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Gebetsberger J, Streif W, Dame C. Update on the Use of Thrombopoietin-Receptor Agonists in Pediatrics. Hamostaseologie 2024. [PMID: 38925157 DOI: 10.1055/a-2247-4209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024] Open
Abstract
This review summarizes the rationale and current data on the use of thrombopoietin receptor agonists (TPO-RAs) for treating severe thrombocytopenia in infants, children, and adolescents. It focuses on substances that have been approved by the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA) for pediatric patients. Romiplostim and eltrombopag are already established as second-line treatment for persistent or chronic immune thrombocytopenia (ITP). As in adults, TPO-RAs are currently also evaluated in severe aplastic anemia (SAA), chemotherapy-induced thrombocytopenia (CIT), myelodysplastic syndromes (MDS), and poor engraftment after hematopoietic stem cell transplantation in pediatric and adolescent patients. Moreover, studies on the implication of TPO-RA in treating rare inherited thrombocytopenias, such as Wiskott-Aldrich syndrome (WAS), congenital amegakaryocytic thrombocytopenia (CAMT), or MYH9-associated thrombocytopenia, deserve future attention. Current developments include testing of avatrombopag and lusutrombopag that are approved for the treatment of thrombocytopenia associated with chronic liver disease (CLD) in adult patients. In pediatric and adolescent medicine, we expect in the near future a broader use of TPO-RAs as first-line treatment in primary ITP, thereby considering immunomodulatory effects that increase the rate of sustained remission off-treatment, and a selective use in rare inherited thrombocytopenias based on current clinical trials.
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Affiliation(s)
| | - Werner Streif
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Christof Dame
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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2
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Kilic Gunes E, Yigit Kaya S, Yaman F, Yeniay MK, Vural K, Comert M, Sevindik OG, Andic N, Dagdas S, Nizam Ozen I, Kaynar L, Yavasoglu F, Ozet G, Karakus V, Ayli M. Eltrombopag treatment in thrombocytopenia following hematopoietic stem cell transplantation: A multicenter real-world experience. Leuk Res 2024; 140:107484. [PMID: 38520796 DOI: 10.1016/j.leukres.2024.107484] [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: 01/05/2024] [Revised: 02/16/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
INTRODUCTION Thrombocytopenia is among the most common complications following hematopoietic stem cell transplantation and is associated with increased mortality and morbidity with no standard treatment yet. In this multicenter and retrospective study, we aim to present our multi-center experience of Eltrombopag treatment in patients with isolated thrombocytopenia following HSCT. MATERIAL-METHOD A total of 73 patients from 5 centers who underwent autologous or allogeneic stem cell transplantation, had no primary disease relapse, all of whom had neutrophil engraftment, complete chimerism, and who were diagnosed with Prolonged Isolated Thrombocytopenia (PIT) or Secondary Failure Of Platelet Recovery (SFPR) were included in the study. The patients were initiated on Eltrombopag at a dose of 50-150 mg. Complete response was defined as a platelet count >50×109/L for 7 consecutive days with no transfusion support. RESULTS A total of 50.3% of the patients underwent Autologous and 49.7% Allogeneic Stem Cell Transplantation, 54.8% were diagnosed with PIT, and 45.2% were diagnosed with SFPR, and the treatment with 50-150 mg/day Eltrombopag was initiated on the median day +42. Complete response was achieved in 71.2% of these patients on the median day 23 of the treatment. No significant effects of the initial dose (50-150 mg/day) were detected in the Complete Response in the multivariate analysis on response. An insufficient number of Megakaryocytes in the bone marrow before Eltrombopag treatment was determined as an independent risk factor in determining the response (OR 3.57, 95% CI 1.21-10.55). The overall survival of the patients who did not respond to Eltrombopag was found to be significantly worse than that of patients who responded (p=0.022, HR:2.74, 95% CI 1.12-6.54). CONCLUSION As a result of the present study, Eltrombopag treatment was found to be effective and safe in thrombocytopenia that develops following hematopoietic stem cell transplantation. It was concluded that its use may be more effective in patients with sufficient bone marrow megakaryocytes before the treatment and an initial dose of 50 mg/day may be appropriate in terms of cost, effectiveness, and toxicity. Large-scale randomized and controlled prospective studies are needed to determine the roles of Eltrombopag treatment in patients with post-transplant PIT and SFPR.
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Affiliation(s)
- Ebru Kilic Gunes
- University of Health and Sciences, Gulhane Training and Research Hospital, Department of Hematology, Ankara, Turkiye.
