainan Province, China
| | - Xin Du
- Department of Hematology, Shenzhen Second People’s Hospital, Shenzhen518035, Guangdong Province, China
| | - Meijuan Huang
- Department of Hematology, Fujian Medical University Union Hospital, Fuzhou350001, Fujian Province, China
| | - Xuehong Ran
- Department of Hematology, Weifang People’s Hospital, Weifang261044, Shandong Province, China
| | - Wei Wang
- Department of Hematology, The Affiliated Hospital of Qingdao University, Qingdao266000Qingdao, Shandong Province, China
| | - Tonghua Yang
- Department of Hematology, The First People’s Hospital of Yunnan Province, Kunming650031, Yunnan Province, China
| | - Feng Zhang
- Department of Hematology, The First Affiliated Hospital of Bengbu Medical College, Bengbu233004, Anhui Province, China
| | - Changcheng Zheng
- Department of Hematology, Anhui Province Hospital, Hefei230002, Anhui Province, China
| | - Xuelan Zuo
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan430071, Hubei Province, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin300052, China
| | - Da Gao
- Department of Hematology, The Affiliated Hospital of Inner Mongolia Medical University, Tongliao028000, Inner Mongolia, China
| | - Zheng Ge
- Department of Hematology, Zhongda Hospital Southeast University, Nanjing210009, Jiangsu Province, China
| | - Ying Han
- Department of Medicine, Qilu Pharmaceutical Co., Ltd, Jinan250100, Shandong Province, China
| | - Yujie Li
- Statistics and Statistical Programming, Qilu Pharmaceutical Co., Ltd, Jinan250100, Shandong Province, China
| | - Xiaoyan Kang
- Department of Medicine, Qilu Pharmaceutical Co., Ltd, Jinan250100, Shandong Province, China
| | - Yan Shi
- Department of Hematology, Qilu Hospital of Shandong University, Jinan250012, Shandong Province, China
| | - Ming Hou
- Department of Hematology, Qilu Hospital of Shandong University, Jinan250012, Shandong Province, China
- Department of Hematology, Shandong Provincial Key Laboratory of Immunohematology, Qilu Hospital of Shandong University, Jinan250012, Shandong Province, China
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Moulis G, Garabet L. Markers of refractory primary immune thrombocytopenia. Br J Haematol 2023; 203:112-118. [PMID: 38019080 DOI: 10.1111/bjh.19076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/31/2023] [Indexed: 11/30/2023]
Abstract
Refractory immune thrombocytopenia (ITP) is a challenging disease that can be defined by refractoriness to second-line treatments. In this review, we list and comment available evidence about clinical and biological factors associated with refractoriness to splenectomy, thrombopoietin receptor agonists (TPO-RAs), rituximab and fostamatinib, as well as those associated with multirefractory ITP (active disease with failure of rituximab, TPO-RAs and splenectomy).
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Affiliation(s)
- Guillaume Moulis
- Department of Internal Medicine, Referral Center for Autoimmune Cytopenia, Toulouse University Hospital, Toulouse, France
- Clinical Investigation Center 1436, Team PEPSS, Toulouse University Hospital, Toulouse, France
| | - Lamya Garabet
- Center for Laboratory Medicine, Østfold Hospital Trust, Grålum, Norway
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An ZY, Wu YJ, Hou Y, Mei H, Nong WX, Li WQ, Zhou H, Feng R, Shen JP, Peng J, Zhou H, Liu Y, Song YP, Yang LH, Fang MY, Li JY, Cheng YF, Liu P, Xu YJ, Wang Z, Luo Y, Cai Z, Liu H, Wang JW, Li J, Zhang X, Sun ZM, Zhu XY, Wang X, Fu R, Huang L, Wang SY, Yang TH, Su LP, Ma LM, Chen XQ, Liu DH, Yao HX, Feng J, Zhang HY, Jiang M, Zhou ZP, Wang WS, Shen XL, Baima Y, Li YY, Wang QF, Huang QS, Fu HX, Zhu XL, He Y, Jiang Q, Jiang H, Lu J, Zhao XY, Chang YJ, Wu T, Pan YZ, Qiu L, Gao D, Jin AR, Li W, Gao SJ, Zhang L, Hou M, Huang XJ, Zhang XH. A life-threatening bleeding prediction model for immune thrombocytopenia based on personalized machine learning: a nationwide prospective cohort study. Sci Bull (Beijing) 2023; 68:2106-2114. [PMID: 37599175 DOI: 10.1016/j.scib.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/24/2023] [Accepted: 06/26/2023] [Indexed: 08/22/2023]
Abstract
Rare but critical bleeding events in primary immune thrombocytopenia (ITP) present life-threatening complications in patients with ITP, which severely affect their prognosis, quality of life, and treatment decisions. Although several studies have investigated the risk factors related to critical bleeding in ITP, large sample size data, consistent definitions, large-scale multicenter findings, and prediction models for critical bleeding events in patients with ITP are unavailable. For the first time, in this study, we applied the newly proposed critical ITP bleeding criteria by the International Society on Thrombosis and Hemostasis for large sample size data and developed the first machine learning (ML)-based online application for predict critical ITP bleeding. In this research, we developed and externally tested an ML-based model for determining the risk of critical bleeding events in patients with ITP using large multicenter data across China. Retrospective data from 8 medical centers across the country were obtained for model development and prospectively tested in 39 medical centers across the country over a year. This system exhibited good predictive capabilities for training, validation, and test datasets. This convenient web-based tool based on a novel algorithm can rapidly identify the bleeding risk profile of patients with ITP and facilitate clinical decision-making and reduce the occurrence of adversities.
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Affiliation(s)
- Zhuo-Yu An
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Ye-Jun Wu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Yu Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250014, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430074, China
| | - Wei-Xia Nong
- Department of Hematology, First Affiliated Hospital, School of Medicine, Shihezi University, Shihezi 832002, China
| | - Wen-Qian Li
- Department of Hematology, Qinghai Provincial People's Hospital, Xining 810007, China
| | - Hu Zhou
- Henan Cancer Hospital, Affiliated Cancer Hospital of Zhengzhou University, Henan Institute of Hematology, Zhengzhou 450008, China
| | - Ru Feng
- Department of Hematology, Beijing Hospital, Beijing 100044, China
| | - Jian-Ping Shen
- Department of Hematology, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Hangzhou 310006, China
| | - Jun Peng
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250014, China
| | - Hai Zhou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250014, China
| | - Yi Liu
- Department of Hematology, Senior Department of Hematology, the Fifth Medical Center of PLA General Hospital, Beijing 100044, China
| | - Yong-Ping Song
- Henan Cancer Hospital, Affiliated Cancer Hospital of Zhengzhou University, Henan Institute of Hematology, Zhengzhou 450008, China
| | - Lin-Hua Yang
- Department of Hematology, the Second Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Mei-Yun Fang
- Department of Hematology, Affiliated Zhongshan Hospital of Dalian University, Dalian 116001, China
| | - Jian-Yong Li
- Department of Hematology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing 210029, China
| | - Yun-Feng Cheng
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Peng Liu
- Department of Hematology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Ya-Jing Xu
- Department of Hematology, Beijing Friendship Hospital, Capital Medical University, Beijing 100044, China
| | - Zhao Wang
- Institute of Hematology, the First Affiliated Hospital, Zhejiang University, Hangzhou 310058, China
| | - Yi Luo
- Department of Hematology, Beijing Tongren Hospital, Beijing 100005, China
| | - Zhen Cai
- Department of Hematology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Hui Liu
- Department of Hematology, Beijing Hospital, Beijing 100044, China
| | - Jing-Wen Wang
- Department of Hematology, Beijing Tongren Hospital, Beijing 100005, China
| | - Juan Li
- Department of Hematology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Xi Zhang
- Medical Center of Hematology, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Zi-Min Sun
- Department of Hematology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230026, China
| | - Xiao-Yu Zhu
- Department of Hematology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei 230026, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250014, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Liang Huang
- Institute of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430074, China
| | - Shao-Yuan Wang
- Department of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Tong-Hua Yang
- Department of Hematology, the First People's Hospital of Yunnan Province, Kunming 650032, China
| | - Li-Ping Su
- Department of Hematology, Shanxi Tumor Hospital Affiliated to Shanxi Medical University, Taiyuan 030001, China
| | - Liang-Ming Ma
- Department of Hematology, Shanxi Bethune Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Xie-Qun Chen
- Department of Hematology, The Affiliated Hospital of Northwest Hospital, Xi'an No.3 Hospital, Xi'an 710054, China
| | - Dai-Hong Liu
- Department of Hematology, Chinese PLA General Hospital & PLA Medical School, Beijing 100044, China
| | - Hong-Xia Yao
- Department of Hematology, Hainan Affiliated Hospital of Hainan Medical University, Hainan General Hospital, Haikou 570311, China
| | - Jia Feng
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen 518036, China
| | - Hong-Yu Zhang
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen 518036, China
| | - Ming Jiang
- Center of Hematologic Diseases, The First Affiliated Hospital of Xinjiang Medical University, Urumchi 830054, China
| | - Ze-Ping Zhou
- Department of Hematology, The Second Affiliated Hospital of Kunming Medical University, Kunming 650500, China
| | - Wen-Sheng Wang
- Department of Hematology, Peking University First Hospital, Beijing 100034, China
| | - Xu-Liang Shen
- Department of Hematology, Heping Hospital Affiliated to Changzhi Medical College, Changzhi 046000, China
| | - Yangjin Baima
- Department of Hematology, People's Hospital of Tibet Autonomous Region, Lhasa 850000, China
| | - Yue-Ying Li
- Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing 100029, China
| | - Qian-Fei Wang
- Key Laboratory of Genomic and Precision Medicine, Collaborative Innovation Center of Genetics and Development, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing 100029, China
| | - Qiu-Sha Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Xiao-Lu Zhu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Yun He
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Qian Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Hao Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Xiang-Yu Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Tao Wu
- Department of Hematology, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou 730050, China
| | - Yao-Zhu Pan
- Department of Hematology, The 940th Hospital of Joint Logistics Support Force of Chinese PLA, Lanzhou 730050, China
| | - Lin Qiu
- Institute of Hematology, Harbin the First Hospital, Harbin 150001, China
| | - Da Gao
- Department of Hematology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - A-Rong Jin
- Department of Hematology, Inner Mongolia People's Hospital, Hohhot 010017, China
| | - Wei Li
- Department of Hematology, The First Bethune Hospital of Jilin University, Changchun 130021, China
| | - Su-Jun Gao
- Department of Hematology, The First Bethune Hospital of Jilin University, Changchun 130021, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin 300020, China.
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan 250014, China.
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China.
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China; Collaborative Innovation Center of Hematology, Peking University, Beijing 100044, China; Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China; National Clinical Research Center for Hematologic Disease, Beijing 100044, China.
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10
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González-López TJ, Provan D, Bárez A, Bernardo-Gutiérrez A, Bernat S, Martínez-Carballeira D, Jarque-Ramos I, Soto I, Jiménez-Bárcenas R, Fernández-Fuertes F. Primary and secondary immune thrombocytopenia (ITP): Time for a rethink. Blood Rev 2023; 61:101112. [PMID: 37414719 DOI: 10.1016/j.blre.2023.101112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/07/2023] [Accepted: 06/27/2023] [Indexed: 07/08/2023]
Abstract
There are not many publications that provide a holistic view of the management of primary and secondary ITP as a whole, reflecting the similarities and differences between the two. Given the lack of major clinical trials, we believe that comprehensive reviews are much needed to guide the diagnosis and treatment of ITP today. Therefore, our review addresses the contemporary diagnosis and treatment of ITP in adult patients. With respect to primary ITP we especially focus on establishing the management of ITP based on the different and successive lines of treatment. Life-threatening situations, "bridge therapy" to surgery or invasive procedures and refractory ITP are also comprehensively reviewed here. Secondary ITP is studied according to its pathogenesis by establishing three major differential groups: Immune Thrombocytopenia due to Central Defects, Immune Thrombocytopenia due to Blocked Differentiation and Immune Thrombocytopenia due to Defective Peripheral Immune Response. Here we provide an up-to-date snapshot of the current diagnosis and treatment of ITP, including a special interest in addressing rare causes of this disease in our daily clinical practice. The target population of this review is adult patients only and the target audience is medical professionals.
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Affiliation(s)
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Abelardo Bárez
- Department of Hematology. Complejo Asistencial de Ávila, Ávila, Spain
| | | | - Silvia Bernat
- Department of Hematology, Hospital Universitario de la Plana, Villarreal, Castellón, Spain
| | | | - Isidro Jarque-Ramos
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Inmaculada Soto
- Department of Hematology, Hospital Central de Asturias, Oviedo, Asturias, Spain
| | | | - Fernando Fernández-Fuertes
- Department of Hematology, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
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11
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Yu J, Miao P, Qian S. Application of recombinant human thrombopoietin in pregnant women with immune thrombocytopenia: a single-center experience of four patients and literature review. J Int Med Res 2023; 51:3000605231187950. [PMID: 37548331 PMCID: PMC10408329 DOI: 10.1177/03000605231187950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023] Open
Abstract
The management of pregnant women with immune thrombocytopenia who fail to respond to corticosteroids and intravenous immunoglobulin is an intractable clinical challenge because of the limited availability of evidence-based information. Recombinant human thrombopoietin (rhTPO) is recommended for refractory immune thrombocytopenia (ITP). To date, however, few studies have investigated rhTPO treatment during pregnancy. We retrospectively reviewed four cases who were diagnosed with ITP and treated with rhTPO during pregnancy in our center from January 2015 to June 2020. Of the four cases, two (50%) responded to rhTPO treatment. No adverse events were noted in the newborns. Our findings indicate that rhTPO treatment is safe for patients with refractory gestational ITP, and that subcutaneous injection is a convenient delivery method that does not lead to adverse events. Thus, rhTPO may be a viable alternative treatment option for patients with refractory gestational ITP who do not respond to first-line therapies.
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Affiliation(s)
- Jingdi Yu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Peiwen Miao
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shenxian Qian
- Department of Hematology, Affiliated Hangzhou First People’s Hospital, Zhejiang Chinese Medical University, Hangzhou, China
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12
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Chandrakala S, Toshniwal M, Halvawala M, Padwal N, Sidharthan N, Malhotra P, Prashantha B, Ballikar R, Shah S, Apte S, Viswanathan TK, Ramanan V, Sharma A, Pawar D, Pawar R, Shahavi V. Efficacy and Safety of Biosimilar Romiplostim Versus Innovator Romiplostim in Patients with Chronic Immune Thrombocytopenia. Indian J Hematol Blood Transfus 2023; 39:435-441. [PMID: 37304488 PMCID: PMC10247600 DOI: 10.1007/s12288-022-01602-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
Romiplostim is a Food and Drug Administration (FDA)-approved therapy for immune thrombocytopenia (ITP). Biosimilar is a biological product that has no clinical meaningful difference from an existing FDA-approved reference product. It has a potential of lowering health-care-related cost. Biosimilar of romiplostim can be made available to patients with ITP at a low cost and can be beneficial in providing the best therapy. Thus, the efficacy and safety of biosimilar romiplostim (ENZ110) was compared with innovator romiplostim (Nplate) with respect to platelet response in patients with chronic ITP. This was a prospective, multicenter, randomized, and double-blind clinical trial. Patients with chronic ITP, aged 18-65 years, were enrolled in a study and were randomized to receive either ENZ110 or Nplate in a 3:1 ratio for a treatment period of 12 weeks, respectively. After completion of the treatment period, the patients were followed-up for one week to evaluate the platelet response and to monitor the adverse events (AEs). Over the duration of 12 weeks, platelet response of > 50 × 109/L was achieved in 85.3% patients treated with ENZ110 and in 75.0% patients treated with Nplate in per protocol population. In intent-to-treat population, 83.8% patients with ENZ110 and 76.9% patients with Nplate achieved a platelet response of > 50 × 109/L. In the ENZ110 group, 111 AEs were recorded in 66.7% patients, while 18 AEs were reported in 61.5% patients in the Nplate group. The study demonstrated non-inferiority with comparable efficacy and safety between biosimilar romiplostim and innovator romiplostim in patients with chronic ITP. Trial registration number and date of registration: CTRI/2019/04/018614.
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Affiliation(s)
- S. Chandrakala
- Seth G. S. Medical College and KEM Hospital, Mumbai, India
| | | | | | | | | | - Pankaj Malhotra
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - B. Prashantha
- Kasturba Medical College (KMC) Hospital, Mangalore, India
| | - Riya Ballikar
- Criticare Hospital and Research Institute, Nagpur, India
| | | | | | | | - Vijay Ramanan
- Grant Medical Foundation Ruby Hall Clinic, Pune, India
| | - Akhilesh Sharma
- Medical Affairs Department, Alkem Laboratories Limited, Alkem House, Senapati Bapat Marg,Lower Parel, Mumbai, India
| | - Dattatray Pawar
- Medical Affairs Department, Alkem Laboratories Limited, Alkem House, Senapati Bapat Marg,Lower Parel, Mumbai, India
| | - Roshan Pawar
- Medical Affairs Department, Alkem Laboratories Limited, Alkem House, Senapati Bapat Marg,Lower Parel, Mumbai, India
| | - Vinayaka Shahavi
- Medical Affairs Department, Alkem Laboratories Limited, Alkem House, Senapati Bapat Marg,Lower Parel, Mumbai, India
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13
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Zhou H, Zhou J, Wu D, Ma L, Du X, Niu T, Yang R, Liu J, Zhang F, Shi Q, Wang X, Jing H, Li J, Wang X, Cui Z, Zhou Z, Hou M, Shao Z, Jin J, Li W, Ren H, Hu J, Shen J, Liu L, Zeng Y, Zhou J, Liu X, Shen Y, Ding K, Taira T, Cai H, Zhao Y. Romiplostim in primary immune thrombocytopenia that is persistent or chronic: phase III multicenter, randomized, placebo-controlled clinical trial in China. Res Pract Thromb Haemost 2023; 7:100192. [PMID: 37601010 PMCID: PMC10439391 DOI: 10.1016/j.rpth.2023.100192] [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: 12/02/2022] [Revised: 04/02/2023] [Accepted: 04/15/2023] [Indexed: 08/22/2023] Open
Abstract
Background Multiple trials have confirmed that romiplostim could increase platelet count in individuals with primary immune thrombocytopenia (ITP), but no related study has assessed Chinese patients. Objectives To assess the effectiveness of romiplostim as a second-line treatment of persistent or chronic ITP in Chinese adults. Methods This phase III multicenter, randomized, placebo-controlled, double-blind, then open-label clinical trial (NCT02868099, CTR20150395) was conducted at 28 investigational sites in China. The patients were randomly assigned (3:1) to romiplostim (starting and maximum doses of 1 and 10 μg/kg, respectively) or placebo for 9 weeks (double-blind period), followed by the open-label period (both groups administered romiplostim) to week 22. The primary endpoint was the time (in weeks) during which platelet counts were ≥50 × 109/L in the double-blind period. Results In this study, 202 patients (romiplostim, n = 151; placebo, n = 51) started the treatment. The median (range) numbers of weeks with platelet response after 6 weeks of treatment were 2 (0-6) and 0 (0-2) in patients administered romiplostim and placebo, respectively (P < .001). During the double-blind period, the proportions of patients with treatment-emergent adverse events were comparable between the romiplostim and placebo groups (82.8% vs 82.4%). The treatment-emergent adverse event with ≥10% difference in incidence between these 2 groups was injection site bleeding (1.3% vs 11.8%). Conclusion Romiplostim significantly increased the time with maintained platelet response in patients with persistent or chronic ITP in comparison with placebo. No new safety signal was observed. Trial registration ClinicalTrials.gov, NCT02868099. www.chinadrugtrials.org.cn/clinicaltrials.searchlist.dhtml, CTR20150395.