| | - Sureyya Yigit Kaya
- Istanbul Medipol University, Faculty of Medicine, Department of Hematology, Istanbul, Turkiye
| | - Fatih Yaman
- Eskisehir Osmangazi University, Faculty of Medicine, Department of Hematology, Eskisehir, Turkiye
| | - Mustafa Kemal Yeniay
- University of Health and Sciences, Ankara Bilkent City Hospital, Department of Hematology, Ankara, Turkiye
| | - Kurtulus Vural
- University of Health and Sciences, Antalya Training and Research Hospital, Department of Hematology, Antalya, Turkiye
| | - Melda Comert
- University of Health and Sciences, Gulhane Training and Research Hospital, Department of Hematology, Ankara, Turkiye
| | - Omur Gokmen Sevindik
- Istanbul Medipol University, Faculty of Medicine, Department of Hematology, Istanbul, Turkiye
| | - Neslihan Andic
- Eskisehir Osmangazi University, Faculty of Medicine, Department of Hematology, Eskisehir, Turkiye
| | - Simten Dagdas
- University of Health and Sciences, Ankara Bilkent City Hospital, Department of Hematology, Ankara, Turkiye
| | - Ilknur Nizam Ozen
- University of Health and Sciences, Antalya Training and Research Hospital, Department of Hematology, Antalya, Turkiye
| | - Leylagul Kaynar
- Istanbul Medipol University, Faculty of Medicine, Department of Hematology, Istanbul, Turkiye
| | - Filiz Yavasoglu
- Eskisehir Osmangazi University, Faculty of Medicine, Department of Hematology, Eskisehir, Turkiye
| | - Gulsum Ozet
- University of Health and Sciences, Ankara Bilkent City Hospital, Department of Hematology, Ankara, Turkiye; Ankara Yildirim Beyazit University, Faculty of Medicine, Department of Hematology, Ankara Bilkent City Hospital, Ankara, Turkiye
| | - Volkan Karakus
- University of Health and Sciences, Antalya Training and Research Hospital, Department of Hematology, Antalya, Turkiye
| | - Meltem Ayli
- University of Health and Sciences, Gulhane Training and Research Hospital, Department of Hematology, Ankara, Turkiye
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3
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Mititelu A, Onisâi MC, Roșca A, Vlădăreanu AM. Current Understanding of Immune Thrombocytopenia: A Review of Pathogenesis and Treatment Options. Int J Mol Sci 2024; 25:2163. [PMID: 38396839 PMCID: PMC10889445 DOI: 10.3390/ijms25042163] [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: 12/21/2023] [Revised: 01/24/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
The management of immune thrombocytopenia (ITP) and the prediction of patient response to therapy still represent a significant and constant challenge in hematology. ITP is a heterogeneous disease with an unpredictable evolution. Although the pathogenesis of ITP is currently better known and its etiology has been extensively studied, up to 75% of adult patients with ITP may develop chronicity, which represents a significant burden on patients' quality of life. A major risk of ITP is bleeding, but knowledge on the exact relationship between the degree of thrombocytopenia and bleeding symptoms, especially at a lower platelet count, is lacking. The actual management of ITP is based on immune suppression (corticosteroids and intravenous immunoglobulins), or the use of thrombopoietin receptor agonists (TPO-RAs), rituximab, or spleen tyrosine kinase (Syk) inhibitors. A better understanding of the underlying pathology has facilitated the development of a number of new targeted therapies (Bruton's tyrosine kinase inhibitors, neonatal Fc receptors, strategies targeting B and plasma cells, strategies targeting T cells, complement inhibitors, and newer TPO-RAs for improving megakaryopoiesis), which seem to be highly effective and well tolerated and result in a significant improvement in patients' quality of life. The disadvantage is that there is a lack of knowledge of the predictive factors of response to treatments, which would help in the development of an optimized treatment algorithm for selected patients.
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Affiliation(s)
- Alina Mititelu
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania; (M.-C.O.); (A.M.V.)
| | - Minodora-Cezarina Onisâi
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania; (M.-C.O.); (A.M.V.)
| | - Adrian Roșca
- Department of Physiology, Carol Davila University of Medicine and Pharmacy, 050471 Bucharest, Romania;
| | - Ana Maria Vlădăreanu
- Department of Hematology, Carol Davila University of Medicine and Pharmacy, Emergency University Hospital of Bucharest, 050098 Bucharest, Romania; (M.-C.O.); (A.M.V.)
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4
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Wang D, Lang T, Zeng H, Zou Z, Yang S, Cheng T, Liu H, Zhu L, Xiang X, Yao H, Tang S, Kong P, Wei J, Xiong J, Gao L, Zhang X, Feng Y. Thrombopoietin receptor agonists for refractory thrombocytopenia in patients after autologous hematopoietic stem cell transplantation. Transpl Immunol 2023; 81:101948. [PMID: 37923019 DOI: 10.1016/j.trim.2023.101948] [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: 08/11/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Autologous hematopoietic stem cell (ASC) transplantation (ASCT) is an effective treatment method for patients with hematological disorders and malignant diseases. The patient's ASCs are harvested prior to radiotherapy/chemotherapy, cryopreserved and then transfused back after the high-dose radiotherapy/chemotherapy conditioning treatment. Since some patients develop thrombocytopenia after receiving ASCT, it is difficult for them to bear simultaneously the management of their original disease and thrombocytopenia. The present study aimed to evaluate the efficacy and safety of thrombocytopenia therapy with thrombopoietin receptor agonists (TPORAs) after ASCT. METHODS We retrospectively analyzed the clinical safety and efficacy of TPORA treatment for the enrolled 20 patients who developed thrombocytopenia after ASCT. The measured parameters were prolonged isolated thrombocytopenia (PIT), secondary failure of platelet recovery (SFPR) and other calculated response index. Patients with platelet count (PC) ≤ 50×109/L were treated with TPORA, namely with either eltrombopag (Elt), hetrombopag (Het), or avatrobopag (Ava). RESULTS The group of 20 patients, who received TPORA administration for their thrombocytopenia after ASCT, had a median age of 50 years (ranging between 17 and 60 years). The median administration time of TPORA application was 48 days (ranging from 7 to 451 days); an overall response rate (ORR) was 85% with no response in 15% of patients, while with complete response (CR) in 70% of patients and partial response (PR) in 15% of patients. The median platelet count was 19 × 109/L before TPORA treatment and increased to 87×109)/L after the treatment. The TPORA treatment was safe as only 4 patients (20%) displayed a mild transaminase elevation. No other reported side effects occurred, such as thrombosis, joint pain, diarrhea, and myelofibrosis. It was demonstrated that the short response time to TPORA treatment correlated to the fast platelet recovery, when the number of megakaryocytes in the bone marrow smear exceeded 35/4.5 cm2 under a low magnification of 100 times (p = 0.015). CONCLUSION TPORA therapy for thrombocytopenia occurring after the radiotherapy/ chemotherapy-conditioned ASCT was well tolerated and effective for platelets recovery.