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Affiliation(s)
- Hu Zhou
- Henan Cancer Hospital/The Affiliated Cancer Hospital of Zhengzhou University, Zhenzhou, China
| | - Jianfeng Zhou
- Tongji Hospital affiliated to Tongji Medical College of Huazhong University of Science & Technology, Wuhan, China
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liping Ma
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xin Du
- Shenzhen Second People’s Hospital, Shenzhen, China
| | - Ting Niu
- West China Hospital, Sichuan University, Chengdu, China
| | - Renchi Yang
- Institute of Hematology & Blood Disease Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Tianjin, China
| | - Jing Liu
- The Third Xiangya Hospital of Central South University, Changsha, China
| | - Feng Zhang
- The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Qingzhi Shi
- The Second affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiuli Wang
- The Second Hospital of Jilin University, Jilin, China
| | - Hongmei Jing
- Peking University Third Hospital, Beijing, China
| | - Junmin Li
- Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin Wang
- Shandong Provincial Hospital, Jinan, China
| | - Zhongguang Cui
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zeping Zhou
- Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ming Hou
- Qilu Hospital of Shandong University, Jinan, China
| | - Zonghong Shao
- Tianjin Medical University General Hospital, Tianjin, China
| | - Jie Jin
- The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenqian Li
- Qinghai Provincial People`s Hospital, Xining, China
| | - Hanyun Ren
- Peking University First Hospital, Beijing, China
| | - Jianda Hu
- Fujian Medical University Union Hospital, Fuzhou, China
| | | | - Li Liu
- Tangdu Hospital, Xi’an, China
| | - Yun Zeng
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jin Zhou
- The First Affiliated Hospital of Haerbin Medical University, Haerbin, China
| | - Xin Liu
- Anhui Provincial Hospital, Hefei, China
| | | | - Kai Ding
- Kyowa Kirin China Pharmaceutical Co, Ltd, Beijing, China
| | | | - Huacong Cai
- Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
| | - Yongqiang Zhao
- Chinese Academy of Medical Sciences & Peking Union Medical College Hospital, Beijing, China
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14
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Aiello A, Mariano EE, Prada M, Teruzzi C, Martone N, Capri S, Carli G, Siragusa S. Budget impact analysis for avatrombopag in the treatment of chronic primary immune thrombocytopenia in adult patients refractory to other treatments. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2230663. [PMID: 37405228 PMCID: PMC10316730 DOI: 10.1080/20016689.2023.2230663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/31/2023] [Accepted: 06/23/2023] [Indexed: 07/06/2023]
Abstract
Introduction: Primary immune thrombocytopenia is a rare autoimmune disease characterised by a decreased platelet count resulting in an increased risk of bleeding events and even life-threatening haemorrhages. Thrombopoietin receptor agonists (TPO-RAs) are the standard of care second-line therapy for adult patients with chronic immune thrombocytopenia. The first TPO-RAs approved and reimbursed in Italy, eltrombopag and romiplostim, while effective, pose some issues in terms of safety (e.g., hepatotoxicity) or general management (e.g., dietary restrictions). Avatrombopag, an effective and well-tolerated TPO-RA, was recently granted reimbursement. Methods: A 3-year (2023-2025) budget impact analysis (BIA) was conducted to estimate its impact on the Italian National Health Service (NHS). Two scenarios were compared, of which one represents the current situation, without avatrombopag, and the other provides for an increasing market share of avatrombopag (up to 26.6%). Results: BIA shows that the increase in the use of avatrombopag correlates with savings for NHS: in the first year, saving would be €1,300,564, increasing to €2,774,210 in the third year, for a total of €6,083,231 over the 3-year period. The sensitivity analysis confirmed these savings in the scenario with avatrombopag. Conclusions: Based on this BIA, the introduction and reimbursement of avatrombopag is an efficient and advantageous choice for the Italian NHS.
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Affiliation(s)
| | | | | | | | | | - Stefano Capri
- School of Economics and Management, LIUC University, Castellanza, Italy
| | - Giuseppe Carli
- Department of Haematology, “S. Bortolo” Hospital, Vicenza, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMise), University of Palermo, Palermo, Italy
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15
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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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16
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Yamasaki S. Bisphosphonate use for glucocorticoid-induced osteoporosis in older patients with immune thrombocytopenia: a clinical perspective. Ann Hematol 2023:10.1007/s00277-023-05266-7. [PMID: 37171596 PMCID: PMC10175903 DOI: 10.1007/s00277-023-05266-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/06/2023] [Indexed: 05/13/2023]
Abstract
Prednisolone, used as a standard initial treatment for immune thrombocytopenia (ITP), is an important risk factor for osteoporosis. Recently, we found that prescription of bisphosphonate during initial loading of prednisolone may prevent reduction in bone mineral density and development of glucocorticoid-induced osteoporosis (GIO) in older patients with ITP receiving prolonged steroid therapy. In this review, I describe the treatment options for older patients with ITP, and present the best practices for screening, evaluating, and diagnosing ITP. I also summarize the literature from 2017 to 2022 on the treatment options for ITP, including discussions on the contraindications and side effects, with an emphasis on GIO, and the relative merits of bisphosphonates as a co-treatment for prevention of GIO. Finally, I present a perspective and an expert recommendation on how older patients with ITP would best be served in the future.
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Affiliation(s)
- Satoshi Yamasaki
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu, Oita, 874-0838, Japan.
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, 810-0065, Japan.
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17
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Ou Y, Zhan Y, Zhuang X, Shao X, Xu P, Li F, Chen H, Ji L, Cheng Y. A bibliometric analysis of primary immune thrombocytopenia from 2011 to 2021. Br J Haematol 2023; 201:954-970. [PMID: 36807900 DOI: 10.1111/bjh.18692] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/22/2023]
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder characterized by isolated thrombocytopenia. This bibliometric analysis was applied to identify the characteristics of global scientific output, the hotspots, and frontiers of ITP over the past 10 years. We retrieved publications from 2011 to 2021 from the Web of Science Core Collection (WoSCC). Bibliometrix package, VOSviewer, and Citespace were used to analyse and visualize the trend, distribution, and hotspots of research on ITP. Altogether, there were 2084 papers, written by 9080 authors from 410 organizations in 70 countries/regions, published in 456 journals with 37 160 co-cited references. In the last decades, the most productive journal was British Journal of Haematology, China was the most productive country. and the most cited journal was Blood. Shandong University was the most productive institution in the field of ITP. NEUNERT C, 2011, BLOOD, CHENG G, 2011, LANCET, and PATEL VL, 2012, BLOOD were the top three most cited documents. "Thrombopoietin receptor agonist", "regulatory T cell" and "sialic acid" were three hotspots of the last decade. And "immature platelet fraction", "Th17", and "fostamatinib" would be research frontiers in the feature. The present study provided a novel insight for future research directions and scientific decision-making.
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Affiliation(s)
- Yang Ou
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China
| | - Yanxia Zhan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xibing Zhuang
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xia Shao
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pengcheng Xu
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Feng Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China
| | - Hao Chen
- Zhongshan Hospital Xuhui Branch, Department of Thoracic Surgery, Fudan University, Shanghai, China
| | - Lili Ji
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yunfeng Cheng
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Zhongshan Hospital Qingpu Branch, Department of Hematology, Fudan University, Shanghai, China.,Institute of Clinical Science, Zhongshan Hospital, Fudan University, Shanghai, China
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18
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Anat GG. Current approaches for the diagnosis and management of immune thrombocytopenia. Eur J Intern Med 2023; 108:18-24. [PMID: 36424271 DOI: 10.1016/j.ejim.2022.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/05/2022] [Accepted: 11/16/2022] [Indexed: 11/22/2022]
Abstract
Immune thrombocytopenia (ITP), is an acquired autoimmune disorder characterized by the destruction of platelets and megakaryocytes, resulting in thrombocytopenia (platelet count <100 × 10⁹/L). This review focuses on the diagnosis and current management of ITP. The diagnosis of ITP is based principally on the exclusion of other causes of isolated thrombocytopenia using patient history, physical examination, blood count, and evaluation of the peripheral blood film. The clinical treatment goals should be to resolve bleeding events and to prevent severe bleeding episodes. The platelet count should be improved to attain a minimum of > 20-30 × 10⁹/L. Therapy should be given as an inpatient in newly diagnosed ITP with a platelet count of > 20 × 10⁹/L or if there is active bleeding. Corticosteroids are considered the standard initial treatment for newly diagnosed patients. Subsequent medical therapies with robust evidence include thrombopoietin receptor agonists (TPO-RAs), rituximab and fostamatinib. Surgical therapy with splenectomy may be considered for patients failing medical therapy. The choice between therapy options is highly dependent upon patient values and preferences.