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Affiliation(s)
- Dan Wang
- Department of Hematology, The First Affiliated Hospital of North Sichuan Medical College, Nanchong, China; Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Tao Lang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Hanqing Zeng
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhongmin Zou
- Department of Chemical Defense Medicine, School of Military Preventive Medicine, Army Medical University, Chongqing, China
| | - Shijie Yang
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Ting Cheng
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Huanfeng Liu
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Lidan Zhu
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xixi Xiang
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Han Yao
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Shuhan Tang
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Peiyan Kong
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Jin Wei
- Department of Hematology, The First Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Jingkang Xiong
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Lei Gao
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Xi Zhang
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China.
| | - Yimei Feng
- Medical Center of Hematology, The Second Affiliated Hospital of Army Medical University, Chongqing, China.
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5
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Gonzalez-Lugo JD, Kambhampati S, Yacoub A, Donnellan WB, Berdeja J, Bhagat P, Fehn K, Remy C, Jasra S, Kazemi M, Pradhan K, Kim M, Mantzaris I, Sica RA, Shah N, Goldfinger M, Kornblum N, Gritsman K, Braunschweig I, Steidl U, Will B, Shastri A, Verma A. Lenalidomide and Eltrombopag for Treatment of Low- or Intermediate-Risk Myelodysplastic Syndrome: Result of a Phase II Clinical Trial. Clin Cancer Res 2023; 29:60-66. [PMID: 36255372 DOI: 10.1158/1078-0432.ccr-22-1457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/15/2022] [Accepted: 10/14/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE Thrombocytopenia is a serious complication of myelodysplastic syndromes (MDS) associated with an increased bleeding risk and worse prognosis. Eltrombopag (ELT), a thrombopoietin receptor agonist, can increase platelet counts and reverse anti-megakaryopoietic effects of lenalidomide (LEN) in preclinical studies. We hypothesized ELT would reduce the incidence of thrombocytopenia in MDS. PATIENTS AND METHODS We conducted a Phase II multicenter trial of ELT and LEN in adult patients with low- or intermediate-1-risk MDS with symptomatic or transfusion-dependent anemia or thrombocytopenia (NCT01772420). Thrombocytopenic patients were started on ELT and subsequently treated with LEN after platelets were increased. Patients without thrombocytopenia were started on LEN monotherapy and treated with ELT if they became thrombocytopenic. RESULTS Fifty-two patients were enrolled; mean age was 71 years (range 34-93). Overall response rate (ORR) in the intention-to-treat population was 35% (18/52). ELT monotherapy led to ORR of 33.3% (7/21), 29% achieving hematologic improvement (HI)-Platelets, and 24% bilineage responses. LEN monotherapy had 38% ORR (6/16) with all responders achieving HI-Erythroid. Fifteen patients received both ELT and LEN with ORR of 33.3%, 20% achieved HI-Erythroid, and 20% HI-Platelets with 13% bilineage responses. Median duration of response was 40 weeks for ELT (range 8-ongoing), 41 weeks (25-ongoing) for LEN, and 88 weeks (8.3-ongoing) for ELT/LEN. Non-hematologic grade 3-4 treatment-related adverse events were infrequent. Among patients on ELT, 2 had major bleeding events, 1 had a reversible increase in peripheral blasts, and 1 developed marrow fibrosis after 6 years on ELT. CONCLUSIONS ELT and LEN are well tolerated and effective in achieving hematologic improvement in patients with low-/intermediate-risk MDS.
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Affiliation(s)
- Jesus D Gonzalez-Lugo
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Suman Kambhampati
- Sarah Cannon Transplant and Cellular Therapy Program, Kansas City, Kansas
| | | | | | - Jesus Berdeja
- Sarah Cannon Research Institute, Nashville, Tennessee
| | - Prafulla Bhagat
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Karen Fehn
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Cassady Remy
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Sakshi Jasra
- University of Vermont Cancer Center, Burlington, Vermont
| | | | - Kith Pradhan
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Mimi Kim
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Ioannis Mantzaris
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - R Alejandro Sica
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Nishi Shah
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Mendel Goldfinger
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Noah Kornblum
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Kira Gritsman
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Ira Braunschweig
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Ulrich Steidl
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York.,Department of Cell Biology, Albert Einstein College of Medicine, Bronx, New York
| | - Britta Will
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York.,Department of Cell Biology, Albert Einstein College of Medicine, Bronx, New York
| | - Aditi Shastri
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
| | - Amit Verma
- Division of Hemato-Oncology, Department of Oncology, Montefiore Einstein Cancer Center, Blood Cancer Institute, Bronx, New York
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6
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Muntión S, Preciado S, Sánchez-Luis E, Corchete L, Díez-Campelo M, Osugui L, Martí-Chillón GJ, Vidriales MB, Navarro-Bailón A, De Las Rivas J, Sánchez-Guijo F. Eltrombopag increases the hematopoietic supporting ability of mesenchymal stem/stromal cells. Ther Adv Hematol 2022; 13:20406207221142137. [PMID: 36601635 PMCID: PMC9806379 DOI: 10.1177/20406207221142137] [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: 06/15/2022] [Accepted: 11/11/2022] [Indexed: 12/28/2022] Open
Abstract
Background Eltrombopag (EP) is a small molecule that acts directly on hematopoietic stem cells (HSCs) and megakaryocytes to stimulate the hematopoietic process. Mesenchymal stem/stromal cells (MSCs) are key hematopoietic niche regulators. Objectives We aimed to determine whether EP has any effect on MSC function and properties (especially on their hematopoietic-supporting ability) and if so, what changes (e.g. genome-wide transcriptomic alterations) are induced in MSC after EP treatment. Design/Methods MSCs were isolated from 12 healthy donors and treated with 15 µM and 50 µM of EP for 24 h. The toxicity of the drug on MSCs and their differentiation ability were analyzed, as well as the transcriptomic profile, reactive oxygen species (ROS) and DNA damage and the changes induced in the clonogenic capacity of HSCs. Results The results show that EP also modifies MSC functions, decreasing their adipogenic differentiation, increasing the expression of genes involved in hypoxia and other pathways related to oxygen homeostasis, and enhancing their ability to support hematopoiesis in vitro. Conclusion Our findings support the use of EP in cases where hematopoiesis is defective, despite its well-known direct effects on hematopoietic cells. Our findings suggest that further studies on the effects of EP on MSCs from patients with aplastic anemia are warranted.