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Affiliation(s)
- Gafter-Gvili Anat
- Department of Medicine A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
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19
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Crickx E, Mahévas M, Michel M, Godeau B. Older Adults and Immune Thrombocytopenia: Considerations for the Clinician. Clin Interv Aging 2023; 18:115-130. [PMID: 36726813 PMCID: PMC9885884 DOI: 10.2147/cia.s369574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/10/2023] [Indexed: 01/28/2023] Open
Abstract
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
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Affiliation(s)
- Etienne Crickx
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France
| | - Matthieu Mahévas
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Institut Necker Enfants Malades (INEM), INSERM U1151/CNRS UMS 8253, ATIP-Avenir Team AI2B, Université de Paris, Université Paris-Est-Créteil, Paris, France,INSERM U955, équipe 2, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Marc Michel
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Bertrand Godeau
- Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l’adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France,Correspondence: Bertrand Godeau, Service de Médecine Interne, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris (AP-HP), 51 avenue du maréchal de Lattre de Tassigny, Créteil, 94000, France, Tel +331 49 81 29 05, Fax +331 49 81 29 02, Email
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20
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Gordon MJ, Ferrajoli A. Unusual complications in the management of chronic lymphocytic leukemia. Am J Hematol 2022; 97 Suppl 2:S26-S34. [PMID: 35491515 DOI: 10.1002/ajh.26585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a common, indolent disease that typically presents with a proliferation of mature, immunologically dysfunctional CD5+ B-cells which preferentially occupy the bone marrow, peripheral blood and lymphoid organs. Immune dysfunction leads to an increase in autoimmune diseases which occur in approximately 10% of patients with CLL. Autoimmune cytopenias are the most common, but other organs may be affected as well. The treatment of these conditions typically depends on the extent of CLL and severity of symptoms, but generally consists of CLL-directed therapies, immunosuppression or both. CLL may also infiltrate extranodal sites in the body. Symptomatic extranodal CLL or extranodal disease which threatens normal organ function is an indication for initiation of CLL-directed therapy. The following review summarizes autoimmune and extranodal complications that can occur in patients with CLL and our suggested approach to their treatment.
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Affiliation(s)
- Max J Gordon
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
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21
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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).
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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
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22
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Rosenberg A, Cashion C, Ali F, Haran H, Biswas RK, Chen V, Crowther H, Curnow J, Deakin E, Tan C, Tan YL, Vanlint A, Ward CM, Bird R, Rabbolini DJ. Treatment of immune thrombocytopenia in Australian adults: A multicenter retrospective observational study. Res Pract Thromb Haemost 2022; 6:e12792. [PMID: 36186101 PMCID: PMC9483174 DOI: 10.1002/rth2.12792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 07/25/2022] [Accepted: 08/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background In Australia, prescribing restrictions limit access to internationally recommended second-line therapies such as rituximab and thrombopoietin agonists (TPO-A) (eltrombopag and romiplostim). Subsequent lines of therapy include an array of immunosuppressive and immune-modulating agents directed by drug availability and physician and patient preference. Objectives The objective of the study was to describe the use of first and subsequent lines of treatment for adult immune thrombocytopenia (ITP) in Australia and to assess their effectiveness and tolerability. Patients/Methods A retrospective review of medical records was conducted of 322 patients treated for ITP at eight participating centers in Australia between 2013 and 2020. Data were analyzed by descriptive statistics and frequency distribution using pivot tables, and comparisons between centers were assessed using paired t tests. Results Mean age at diagnosis of ITP was 48.8 years (standard deviation [SD], 22.6) and 58.3% were women. Primary ITP was observed in 72% and secondary ITP in 28% of the patients; 95% of patients received first-line treatment with prednisolone (76%), dexamethasone (15%), or intravenous immunoglobulin (48%) alone or in combination. Individuals with secondary ITP were less steroid dependent (72% vs. 76%) and required less treatment with a second-line agent (47% vs. 58%) in the study sample. Over half (56%) of the cohort received treatment with one or more second-line agents. The mean number of second-line agents used for each patient was 1.9 (SD, 1.2). The most used second-line therapy was rituximab, followed by etrombopag and splenectomy. These also generated the highest rates of complete response (60.3%, 72.1%, and 71.8% respectively). The most unfavorable side effect profiles were seen in long-term corticosteroids and splenectomy. Conclusion A wide range of "second-line" agents were used across centers with variable response rates and side effect profiles. Findings suggest greater effectiveness of rituximab and TPO-A, supporting their use earlier in the treatment course of patients with ITP across Australia.
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Affiliation(s)
| | - Catelyn Cashion
- The Royal North Shore HospitalSydneyNew South WalesAustralia
| | - Fariya Ali
- Westmead HospitalWestmeadNew South WalesAustralia
| | - Harini Haran
- Westmead HospitalWestmeadNew South WalesAustralia
| | - Raaj K. Biswas
- Sydney Local Health District Clinical Research CentreCamperdownNew South WalesAustralia
| | - Vivien Chen
- The Concord & Repatriation HospitalConcord WestNew South WalesAustralia
- ANZAC Research Institute and Concord Repatriation HospitalConcordNew South WalesAustralia
| | - Helen Crowther
- Blacktown & Mount Druitt HospitalBlacktownNew South WalesAustralia
| | | | | | - Chee‐Wee Tan
- The Royal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Yi Ling Tan
- Nepean HospitalKingswoodNew South WalesAustralia
| | - Andrew Vanlint
- The Royal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Christopher M. Ward
- The Royal North Shore HospitalSydneyNew South WalesAustralia
- Northern Blood Research Centre, Kolling Institute, University of SydneySydneyNew South WalesAustralia
| | - Robert Bird
- The Princess Alexandra HospitalWoollongabbaQueenslandAustralia
| | - David J. Rabbolini
- Lismore Base HospitalLismoreNew South WalesAustralia
- Northern Clinical School and the Rural Clinical School (Northern Rivers), University of SydneySydneyNew South WalesAustralia
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Cuker A, Lal L, Roy A, Elliott C, Carlyle M, Martin C, Haenig J, Viana R. Thrombopoietin receptor agonist discontinuation rates and reasons among patients with immune thrombocytopenia: a study of administrative claims linked with medical chart review. Ann Hematol 2022; 101:1915-1924. [PMID: 35849155 DOI: 10.1007/s00277-022-04888-7] [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: 12/07/2021] [Accepted: 06/04/2022] [Indexed: 11/01/2022]
Abstract
Administrative claims provide a rich data source for retrospective studies of real-world clinical practice, yet some important data may be inconsistent or unavailable. This study explored factors influencing discontinuation of thrombopoietin receptor agonists (TPO-RAs) among patients with immune thrombocytopenia (ITP), by adding medical chart abstraction for additional details. Adult (≥ 18 years) patients with continuous commercial or Medicare Advantage with Part D health insurance coverage were included. Inclusion criteria were ≥ 1 claim for eltrombopag or romiplostim and ≥ 2 diagnoses of ITP between December 31, 2017, and January 1, 2020. Providers were asked to provide access to medical charts for abstraction. The analyses included only patients who discontinued TPO-RA and described patient characteristics, treatment patterns, platelet values, and reasons for discontinuation. Among 207 ITP patients treated with a TPO-RA, 137 (66%) discontinued treatment during the observation period. The mean TPO-RA treatment duration was 185 days. Mean platelet count at the time of discontinuation was 197 × 109/L. The most common reason for discontinuation was improvement of the patient's condition (42%). Other reasons included worsening of ITP/lack of response (12%), adverse events (12%), and cost-related or social reasons (23%). No reason was reported for 10%. Notably 26% of patients who discontinued remained off all ITP therapy for the remainder of the study, with a mean treatment-free period of 262 days. These results emphasize that some patients with ITP are able to discontinue TPO-RA therapy and achieve durable treatment-free periods.
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Affiliation(s)
- Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Anuja Roy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Lu J, Jamieson BD, Hui AM. Avatrombopag ethnic sensitivity analysis in chronic liver disease and thrombocytopenia patients: individual-level pooled analysis. Therap Adv Gastroenterol 2022; 15:17562848221105976. [PMID: 35795378 PMCID: PMC9252017 DOI: 10.1177/17562848221105976] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/19/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Few data have been published on the ethnic sensitivity of effectiveness, pharmacokinetics (PK), and pharmacodynamics (PD) of avatrombopag for the management of thrombocytopenia in patients with chronic liver disease (CLD). METHODS An ethnic sensitivity analysis was performed based on the results from two phase III studies (ADAPT-1 and ADAPT-2), with a primary endpoint of the proportion of patients without the requirement of platelet transfusion or rescue treatment for bleeding after randomization to 7 days following a scheduled procedure, and three phase I studies in healthy subjects. Cochran-Mantel-Haenszel and Fisher's exact tests were used to compare the differences in effectiveness in different ethnicities and overall population. RESULTS In total, 435 patients (placebo, n = 158; avatrombopag, n = 277) were stratified into various ethnic groups: 121 East Asians, including the subgroup of 27 Chinese, and 259 Caucasians. The proportion of patients who did not receive a platelet transfusion and those with a platelet count ⩾50 × 109/L in the avatrombopag 40 and 60 mg groups were higher than that of placebo for all ethnicities and in the overall population. Statistical significance was obtained in the overall population and for all ethnicities other than Chinese patients, a group with a very small sample size. No significant difference was observed in the proportion of responders in each ethnic group compared to overall population (p > 0.05). The incidence of adverse events in East Asians was similar to that in both Caucasians and the overall population. CONCLUSION Avatrombopag was effective and safe in the management of thrombocytopenia in Chinese patients with CLD. Ethnicity does not appear to influence the efficacy, safety, PK, or PD of avatrombopag.