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Affiliation(s)
| | - Silvia Preciado
- Cell Therapy Area, Department of Hematology,
Institute of Biomedical Research of Salamanca-Hospital Universitario de
Salamanca (IBSAL-HUS), Salamanca, Spain,RICORS TERAV, ISCIII, Madrid, Spain,Centro en Red de Medicina Regenerativa y
Terapia Celular de Castilla y León, Valladolid, Spain
| | - Elena Sánchez-Luis
- Bioinformatics and Functional Genomics Group,
Cancer Research Center (CiC-IBMCC), Consejo Superior de Investigaciones
Científicas (CSIC) and University of Salamanca (USAL), Salamanca,
Spain
| | - Luis Corchete
- Institute of Biomedical Research of Salamanca
(IBSAL), Cancer Research Center (CiC-IBMCC, CSIC/USAL), Center for
Biomedical Research in Network of Cancer (CIBERONC), Hematology Department,
University Hospital of Salamanca, Salamanca, Spain
| | - María Díez-Campelo
- RICORS TERAV, ISCIII, Madrid, Spain,Center for Biomedical Research in Network of
Cancer (CIBERONC), Department of Hematology, University Hospital of
Salamanca (IBSAL-HUS), Salamanca, Spain,Department of Medicine, University of
Salamanca (USAL), Salamanca, Spain
| | - Lika Osugui
- Cell Therapy Area, Department of Hematology,
Institute of Biomedical Research of Salamanca-Hospital Universitario de
Salamanca (IBSAL-HUS), Salamanca, Spain,Centro en Red de Medicina Regenerativa y
Terapia Celular de Castilla y León, Valladolid, Spain
| | - Gerardo-Javier Martí-Chillón
- Cell Therapy Area, Department of Hematology,
Institute of Biomedical Research of Salamanca-Hospital Universitario de
Salamanca (IBSAL-HUS), Salamanca, Spain,Centro en Red de Medicina Regenerativa y
Terapia Celular de Castilla y León, Valladolid, Spain
| | - María-Belén Vidriales
- Center for Biomedical Research in Network of
Cancer (CIBERONC), Department of Hematology, University Hospital of
Salamanca (IBSAL-HUS), Salamanca, Spain
| | - Almudena Navarro-Bailón
- Cell Therapy Area, Department of Hematology,
Institute of Biomedical Research of Salamanca-Hospital Universitario de
Salamanca (IBSAL-HUS), Salamanca, Spain,RICORS TERAV, ISCIII, Madrid, Spain,Centro en Red de Medicina Regenerativa y
Terapia Celular de Castilla y León, Valladolid, Spain
| | - Javier De Las Rivas
- Bioinformatics and Functional Genomics Group,
Cancer Research Center (CiC-IBMCC), Consejo Superior de Investigaciones
Científicas (CSIC) and University of Salamanca (USAL), Salamanca,
Spain
| | - Fermín Sánchez-Guijo
- Cell Therapy Area, Department of Hematology,
Institute of Biomedical Research of Salamanca-Hospital Universitario de
Salamanca (IBSAL-HUS), Salamanca, Spain,RICORS TERAV, ISCIII, Madrid, Spain,Centro en Red de Medicina Regenerativa y
Terapia Celular de Castilla y León, Valladolid, Spain,Center for Biomedical Research in Network of
Cancer (CIBERONC), Department of Hematology, University Hospital of
Salamanca (IBSAL-HUS), Salamanca, Spain,Department of Medicine, University of
Salamanca (USAL), Salamanca, Spain
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7
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Okoye-Okafor UC, Javarappa KK, Tsallos D, Saad J, Yang D, Zhang C, Benard L, Thiruthuvanathan VJ, Cole S, Ruiz S, Tatiparthy M, Choudhary G, DeFronzo S, Bartholdy BA, Pallaud C, Ramos PM, Shastri A, Verma A, Heckman CA, Will B. Megakaryopoiesis impairment through acute innate immune signaling activation by azacitidine. J Exp Med 2022; 219:e20212228. [PMID: 36053753 PMCID: PMC9441716 DOI: 10.1084/jem.20212228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/02/2022] [Accepted: 07/22/2022] [Indexed: 11/04/2022] Open
Abstract
Thrombocytopenia, prevalent in the majority of patients with myeloid malignancies, such as myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML), is an independent adverse prognostic factor. Azacitidine (AZA), a mainstay therapeutic agent for stem cell transplant-ineligible patients with MDS/AML, often transiently induces or further aggravates disease-associated thrombocytopenia by an unknown mechanism. Here, we uncover the critical role of an acute type-I interferon (IFN-I) signaling activation in suppressing megakaryopoiesis in AZA-mediated thrombocytopenia. We demonstrate that megakaryocytic lineage-primed progenitors present IFN-I receptors and, upon AZA exposure, engage STAT1/SOCS1-dependent downstream signaling prematurely attenuating thrombopoietin receptor (TPO-R) signaling and constraining megakaryocytic progenitor cell growth and differentiation following TPO-R stimulation. Our findings directly implicate RNA demethylation and IFN-I signal activation as a root cause for AZA-mediated thrombocytopenia and suggest mitigation of TPO-R inhibitory innate immune signaling as a suitable therapeutic strategy to support platelet production, particularly during the early phases of AZA therapy.