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Affiliation(s)
- Jun Lu
- Clinical Research Department, Shanghai Fosun Pharmaceutical Development, Co., Ltd, Shanghai, China
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Novel Therapies to Address Unmet Needs in ITP. Pharmaceuticals (Basel) 2022; 15:ph15070779. [PMID: 35890078 PMCID: PMC9318546 DOI: 10.3390/ph15070779] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 02/04/2023] Open
Abstract
Primary immune thrombocytopenia (ITP) is an autoimmune disorder that causes low platelet counts and subsequent bleeding risk. Although current corticosteroid-based ITP therapies are able to improve platelet counts, up to 70% of subjects with an ITP diagnosis do not achieve a sustained clinical response in the absence of treatment, thus requiring a second-line therapy option as well as additional care to prevent bleeding. Less than 40% of patients treated with thrombopoietin analogs, 60% of those treated with splenectomy, and 20% or fewer of those treated with rituximab or fostamatinib reach sustained remission in the absence of treatment. Therefore, optimizing therapeutic options for ITP management is mandatory. The pathophysiology of ITP is complex and involves several mechanisms that are apparently unrelated. These include the clearance of autoantibody-coated platelets by splenic macrophages or by the complement system, hepatic desialylated platelet destruction, and the inhibition of platelet production from megakaryocytes. The number of pathways involved may challenge treatment, but, at the same time, offer the possibility of unveiling a variety of new targets as the knowledge of the involved mechanisms progresses. The aim of this work, after revising the limitations of the current treatments, is to perform a thorough review of the mechanisms of action, pharmacokinetics/pharmacodynamics, efficacy, safety, and development stage of the novel ITP therapies under investigation. Hopefully, several of the options included herein may allow us to personalize ITP management according to the needs of each patient in the near future.
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Kanda RG, Niero-Melo L, Domingues MAC, Oliveira CC. Impact of reticulin stain in clinical outcome of Immune Thrombocytopenic Purpura (ITP): a pathologist perspective. SURGICAL AND EXPERIMENTAL PATHOLOGY 2022. [DOI: 10.1186/s42047-022-00108-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
This study evaluated histopathological characteristics of bone marrow (BM) of patients with immune thrombocytopenic purpura (ITP) and sought to find possible associations among them and clinical aspects.
Method
A retrospective study was carried out with 120 patients using BM clot and BM biopsy samples, including morphological (cytological and histological) re-evaluation, reticulin and hemosiderin analysis, and clinical outcome review of medical records. Immunohistochemistry (CD34 and CD117) was applied in a group of patients with increased reticulin, with the objective of exclusion Myelodysplastic syndrome cases
Results
Megakaryocytic hyperplasia was observed in 109 (90.8%) patients and increased reticulin was diagnosed in nine patients, five of them with a clinically unfavorable outcome (p = 0.042). The increase in reticulin graduation was associated with a higher risk of an unfavorable outcome.
Conclusion
Increased reticulin degree in BM of patients with ITP is associated with an unfavorable outcome in this study. It is rarely explored in the literature and may provide information that contributes to understanding the patient's outcomes.
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Sheng XY, Liu ZY, Zhao J, Song L, Zhao WM, Zhao X, Cui YM. Safety, tolerance, pharmacokinetic and pharmacodynamic properties of thrombopoietin mimetic peptide for injection in Chinese healthy volunteers: a randomized, placebo-controlled, double-blind study. Platelets 2022; 33:1185-1191. [PMID: 35549802 DOI: 10.1080/09537104.2022.2073344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The thrombopoietin mimetic peptide for injection is a second-generation thrombopoietin receptor agonist (TPO-RA) used in the treatment of patients with immune thrombocytopenia. The aim of the present study was to assess the safety, tolerance, pharmacokinetic and pharmacodynamic properties of thrombopoietin mimetic peptide for injection in Chinese healthy volunteers. A randomized, placebo-controlled, double-blind, dose-escalation study was conducted in healthy Chinese subjects aged 18-50 years. Thirty subjects received single subcutaneous injection of 0.3 μg/kg, 1.0 μg/kg, 2.0 μg/kg thrombopoietin mimetic peptide or placebo. Thrombopoietin mimetic peptide was safe and well tolerated at doses of 0.3-2.0 μg/kg. There was no significant change in mean platelet count (PLT) from baseline at the 0.3 μg/kg or placebo groups. The mean PLT of subjects in the 1.0 μg/kg and 2.0 μg/kg groups peaked at day 12 (± 1), began to decline around day 17, and returned to the baseline level at day 28 (± 1). Platelet aggregation rates of the three dose groups showed no significant change before and after administration. Serum concentrations of thrombopoietin mimetic peptide in all subjects were below the quantization limit. This was the first study to demonstrate that subcutaneous injection of thrombopoietin mimetic peptide at doses of 0.3-2.0 μg/kg was safe and well tolerated in Chinese healthy subjects. As a second-generation TPO-RA, thrombopoietin mimetic peptide is effective at improving PLT after single subcutaneous injection at dose of ≥1 μg/kg.Plain language summaryWhat is the context?● Immune thrombocytopenia (ITP) is a rare, serious autoimmune disorder characterized by low platelet count (PLT) without an alternate cause. The treatment goal of ITP is to increase the platelet count to a safe level that can stop active bleeding and reduce the risks of future bleeding.● Thrombopoietin receptor agonists (TPO-RAs, e.g. eltrombopag, avatrombopag, hetrombopag, and romiplostim) have shown high response rates in stimulating platelet production and reducing the risk of bleeding. TPO-RAs provide ITP patients with well-tolerated, long-term treatment choices.What is new?● The thrombopoietin mimetic peptide for injection is a new TPO-RAs developed by Shandong Quangang Pharmaceutical Co., Ltd. (China).● This study showed that thrombopoietin mimetic peptide is effective at improving PLT after a single subcutaneous injection.● The thrombopoietin mimetic peptide is safe and well-tolerated in Chinese healthy subjects.What is the impact?● This study provides evidence for the further development potential of the thrombopoietin mimetic peptide.
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Affiliation(s)
- Xiao-Yan Sheng
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhi-Yan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Jing Zhao
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Lei Song
- Research and Development Center, Shandong Quangang Pharmaceutical Co. Ltd., Jinan, China
| | - Wen-Ming Zhao
- Research and Development Center, Shandong Quangang Pharmaceutical Co. Ltd., Jinan, China
| | - Xia Zhao
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yi-Min Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,Institute of Clinical Pharmacology, Peking University, Beijing, China
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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.
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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
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29
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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
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30
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Vianelli N, Auteri G, Buccisano F, Carrai V, Baldacci E, Clissa C, Bartoletti D, Giuffrida G, Magro D, Rivolti E, Esposito D, Podda GM, Palandri F. Refractory primary immune thrombocytopenia (ITP): current clinical challenges and therapeutic perspectives. Ann Hematol 2022; 101:963-978. [PMID: 35201417 PMCID: PMC8867457 DOI: 10.1007/s00277-022-04786-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 02/01/2022] [Indexed: 01/19/2023]
Abstract
Chronic primary immune thrombocytopenia (ITP) can today benefit from multiple therapeutic approaches with proven clinical efficacy, including rituximab, thrombopoietin receptor agonists (TPO-RA), and splenectomy. However, some ITP patients are unresponsive to multiple lines of therapy with prolonged and severe thrombocytopenia. The diagnosis of refractory ITP is mainly performed by exclusion of other disorders and is based on the clinician's expertise. However, it significantly increases the risk of drug-related toxicity and of bleedings, including life-threatening events. The management of refractory ITP remains a major clinical challenge. Here, we provide an overview of the currently available treatment options, and we discuss the emerging rationale of new therapeutic approaches and their strategic combination. Particularly, combination strategies may target multiple pathogenetic mechanisms and trigger additive or synergistic effects. A series of best practices arising both from published studies and from real-life clinical experience is also included, aiming to optimize the management of refractory ITP.
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Affiliation(s)
- Nicola Vianelli
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy
| | - Giuseppe Auteri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | - Francesco Buccisano
- Dipartimento Di Biomedicina E Prevenzione, Università Tor Vergata, Rome, Italy
| | | | | | | | - Daniela Bartoletti
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.,Dipartimento Di Medicina Specialistica, Diagnostica E Sperimentale, Università Di Bologna, Bologna, Italy
| | | | | | - Elena Rivolti
- Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniela Esposito
- Presidio Ospedaliero San G. Moscati Di Aversa - ASL Caserta, Caserta, Italy
| | - Gian Marco Podda
- Medicina III, Ospedale San Paolo, ASST Santi Paolo E Carlo, Dipartimento Di Scienze Della Salute, Università Degli Studi Di Milano, Milano, Italy
| | - Francesca Palandri
- IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Istituto Di Ematologia "Seràgnoli, Bologna, Italy.
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31
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Oo Z, Manvar K, Wang JC. Eltrombopag-Induced Thrombocytosis and Thrombosis in Patients With Antiphospholipid Syndrome and Immune Thrombocytopenic Purpura. J Investig Med High Impact Case Rep 2022; 10:23247096211060581. [PMID: 35277086 PMCID: PMC8922183 DOI: 10.1177/23247096211060581] [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: 11/23/2022] Open
Abstract
Antiphospholipid syndrome (APS) may be either as a primary or in association with an underlying systemic autoimmune etiology (36.2%), particularly systemic lupus erythematosus (SLE). Thrombocytopenia is infrequently observed in APS patients, with an occurrence of 22% to 42% with the frequency of thrombocytopenia, higher in APS and SLE combination than in primary APS. There have been some controversial reports regarding the treatment of APS syndrome with thrombocytopenia with TPO agonists. We like to report a case with APS syndrome with severe thrombocytopenia treated with TPO-RA and developed severe thrombocytosis and thrombosis. Our case represented the first case of TPO-RA in treating APS syndrome developed severe thrombocytosis and our case also concurred that use of TPO-RA agents should be strongly discouraged in APS until larger studies clarify the safety of TPO-RA agents in APS.