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Affiliation(s)
- Ujunwa Cynthia Okoye-Okafor
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Komal K. Javarappa
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Dimitrios Tsallos
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Joseph Saad
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Daozheng Yang
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | - Chi Zhang
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | - Lumie Benard
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Victor J. Thiruthuvanathan
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Sally Cole
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Stephen Ruiz
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Madhuri Tatiparthy
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
| | - Gaurav Choudhary
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
| | - Stefanie DeFronzo
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | - Boris A. Bartholdy
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
| | | | | | - Aditi Shastri
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
| | - Amit Verma
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
| | - Caroline A. Heckman
- Institute for Molecular Medicine Finland (FIMM), Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Britta Will
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Cell Biology, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Cancer Stem Cell Pharmacodynamics Unit, Bronx, NY
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Medicine (Oncology), Bronx, NY
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8
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Zhou M, Qi J, Gu C, Wang H, Zhang Z, Wu D, Han Y. Avatrombopag for the treatment of thrombocytopenia post hematopoietic stem-cell transplantation. Ther Adv Hematol 2022; 13:20406207221127532. [PMID: 36185780 PMCID: PMC9523859 DOI: 10.1177/20406207221127532] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Thrombocytopenia post hematopoietic stem-cell transplantation (HCT) usually contributes to poor outcomes with no standardized treatment. Eltrombopag and romiplostim can be feasible for post-HCT thrombocytopenia, but the use of avatrombopag has not yet been evaluated. Objectives: We aimed to evaluate the efficacy and safety of avatrombopag treatment in patients diagnosed with post-HCT thrombocytopenia. Design: In this retrospective study, we evaluated the efficacy and safety of avatrombopag treatment in a cohort of 61 patients diagnosed with thrombocytopenia post HCT in our clinical center. Methods: Avatrombopag was initiated at 20 mg daily, with a dosage adjustment to achieve platelet recovery to >20 × 109/l independent from transfusion for 7 consecutive days (overall response, OR) or to >50 × 109/l free from transfusion for 7 consecutive days (complete response, CR). Factors influencing OR and CR were studied in univariate and multivariate analyses, respectively. Within the follow-up, adverse events like myelofibrosis, thrombosis, and organ toxicities were monitored carefully. Results: The overall response rate (ORR) to avatrombopag was 68.9% and the cumulative incidence (CI) of OR was 69.1%. The complete response rate (CRR) and the CI of CR were both 39.3%. The median days from avatrombopag initiation to OR and CR were 21 and 25 days, respectively. An adequate number of megakaryocytes before the initiation of avatrombopag was an independent protective factor of avatrombopag treatment for OR (hazard ratio, HR = 4.628, 95% confidence interval 1.92–11.15, p = 0.0006) and CR (HR = 4.892, 95% confidence interval 1.58–15.18, p = 0.006). Avatrombopag was well tolerated in all patients with no severe adverse events. Conclusion: Our findings suggested that avatrombopag can be optional for thrombocytopenia post HCT.
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Affiliation(s)
- Meng Zhou
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Jiaqian Qi
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Chengyuan Gu
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Hong Wang
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Ziyan Zhang
- National clinical research center for hematologic diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Depei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, 188 Shizi Street, Suzhou, Jiangsu province, China 215006
| | - Yue Han
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, 188 Shizi Street, Suzhou, Jiangsu province, China 215006
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9
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Tarantini F, Cumbo C, Anelli L, Zagaria A, Conserva MR, Redavid I, Specchia G, Musto P, Albano F. Exploring the Potential of Eltrombopag: Room for More? Front Pharmacol 2022; 13:906036. [PMID: 35677428 PMCID: PMC9168361 DOI: 10.3389/fphar.2022.906036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/06/2022] [Indexed: 11/26/2022] Open
Abstract
Since its introduction in clinical practice, eltrombopag (ELT) has demonstrated efficacy in heterogeneous clinical contexts, encompassing both benign and malignant diseases, thus leading researchers to make a more in-depth study of its mechanism of action. As a result, a growing body of evidence demonstrates that ELT displays many effects ranging from native thrombopoietin agonism to immunomodulation, anti-inflammatory, and metabolic properties. These features collectively explain ELT effectiveness in a broad spectrum of indications; moreover, they suggest that ELT could be effective in different, challenging clinical scenarios. We reviewed the extended ELT mechanism of action in various diseases, with the aim of further exploring its full potential and hypothesize new, fascinating indications.