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Affiliation(s)
- Zayar Oo
- Brookdale University Hospital Medical Center, New York, NY, USA
| | | | - Jen Chin Wang
- Brookdale University Hospital Medical Center, New York, NY, USA
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32
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Nam CH, Byun JM, Shin DY, Hong J, Kim I, Yoon SS, Koh Y. Romiplostim plus danazol as salvage treatment for eltrombopag refractory immune thrombocytopenia: a retrospective pilot study. Blood Res 2021; 56:202-204. [PMID: 34462405 PMCID: PMC8478612 DOI: 10.5045/br.2021.2021067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/11/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Chang Hyun Nam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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33
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Meyer O, Richter H, Lebioda A, Schill M. Treatment patterns in adults with immune thrombocytopenia before, during and after use of thrombopoietin receptor agonists: a longitudinal prescription database study from Germany. Hematology 2021; 26:697-708. [PMID: 34547980 DOI: 10.1080/16078454.2021.1974203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To assess real-world treatment patterns in patients with immune thrombocytopenia (ITP) who received thrombopoietin receptor agonists (TPO-RAs) in Germany. METHODS This was a longitudinal, retrospective study using anonymized patient-level data (IQVIA healthcare prescription database, covering 82% of German statutory prescriptions). Eligible patients (aged ≥18 years) had received ≥1 TPO-RA prescription (romiplostim/eltrombopag) from July 2016 to June 2019 (treatment duration ≥30 days). ITP medication use was assessed for 18 months prior to, during and for ≥6 months after TPO-RA treatment. RESULTS A total of 3553 patients (median age 64 years) were included. Median persistence on TPO-RAs was 12 months (range 1-34). In the periods before, during and after TPO-RA treatment, oral corticosteroids were the most commonly used therapy (64.4%, 43.4% and 36.1% of patients, respectively); median cumulative doses across each period were 2521.9, 2000.0 and 2277.8 mg. The median total duration of corticosteroid use before, during and after TPO-RA therapy was 15, 18 and 32 weeks, respectively. The total median cumulative corticosteroid dose was 6799.7 mg. CONCLUSION We identified a potential overuse of corticosteroids in patients with ITP in Germany. Earlier use of TPO-RA therapy after a short course of corticosteroids could avoid side effects associated with long-term use.
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Chen F, McDonald V, Newland A. Experts' review: the emerging roles of romiplostim in immune thrombocytopenia (ITP). Expert Opin Biol Ther 2021; 21:1383-1393. [PMID: 34313512 DOI: 10.1080/14712598.2021.1960979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The management of ITP has in recent years been transformed from reliance on immunosuppressants and splenectomy to targeted therapy with thrombopoietin receptor agonists (TPO-RA) that directly stimulate platelet production in the bone marrow. This has reduced the long-term infective complications and toxicities associated with the use of potent immunosuppressants and splenectomy. The welltolerated romiplostim, itself a novel drug construct called peptibody, has established itself, alongside other TPO-RA as the preferred 2nd line therapy in major international guidelines on treatment of ITP. AREAS COVERED This review summarizes the data from early licensing trials of romiplostim and discusses the real-world experience to date, the unexpected emerging data on treatment-free long-term remission achieved using TPO-RA, and the case for its early introduction in the therapeutic pathway. The emerging risk of thrombosis is also discussed. EXPERT OPINION The use of romiplostim and other TPO-RA will be increasingly brought forward in the management pathway of ITP with the prospect of modifying the long-term outcome of the disease by increasing sustained treatment-free remission. With the prospect of several new targeted therapies been introduced into clinical practice, TPO-RA will likely be a key component of future combination therapies for difficult cases.
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Affiliation(s)
- Frederick Chen
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Vickie McDonald
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry,QMUL, London, UK
| | - Adrian Newland
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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35
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Song F, Al-Samkari H. Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice. J Blood Med 2021; 12:653-664. [PMID: 34345191 PMCID: PMC8323851 DOI: 10.2147/jbm.s259101] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/12/2021] [Indexed: 12/17/2022] Open
Abstract
Immune thrombocytopenia (ITP) is an autoimmune process resulting in increased destruction and inadequate production of platelets that can result in bleeding, fatigue, and reduced health-related quality of life. While treatment is not required for many patients with ITP, the occurrence of bleeding manifestations, severe thrombocytopenia, and requirement for invasive procedures are among the reasons necessitating initiation of therapy. Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are typical first-line and rescue treatments, but these agents typically do not result in a durable remission in adult patients. Most patients requiring treatment therefore require subsequent line therapies, such as thrombopoietin receptor agonists (TPO-RAs), rituximab, fostamatinib, splenectomy, or a number of other immunosuppressive agents. In this focused review, we discuss management of adult ITP in the acute and chronic settings.
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Affiliation(s)
- Fei Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, USA.,Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
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36
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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.
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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
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37
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Nomura S, Abe M, Yamaoka M, Ito T. Effect of Cytokine Gene Polymorphisms on Eltrombopag Reactivity in Japanese Patients with Immune Thrombocytopenia. J Blood Med 2021; 12:421-429. [PMID: 34113203 PMCID: PMC8187034 DOI: 10.2147/jbm.s309680] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/10/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by low platelet counts resulting from antiplatelet autoantibodies. Analysis of polymorphisms in cytokine-encoding genes is important for understanding the pathophysiology of ITP and selecting appropriate treatments. We investigated associations between polymorphisms in cytokine-encoding genes and responses to therapy in Japanese patients with ITP. METHODS The participants in this study comprised 153 patients with ITP and 70 healthy controls. We extracted data on sex, age, platelet counts, bleeding symptoms, and therapeutic responses, including those to prednisolone (PSL) and eltrombopag. Genomic DNA was isolated from peripheral blood and polymorphisms in TNF-α, IL-10, TGF-β1, and IFN-γ genes were analyzed using the PCR-SSP method. RESULTS Our results showed that the TGF-β1 +869 C/C genotype might be related to ITP in Japanese patients. The IL-10 -592 C/C and A/A, -819 C/C and T/T, and -1082, -819, -592 ATA/ATA genotypes might be associated with reactivity to PSL. Furthermore, the IL-10 -592 C/A -819 C/T genotypes, IL-10 ACC/ATA genotype, and TGF-β1 +869 T/T and T/C genotypes might be linked to the response to eltrombopag. CONCLUSION Our results indicate that analysis of polymorphisms in cytokine-encoding genes could aid in understanding PSL and eltrombopag responsiveness in Japanese patients with ITP.
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Affiliation(s)
- Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
| | - Misao Abe
- Division of Blood Transfusion, Kansai Medical University, Hirakata, Osaka, Japan
| | - Manabu Yamaoka
- Division of Blood Transfusion, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Osaka, Japan
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38
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Bussel JB, Soff G, Balduzzi A, Cooper N, Lawrence T, Semple JW. A Review of Romiplostim Mechanism of Action and Clinical Applicability. Drug Des Devel Ther 2021; 15:2243-2268. [PMID: 34079225 PMCID: PMC8165097 DOI: 10.2147/dddt.s299591] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Thrombocytopenia results from a variety of conditions, including radiation, chemotherapy, autoimmune disease, bone marrow disorders, pathologic conditions associated with surgical procedures, hematopoietic stem cell transplant (HSCT), and hematologic disorders associated with severe aplastic anemia. Immune thrombocytopenia (ITP) is caused by immune reactions that accelerate destruction and reduce production of platelets. Thrombopoietin (TPO) is a critical component of platelet production pathways, and TPO receptor agonists (TPO-RAs) are important for the management of ITP by increasing platelet production and reducing the need for other treatments. Romiplostim is a TPO-RA approved for use in patients with ITP in the United States, European Union, Australia, and several countries in Africa and Asia, as well as for use in patients with refractory aplastic anemia in Japan and Korea. Romiplostim binds to and activates the TPO receptor on megakaryocyte precursors, thus promoting cell proliferation and viability, resulting in increased platelet production. Through this mechanism, romiplostim reduces the need for other treatments and decreases bleeding events in patients with thrombocytopenia. In addition to its efficacy in ITP, studies have shown that romiplostim is effective in improving platelet counts in various settings, thereby highlighting the versatility of romiplostim. The efficacy of romiplostim in such disorders is currently under investigation. Here, we review the structure, mechanism, pharmacokinetics, and pharmacodynamics of romiplostim. We also summarize the clinical evidence supporting its use in ITP and other disorders that involve thrombocytopenia, including chemotherapy-induced thrombocytopenia, aplastic anemia, acute radiation syndrome, perisurgical thrombocytopenia, post-HSCT thrombocytopenia, and liver disease.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Gerald Soff
- Department of Medicine, Hematology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | | | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
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Xiao Q, Lin B, Wang H, Zhan W, Chen P. The Efficacy of High-Dose Dexamethasone vs. Other Treatments for Newly Diagnosed Immune Thrombocytopenia: A Meta-Analysis. Front Med (Lausanne) 2021; 8:656792. [PMID: 34113634 PMCID: PMC8185030 DOI: 10.3389/fmed.2021.656792] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/27/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To compare the therapeutic efficacies of high dose dexamethasone, prednisone and rituximab in combination with dexamethasone for newly diagnosed ITP (Immune Thrombocytopenia, ITP) patients. Methods and results: Relevant publications for this study were obtained by searching PubMed, Embase, Cochrane, and CNKI (National Knowledge Infrastructure, CNKI) databases following the PRISMA guidelines. A total of, 15 publications were retrieved that contained sufficient data from 1,362 patients for high quality analysis of this study endpoints. Data analysis was carried out using Stata 11.0 software. The primary outcomes were OR (Overall Response, OR) at 1 month after intervention and SR at 6 and 12 months. The secondary outcomes were AEs and relapse. There were no differences in the OR, while the SR was higher at 6 months (p = 0.001) as well as 12 months (p < 0.001) in the rituximab + dexamethasone group. In addition, the incidences of AEs (p = 0.008) were also higher in the rituximab + dexamethasone group. Dexamethasone was superior to prednisone based on OR (p = 0.006). We found no differences in SR at 6 months between dexamethasone and prednisone but SR at 12 months was higher in the dexamethasone group (p = 0.014). The relapse rate was higher in the high dose dexamethasone group compared to the rituximab + dexamethasone group (p = 0.042). Conclusion: This demonstrated that new treatment options such as Rituximab + dexamethasone, could be a good alternative to traditional therapy in improving long-term response and reducing the rate of relapse. However, further studies are required on the increased risk of AEs associated with Rituximab + dexamethasone.