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Affiliation(s)
- Francesco Tarantini
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Cosimo Cumbo
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Luisa Anelli
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Antonella Zagaria
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Maria Rosa Conserva
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Immacolata Redavid
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | | | - Pellegrino Musto
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
| | - Francesco Albano
- Department of Emergency and Organ Transplantation (D.E.T.O.), Hematology and Stem Cell Transplantation Unit, University of Bari “Aldo Moro”, Bari, Italy
- *Correspondence: Francesco Albano,
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10
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Efficacy and Immunomodulating Properties of Eltrombopag in Aplastic Anemia following Autologous Stem Cell Transplant: Case Report and Review of the Literature. Pharmaceuticals (Basel) 2022; 15:ph15040419. [PMID: 35455416 PMCID: PMC9032708 DOI: 10.3390/ph15040419] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/23/2022] [Accepted: 03/28/2022] [Indexed: 12/20/2022] Open
Abstract
Thrombopoietin receptor agonists (TPO-RA) are currently indicated for the treatment of chronic immune thrombocytopenia and relapsed refractory aplastic anemia. However, the off-label use of these drugs is more and more frequent, including in the setting of aplasia secondary to chemotherapy and hemopoietic stem cell transplant (SCT). Growing evidence suggests that mechanisms of action of TPO-RA go beyond the TPO-receptor stimulation and point at the immunomodulating properties of these drugs. Here, we present a case of prolonged bone marrow aplasia secondary to autologous SCT treated with eltrombopag. We describe the clinical efficacy and the immunomodulating effect of this drug on inflammatory cytokine profile and bone marrow histology. Furthermore, we provide a review of the most recent literature highlighting the efficacy and safety of TPO-RA after SCT and chemotherapy for hematologic conditions.
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11
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Huang L, Tian M, Liu Z, Liu C, Fu R. Deferasirox combination with eltrombopag shows anti-myelodysplastic syndrome effects by enhancing iron deprivation-related apoptosis. J Investig Med 2021; 70:953-962. [PMID: 34921125 DOI: 10.1136/jim-2021-002147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/04/2022]
Abstract
Iron overload (IO) affected the survival of patients with myelodysplastic syndrome (MDS). Deferasirox (DFX) is widely used in patients with MDS for iron chelation therapy, but is not suitable for MDS patients with severe thrombocytopenia. Eltrombopag (ELT) is a type of thrombopoietin receptor (TPOR) analog used in the treatment of thrombocytopenia. Therefore, we sought to explore the synergistic effects and possible mechanisms of DFX combination with ELT in MDS cells. In our study, the combination of DFX with ELT synergistically inhibited proliferation, induced apoptosis and arrested cell cycle of MDS cells. Through the RNA-sequence and gene set enrichment analysis (GSEA), iron metabolism-related pathway played important roles in apoptosis of SKM-1 cells treated with DFX plus ELT. Transferrin receptor (TFRC) was significantly highly expressed in combination group than that in single agent groups, without affecting TPOR. Furthermore, the apoptosis of the combination group MDS cells could be partially reversed by ferric ammonium citrate (FAC), accompanied with decreased expression of TFRC. These results suggested that the combination of DFX and ELT synergistically induced apoptosis of MDS cells by enhancing iron deprivation-related pathway.
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Affiliation(s)
- Lei Huang
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Mengyue Tian
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhaoyun Liu
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Chunyan Liu
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Rong Fu
- Hematology, Tianjin Medical University General Hospital, Tianjin, China
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12
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Eltrombopag in the treatment of patients with persistent thrombocytopenia after haploidentical peripheral blood stem cell transplantation: a single-center experience. Ann Hematol 2021; 101:397-408. [PMID: 34735613 DOI: 10.1007/s00277-021-04706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 10/20/2021] [Indexed: 10/19/2022]
Abstract
Persistent thrombocytopenia (PT) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is associated with an increased risk of bleeding and poor survival. The exact pathogenesis underlying PT remains unclear, and its management is difficult. Here we conducted a retrospective study to evaluate the efficacy and safety of eltrombopag (EPAG) in 34 patients with PT after allo-HSCT. Seven patients suffered from prolonged isolated thrombocytopenia (PIT), and 27 had secondary failure of platelet recovery (SFPR). For most patients, the initial dose was 25 mg or 50 mg daily, then adjusted to the maximum dose of 50-100 mg per day according to the response of platelet recovery and toleration of patients. The cumulative incidence (CI) of platelet recovery to at least 20 × 109/L and 50 × 109/L without transfusion support for at least 7 days was 72.1% and 60.7%, respectively. Nineteen (86.4%) of 22 responders were able to taper off the medication; furthermore, the platelet counts remained stable 1 month after withdrawal of EPAG. Although two patients discontinued EPAG during treatment due to headache and nausea, no patients developed grade 3 or 4 toxicities. Hypoplasia of bone marrow and decreased megakaryocytes (MKs) were found to be risk factors for overall response (OR) and complete response (CR) in multivariate analysis, respectively. Overall, our results indicated that EPAG can be used in the treatment of PT and that continuous exposure to EPAG may not be necessary.
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13
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Kapoor S, Champion G, Olnes MJ. Thrombopoietin receptor agonists for marrow failure: A concise clinical review. Best Pract Res Clin Haematol 2021; 34:101274. [PMID: 34404526 DOI: 10.1016/j.beha.2021.101274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 11/29/2022]
Abstract
Bone marrow failure is characterized by a disruption of hematopoietic stem cell (HSC) homeostasis and function, which causes decreased blood counts. Germline and somatic mutations within HSCs and immune dysregulation contribute to the pathogenesis of marrow failure. Allogeneic HSC transplant is a potentially curative therapy for marrow failure, although not all patients are candidates for this procedure. Immune suppressive therapy (IST) is an effective treatment for patients with aplastic anemia (AA) and select patients with myelodysplastic syndromes, but some patients fail to respond or relapse after IST. Over the past decade, the oral thrombopoietin receptor agonist eltrombopag has become a therapeutic option for AA in combination with frontline IST, and as a single agent for relapsed and refractory patients after IST. In this review, we highlight current knowledge of thrombopoietin receptor agonist mechanisms of action, and clinical indications and toxicities in patients with marrow failure, including the risk of clonal evolution.