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Affiliation(s)
- Qirong Xiao
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
- Central Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Bicun Lin
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
- Central Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hanyu Wang
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Weiwu Zhan
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
- Central Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ping Chen
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
- Central Laboratory, Fujian Medical University Union Hospital, Fuzhou, China
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Recombinant human thrombopoietin promotes platelet engraftment after umbilical cord blood transplantation. Blood Adv 2021; 4:3829-3839. [PMID: 32790845 DOI: 10.1182/bloodadvances.2020002257] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/08/2020] [Indexed: 01/01/2023] Open
Abstract
Delayed platelet engraftment is a common complication after umbilical cord blood transplantation (UCBT) accompanied by increased transplant-related complications or death. This study was designed to determine the safety and efficacy of recombinant human thrombopoietin (rhTPO) in promoting platelet engraftment after UCBT. A total of 120 patients scheduled to receive UCBT were randomly assigned to the rhTPO group (300 U/kg once daily from days 14 to 28 after UCBT, n = 60) or the control group (n = 60). The primary outcome was the 60-day cumulative incidence of platelet engraftment after single-unit cord blood transplantation. The 60-day cumulative incidence of platelet engraftment (platelet count ≥20 × 109/L) and the 120-day cumulative incidence of platelet recovery (platelet count ≥50 × 109/L) were both significantly higher in the rhTPO group than in the control group (83.1% vs 66.7%, P = .020; and 81.4% vs 65.0%, P = .032, respectively). In addition, the number of required platelet infusions was significantly lower in the rhTPO group than in the control group (6 vs 8 units, respectively; P = .026). The cumulative incidence of neutrophil engraftment and the probability of 2-year overall survival, disease-free survival, and graft-versus-host disease-free relapse-free survival did not differ between the 2 groups. Other transplant-related outcomes and complications did not differ between the 2 groups, and no severe adverse effects were observed in patients receiving rhTPO. This study demonstrated that rhTPO is well tolerated in patients and could effectively promote platelet engraftment after UCBT. This study was registered on the Chinese Clinical Trial Registry (http://www.chictr.org.cn/index.aspx) as ChiCTR-IPR-16009357.
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Cooper N, Altomare I, Thomas MR, Nicolson PLR, Watson SP, Markovtsov V, Todd LK, Masuda E, Bussel JB. Assessment of thrombotic risk during long-term treatment of immune thrombocytopenia with fostamatinib. Ther Adv Hematol 2021; 12:20406207211010875. [PMID: 33995988 PMCID: PMC8111531 DOI: 10.1177/20406207211010875] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Patients with immune thrombocytopenia (ITP) are at risk of bleeding and, paradoxically, thromboembolic events (TEEs), irrespective of thrombocytopenia. The risk of thrombosis is increased by advanced age, obesity, and prothrombotic comorbidities: cancer, hyperlipidemia, diabetes, hypertension, coronary artery disease, and chronic kidney disease, among others. Certain ITP treatments further increase the risk of TEE, especially splenectomy and thrombopoietin receptor agonists. Spleen tyrosine kinase (SYK) is a key signaling molecule common to thromboembolic and hemostatic (in addition to inflammatory) pathways. Fostamatinib is an orally administered SYK inhibitor approved in the USA and Europe for treatment of chronic ITP in adults. Methods: The phase III and extension studies included heavily pretreated patients with long-standing ITP, many of whom had risk factors for thrombosis prior to initiating fostamatinib. This report describes long-term safety and efficacy of fostamatinib in 146 patients with up to 5 years of treatment, a total of 229 patient-years, and assesses the incidence of thromboembolic events (by standardized MedDRA query). Results: Platelet counts ⩾50,000/µL were achieved in 54% of patients and the safety profile was as described in the phase III clinical studies with no new toxicities observed over the 5 years of follow-up. The only TEE occurred in one patient (0.7%, or 0.44/100 patient-years), who experienced a mild transient ischemic attack. This is a much lower rate than might be expected in ITP patients. Conclusion: This report demonstrates durable efficacy and a very low incidence of TEE in patients receiving long-term treatment of ITP with the SYK inhibitor fostamatinib. ClinicalTrials.gov identifiers: NCT02076399, NCT02076412, and NCT02077192.
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Affiliation(s)
- Nichola Cooper
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, UK
| | - Ivy Altomare
- Duke University School of Medicine, Durham, NC, USA
| | - Mark R Thomas
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Phillip L R Nicolson
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Steve P Watson
- Institute of Cardiovascular Sciences, The Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Vadim Markovtsov
- Department of Research and Discovery, Rigel Pharmaceuticals Inc., South San Francisco, CA, USA
| | - Leslie K Todd
- Department of Research and Discovery, Rigel Pharmaceuticals Inc., South San Francisco, CA, USA
| | - Esteban Masuda
- Department of Research and Discovery, Rigel Pharmaceuticals Inc., South San Francisco, CA, USA
| | - James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Medical College of Cornell University, 115 East 67th Street, New York, NY 10065, USA
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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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Cooper N, Hill QA, Grainger J, Westwood JP, Bradbury C, Provan D, Thachil J, Ramscar N, Roy A. Tapering and Discontinuation of Thrombopoietin Receptor Agonist Therapy in Patients with Immune Thrombocytopenia: Results from a Modified Delphi Panel. Acta Haematol 2021; 144:418-426. [PMID: 33789275 DOI: 10.1159/000510676] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/31/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Recent evidence suggests that in patients with immune thrombocytopenia (ITP) with a stable response on thrombopoietin receptor agonists, treatment may be tapered and/or discontinued. OBJECTIVES The objective of this study was to provide a guide for tapering and discontinuation of TPO-RA therapy in patients with ITP, based on hematologist survey results, existing evidence, and expert consensus. PATIENTS/METHODS UK hematologists completed a survey to characterize self-reported practice patterns related to TPO-RA tapering and discontinuation in patients with ITP. Using a modified Delphi panel approach, ITP experts developed consensus statements regarding the use of TPO-RA tapering and discontinuation. RESULTS Survey respondents estimated that 30-34% of their patients were suitable for tapering or discontinuation and that 29-35% of these patients required treatment re-initiation after an average treatment-free interval of 86-106 days. No clear predictors of patient suitability or response to tapering or discontinuation were identified. The ITP expert consensus was that approximately 30% of patients are eligible for tapering and discontinuation, which may be considered after 6-12 months for patients demonstrating an adequate treatment response (platelet count >50,000/µL at ≥75% of assessments in the preceding 6 months). Treatment re-initiation may be considered if the platelet count decreases or if the patient becomes symptomatic. Individual differences need to be taken into account when considering TPO-RA tapering or discontinuation. CONCLUSIONS Tapering and discontinuation of TPO-RA therapy may be considered for certain patients with ITP. Further study is needed to better predict patients likely to achieve sustained off-treatment responses after tapering and discontinuation.
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Affiliation(s)
- Nichola Cooper
- Department of Haematology, Hammersmith Hospital, London, United Kingdom
| | - Quentin A Hill
- Department of Haematology, The Leeds Teaching Hospital, Leeds, United Kingdom
| | - John Grainger
- Department of Pediatric Haematology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - John-Paul Westwood
- Department of Haematology, University College London Hospital, London, United Kingdom
| | - Charlotte Bradbury
- Bristol Haematology and Oncology Centre, University of Bristol, Bristol, United Kingdom
| | - Drew Provan
- Department of Haematology, Barts and the London School of Medicine, London, United Kingdom
| | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospital, Manchester, United Kingdom
| | | | - Anuja Roy
- Novartis Pharmaceuticals, East Hanover, New Jersey, USA
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Emerging Therapies in Immune Thrombocytopenia. J Clin Med 2021; 10:jcm10051004. [PMID: 33801294 PMCID: PMC7958340 DOI: 10.3390/jcm10051004] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a rare autoimmune disorder caused by peripheral platelet destruction and inappropriate bone marrow production. The management of ITP is based on the utilization of steroids, intravenous immunoglobulins, rituximab, thrombopoietin receptor agonists (TPO-RAs), immunosuppressants and splenectomy. Recent advances in the understanding of its pathogenesis have opened new fields of therapeutic interventions. The phagocytosis of platelets by splenic macrophages could be inhibited by spleen tyrosine kinase (Syk) or Bruton tyrosine kinase (BTK) inhibitors. The clearance of antiplatelet antibodies could be accelerated by blocking the neonatal Fc receptor (FcRn), while new strategies targeting B cells and/or plasma cells could improve the reduction of pathogenic autoantibodies. The inhibition of the classical complement pathway that participates in platelet destruction also represents a new target. Platelet desialylation has emerged as a new mechanism of platelet destruction in ITP, and the inhibition of neuraminidase could dampen this phenomenon. T cells that support the autoimmune B cell response also represent an interesting target. Beyond the inhibition of the autoimmune response, new TPO-RAs that stimulate platelet production have been developed. The upcoming challenges will be the determination of predictive factors of response to treatments at a patient scale to optimize their management.