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Affiliation(s)
- Sargam Kapoor
- Hematology and Medical Oncology, Alaska Native Tribal Health Consortium, 3900 Ambassador Dr, Anchorage, AK, 99508, USA
| | - Grace Champion
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Matthew J Olnes
- Hematology and Medical Oncology, Alaska Native Tribal Health Consortium, 3900 Ambassador Dr, Anchorage, AK, 99508, USA; University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, USA; WWAMI School of Medical Education, University of Alaska Anchorage, 3211 Providence Drive, Anchorage, AK, 99508, USA.
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14
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Shallis RM, Zeidan AM. Management of the Older Patient with Myelodysplastic Syndrome. Drugs Aging 2021; 38:751-767. [PMID: 34342860 DOI: 10.1007/s40266-021-00881-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 01/19/2023]
Abstract
No two diagnoses of myelodysplastic syndrome are genuinely alike, owing to differing and dynamic mutational topography and epigenetic aberrancy. Consequently, no two patients with myelodysplastic syndrome are identical and disease-specific and patient-specific factors are considered in formulating the optimal treatment, which includes few that are disease modifying. Age itself should not be an absolute contraindication to therapy, including intensive therapy such as allogeneic hematopoietic stem cell transplantation, which is the only curative therapy. However, age associates with an increased prevalence of frailty and comorbidities that must be considered and may preclude a path to cure. Palliative therapies are the mainstay for many patients with myelodysplastic syndrome, which is a disease of older adults with the majority of patients diagnosed at age ≥ 75 years. The older patient requires heightened attention to end organ function/reserve and drug-drug interactions as well as insurance, income, cost, and socioeconomic and psychosocial issues that influence management. Many prior studies have included relatively younger populations or have not specifically performed high-quality subgroup analyses of older patients. In this review, we discuss the available standard-of-care therapies for myelodysplastic syndrome as they specifically relate to the older population and assess the emerging therapeutics that may further the pursuit for personalized treatment and improve both the outcomes and quality of life of the older patient with myelodysplastic syndrome.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT, 06520-8028, USA.
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15
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Comont T, Meunier M, Cherait A, Santana C, Cluzeau T, Slama B, Laribi K, Giraud JT, Dimicoli S, Berceanu A, Le Clech L, Cony-Makhoul P, Gruson B, Torregrosa J, Sanhes L, Jachiet V, Azerad MA, Al Jijakli A, Gyan E, Gaudin C, Broner J, Guerveno C, Guillaume T, Ades PL, Beyne-Rauzy O, Fenaux P. Eltrombopag for myelodysplastic syndromes or chronic myelomonocytic leukaemia with no excess blasts and thrombocytopenia: a French multicentre retrospective real-life study. Br J Haematol 2021; 194:336-343. [PMID: 34151423 DOI: 10.1111/bjh.17539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/30/2021] [Indexed: 12/15/2022]
Abstract
Despite a moderate prevalence in low-risk myelodysplastic syndromes (MDS) and chronic myelomonocytic leukaemia (CMML), thrombocytopenia remains a risk of severe bleeding and therapeutic options are still limited. There are only a few studies with eltrombopag (ELT), a thrombopoietin receptor agonist, in those patients. In this retrospective multicentre study, ELT was used in 50 patients with MDS and 11 with CMML, with no excess of marrow blasts and platelet counts of <50 × 109 /l in a 'real-life' situation. Platelet response occurred in 47 (77%) patients. The median (range) duration of response was 8 (0-69) months. None of the eight still responders who discontinued ELT had relapsed, at a median (range) of 16 (6-23) months after ELT discontinuation. Although 36% of the patients were anti-coagulated or anti-aggregated only 10% of patients had Grade ≥3 bleeding events. Thrombotic events were observed in six (10%) patients, who all but one had a medical history of arterial or venous thrombosis. Progression to acute myeloid leukaemia occurred in four (7%) patients. In this first 'real-life' study, ELT was effective and generally well tolerated in patients with MDS/CMML without excess blasts.