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Christakopoulos GE, DeFor TE, Hage S, Wagner JE, Linden MA, Brunstein C, Bejanyan N, Verneris MR, Smith AR. Phase I Dose-Finding, Safety, and Tolerability Trial of Romiplostim to Improve Platelet Recovery After UCB Transplantation. Transplant Cell Ther 2021; 27:497.e1-497.e6. [PMID: 33785364 DOI: 10.1016/j.jtct.2021.02.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/22/2020] [Accepted: 02/26/2021] [Indexed: 11/18/2022]
Abstract
Platelet recovery is delayed after umbilical cord blood transplant (UCBT). Romiplostim is a thrombopoietin receptor agonist that has the potential to improve platelet engraftment after UCBT. The purpose of this study was to determine the safety profile and maximum tolerated dose (MTD) of romiplostim and to investigate whether romiplostim accelerates platelet recovery post-UCBT. It was a single-center, dose-finding, safety and tolerability phase I trial of weekly romiplostim in 20 adult patients who failed to achieve an un-transfused platelet count of 20 × 109/L by day +28 post-UCBT. Romiplostim was administered at the assigned dose as 6 weekly injections beginning by day +42 post-UCBT. Four dose levels (4, 6, 8, and 10 µg/kg per dose) were evaluated. The MTD of romiplostim was determined by the continual reassessment method, with a goal to identify a dose level with desired toxicity rate of ≤20%. Median age of the patients was 59.5 years, and 60% were female. Eleven patients received nonmyeloablative (NMA) double UCBT, seven patients received myeloablative single UCBT, and two patients received NMA single UCBT. Two patients received 4 µg/kg per dose, two received 6 µg/kg per dose, four received 8 µg/kg per dose, and the remaining 12 received 10 µg/kg per dose. Only five patients completed the full six doses of treatment. Of the 15 patients who received fewer than six doses, 12 were due to a platelet count of >100 × 109/L, two were due to platelet count of >400 × 109/L, and one was due to right upper extremity edema without thrombosis. All romiplostim-treated patients achieved platelet engraftment to 20 × 109/L at a median of 45 days post-UCBT compared to 90% of controls at a median of 45 days (P = .08). Similarly, 90% of romiplostim-treated patients achieved platelet engraftment to 50 × 109/L at a median of 48 days compared to 75% of controls at a median of 52 days (P = .09). All dose levels were effective with low toxicity; therefore, the MTD of romiplostim was 10 µg/kg per dose, and romiplostim is a safe and potentially effective therapy to counter delayed platelet recovery post-UCBT.
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Affiliation(s)
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Stefanie Hage
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - John E Wagner
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Michael A Linden
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Claudio Brunstein
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Nelli Bejanyan
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Michael R Verneris
- Division of Hematology, Oncology, and Bone Marrow Transplantation, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Angela R Smith
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota.
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Kuter DJ, Tarantino MD, Lawrence T. Clinical overview and practical considerations for optimizing romiplostim therapy in patients with immune thrombocytopenia. Blood Rev 2021; 49:100811. [PMID: 33781612 DOI: 10.1016/j.blre.2021.100811] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/23/2020] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
The fundamental treatment goal for patients with immune thrombocytopenia (ITP) is reduced or ameliorated bleeding. Although various treatment options exist for the management of ITP, recent advances have led to the approval of three thrombopoietin receptor agonists (TPO-RAs; romiplostim, eltrombopag, and avatrombopag) in the United States and European Union. Current treatment guidelines for ITP indicate that medical therapy is preferred over surgical therapy and support the use of TPO-RAs as early as 3 months after disease onset. More recent data are available on the use of romiplostim in patients who have had ITP for <1 year, and romiplostim is now indicated for the treatment of adults who have not responded adequately to initial treatment, as well as children aged ≥1 year who have had ITP for ≥6 months. Here we review the role of romiplostim in the management of ITP, with a focus on efficacy and safety data, emerging data on early use (beginning within 3 months of disease onset) and treatment-free remission, and practical considerations for optimal management of ITP.
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Affiliation(s)
- David J Kuter
- Hematology Division, Massachusetts General Hospital, Suite 118, Room 110, Zero Emerson Place, Boston, MA 02114, USA.
| | - Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, 9128 North Lindbergh Drive, Peoria, IL 61615, USA.
| | - Tatiana Lawrence
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 91320, USA.
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Takeuchi H, Furuichi Y, Yoshimasu Y, Kasai Y, Abe M, Sugimoto K, Itoi T. The Thrombopoietin Receptor Agonist Lusutrombopag Is Effective for Patients with Chronic Liver Disease and Impaired Renal Function. J NIPPON MED SCH 2021; 87:325-333. [PMID: 32238734 DOI: 10.1272/jnms.jnms.2020_87-603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The thrombopoietin (TPO) receptor agonist lusutrombopag was developed to treat thrombocytopenia in chronic liver disease (CLD). However, its effectiveness remains unclear. The purpose of this study was to assess the efficacy of lusutrombopag and identify predictors associated with increase in platelet count. METHODS Eighty CLD patients with thrombocytopenia were enrolled. The primary endpoint was a satisfactory increase in platelets (greater than 1.0 × 104/μL from baseline) in the absence of platelet transfusion. The secondary endpoints were response rate (an increase of greater than 1.0 × 104/μL from baseline), independent predictors of increase in platelets, and the superiority of lusutrombopag over platelet transfusion. RESULTS The primary endpoint was achieved in 93.8% (75 of 80) patients. The response rate was 96.2% (77 of 80). Renal function parameters (blood urea nitrogen, creatinine, eGFR) were significantly negatively associated with platelet count (p = 0.033, 0.049, and 0.0014, respectively) and were identified as independent predictors by multiple regression analysis (p = 0.049, 0.0023, and 0.0016, respectively). The median increase in platelet count was significantly higher after lusutrombopag than after platelet transfusion (41,000 vs. 12,000/μL, p = 0.015). CONCLUSION Lusutrombopag was more effective than platelet transfusion for CLD patients, and renal function independently predicted increase in platelet count. Renal function parameters were significantly associated with platelet count.
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Affiliation(s)
- Hirohito Takeuchi
- Department of Gastroenterology and Hepatology, Tokyo Medical University
| | - Yoshihiro Furuichi
- Department of Gastroenterology and Hepatology, Tokyo Medical University.,Department of Gastroenterology and Hepatology, Niizashiki Central General Hospital
| | - Yu Yoshimasu
- Department of Gastroenterology and Hepatology, Tokyo Medical University
| | - Yoshitaka Kasai
- Department of Gastroenterology and Hepatology, Tokyo Medical University
| | - Masakazu Abe
- Department of Gastroenterology and Hepatology, Tokyo Medical University
| | | | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University
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Comparative Utilization and Efficacy of Thrombopoietin Receptor Agonists in Relapsed/Refractory Immune Thrombocytopenia. Am J Ther 2021; 28:e525-e530. [PMID: 33491968 DOI: 10.1097/mjt.0000000000001335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The thrombopoietin (TPO) agonists, eltrombopag and romiplostim, stimulate the production of platelets and offer an effective treatment option in relapsed/refractory immune thrombocytopenia (ITP). Recently published 2019 ITP guidelines recommend the TPO agonists as second-line therapy following corticosteroids; however, little data offer insights into comparative efficacy and tolerability. STUDY QUESTION Is there a difference in the efficacy between romiplostim and eltrombopag in relapsed/refractory ITP? STUDY DESIGN We conducted a single-center, retrospective chart review of patients with ITP treated with romiplostim or eltrombopag. MEASURES AND OUTCOMES The primary objective was a sustained platelet response, defined as platelets greater than 50,000/μL in more than 66% of clinic visits over a 6-month period. Secondary objectives sought to evaluate response to and tolerability of TPO agonists. RESULTS The study included 107 consecutive patients, 67 (63%) on romiplostim and 40 (37%) on eltrombopag. Previous corticosteroids and rituximab were used in 95% and 50% of patients, respectively. There was no difference identified in platelet responses between the TPO-RAs, 72% romiplostim versus 65% eltrombopag (P = 0.520). In addition, no differences were identified in secondary measures of response. CONCLUSIONS In our experience with romiplostim and eltrombopag for ITP, we did not identify a difference in the efficacy of these agents. Further larger and prospective evaluations should be considered.
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Lozano ML, Godeau B, Grainger J, Matzdorff A, Rodeghiero F, Hippenmeyer J, Kuter DJ. Romiplostim in adults with newly diagnosed or persistent immune thrombocytopenia. Expert Rev Hematol 2020; 13:1319-1332. [PMID: 33249935 DOI: 10.1080/17474086.2020.1850253] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Three distinct phases are recognized in immune thrombocytopenia (ITP): newly diagnosed (≤3 months after diagnosis), persistent (>3-12 months after diagnosis), and chronic (>12 months). Several international guidelines/expert recommendations have been released in the past 2 years regarding the treatment of newly diagnosed/persistent ITP. Areas covered: Across the guidelines/expert recommendations, thrombopoietin receptor agonists (TPO-RAs), including romiplostim (the focus of this review), are recommended in newly diagnosed or persistent ITP for patients who fail to respond to corticosteroids or intravenous immunoglobulin (or where these are contraindicated). To identify data relating to romiplostim in adults with newly diagnosed or persistent ITP, we conducted a search of PubMed (with no time limit applied) and abstracts from 2019 EHA/ASH meetings using the term 'romiplostim.' Expert opinion: The findings from nine clinical trials, six real-world studies and ten case reports provide insight into the early use of romiplostim, which could help to reduce exposure to the adverse effects associated with prolonged corticosteroid use, as well as reduce the risk of severe bleeding. Additionally, given the durable responses observed in patients with newly diagnosed/persistent ITP, as well as the potential for treatment-free responses following discontinuation, romiplostim might help to avoid the need for subsequent treatment.
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Affiliation(s)
- Maria L Lozano
- Hospital JM Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca , Murcia, Spain.,Grupo de investigación CB15/00055 del Centro de Investigación Biomedica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III (ISCIII) , Madrid, Spain
| | - Bertrand Godeau
- Centre de Référence des Cytopénies Auto-Immunes de l'Adulte, Service de Médecine Interne, CHU Henri Mondor, AP-HP, Université Paris-Est Créteil , Créteil, France
| | - John Grainger
- Department of Haematology, Royal Manchester Children's Hospital , Manchester, UK
| | - Axel Matzdorff
- Department of Internal Medicine II, Asklepios Clinic Uckermark , Schwedt, Germany
| | - Francesco Rodeghiero
- Hematology Project Foundation and Department of Hematology, S. Bortolo Hospital , Vicenza, Italy
| | | | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School , Boston, MA, USA
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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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