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Affiliation(s)
- Thibault Comont
- Service de Médecine Interne, IUCT Oncopole, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Mathieu Meunier
- CHU Grenoble Alpes, Université Grenoble Alpes, Institute for Advanced Biosciences, INSERM U1209, CNRS, UMR 5309, Grenoble, France
| | - Amina Cherait
- Service d'Hématologie Sénior, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris (APHP), Université de Paris, Paris, France
| | | | - Thomas Cluzeau
- Service d'Hématologie Clinique, CHU de Nice, Nice, France
| | - Bohrane Slama
- Service d'onco-hématologie, Centre Hospitalier Général d'Avignon, Avignon, France
| | - Kamel Laribi
- Service d'Hématologie, Centre Hospitalier Le Mans, Le Mans, France
| | - Jean-Thomas Giraud
- Service de Médecine Interne, Centre Hospitalier de Tarbes, Tarbes, France
| | - Sophie Dimicoli
- Service d'Hématologie, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Ana Berceanu
- Service d'Hématologie, Centre Hospitalier Universitaire de Besançon, Besançon, France
| | - Lenaïg Le Clech
- Service d'Hématologie, Centre Hospitalier de Quimper, Quimper, France
| | | | - Berangere Gruson
- Service d'Hématologie, Centre Hospitalier Universitaire d'Amiens, Amiens, France
| | - Jose Torregrosa
- Service d'Hématologie et Thérapie Cellulaire, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Laurence Sanhes
- Service d'Hématologie, Centre Hospitalier de Perpignan, Perpignan, France
| | - Vincent Jachiet
- Service de Médecine Interne, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Marie-Agnes Azerad
- Service d'Hématologie, Centre Hospitalier Universitaire de Liège, Liège, Belgique
| | - Ahmad Al Jijakli
- Service d'Hématologie, Centre Hospitalier d'Argenteuil, Argenteuil, France
| | - Emmanuel Gyan
- Service d'Hématologie et Thérapie Cellulaire, Centre Hospitalier Universitaire de Tours, Tours, France
| | - Clement Gaudin
- Service de Médecine Interne-Oncogériatrie, Hôpital Purpan, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Jonathan Broner
- Service de Médecine Interne, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
| | - Claire Guerveno
- Service de Médecine Interne, Centre Hospitalier d'Albi, Albi, France
| | - Thierry Guillaume
- Service d'Hématologie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Pr Lionel Ades
- Service d'Hématologie Sénior, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris (APHP), Université de Paris, Paris, France
| | - Odile Beyne-Rauzy
- Service de Médecine Interne, IUCT Oncopole, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Pierre Fenaux
- Service d'Hématologie Sénior, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris (APHP), Université de Paris, Paris, France
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16
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Efficacy and cost analysis of eltrombopag in thrombocytopenia and poor graft function post allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2021; 56:2471-2476. [PMID: 34108675 DOI: 10.1038/s41409-021-01362-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/09/2021] [Accepted: 05/18/2021] [Indexed: 11/08/2022]
Abstract
Eltrombopag has shown efficacy in the treatment of thrombocytopenia and poor graft function (PGF) after allogeneic hematopoietic cell transplantation (HCT) in retrospective observational studies, but is not approved for this indication. The cost of this drug is also a major concern in publicly funded health care systems. We collected data about patients who received eltrombopag for thrombocytopenia or PGF after HCT. Post-HCT thrombocytopenia, PGF, and eltrombopag response were defined as per previously published criteria. Primary outcome was treatment efficacy and secondary outcome was cost comparison between estimated treatment cost prior to and after initiation of eltrombopag. Seventeen patients (males 70.6%; median age = 58) received eltrombopag. Isolated thrombocytopenia was present in 11.8% (n = 2) patients while PGF was present in 88.2% (n = 15) of patients. After 8 weeks of treatment at the maximum dose of 150 mg orally daily, overall response rate (ORR) was seen in 76.5% (13/17) of patients: complete response (CR) in 10/13 patients and partial response (PR) in 3/13 patients. The use of eltrombopag was associated with an overall decrease in the total weekly care costs (5021 vs 2,524 CA$; P = 0.04). Thus, Eltrombopag is an efficacious and possibly cost-effective therapy for thrombocytopenia and PGF after allogeneic HCT.
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17
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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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18
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Jachiet V, Moulis G, Hadjadj J, Seguier J, Laribi K, Schleinitz N, Vey N, Sacre K, Godeau B, Beyne-Rauzy O, Bouvet R, Broner J, Brun N, Comont T, Gaudin C, Lambotte O, Le Clech L, Peterlin P, Roy-Peaud F, Salvado C, Versini M, Isnard F, Kahn JE, Gobert D, Adès L, Fenaux P, Fain O, Mekinian A. Clinical spectrum, outcome and management of immune thrombocytopenia associated with myelodysplastic syndromes and chronic myelomonocytic leukemia. Haematologica 2021; 106:1414-1422. [PMID: 33626866 PMCID: PMC8094121 DOI: 10.3324/haematol.2020.272559] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022] Open
Abstract
Myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML) are associated with systemic inflammatory or autoimmune diseases in 10-20 % of cases. Among them, immune thrombocytopenia (ITP) has been reported but large studies assessing this association are missing. Whether such patients have a particular phenotype and require particular management is unclear. This study analyzes the clinical spectrum, outcome and therapeutic management of patients with ITP associated with MDS or CMML, in comparison (i) to patients with primary ITP without MDS/CMML and (ii) to patients with MDS/CMML without ITP. Forty-one MDS/CMML-associated ITP patients were included, with chronic ITP in 26 (63%) patients, low-risk myelodysplasia in 30 (73%) patients and CMML in 24 (59%) patients. An associated autoimmune disease was noted in 10 (24%) patients. In comparison to primary ITP patients, MDS/CMML-associated ITP patients had a higher occurrence of severe bleeding despite similar platelet counts at diagnosis. First-line treatment consisted of glucocorticoids (98%) and intravenous immunoglobulin (IVIg) (56%). Response achievement with IVIg was more frequent in primary ITP than in MDS/CMML-associated ITP patients. Response rates to second-line therapies were not statistically different between primary ITP and MDS/CMMLassociated ITP patients. Ten percent (n=4) of patients with MDS/CMML-associated ITP had multirefractory ITP versus none in primary ITP controls. After a median follow-up of 60 months, there was no difference in overall survival between MDS/CMML-associated ITP and primary ITP patients. Leukemia-free-survival was significantly better in MDS/CMMLassociated ITP patients than in MDS/CMML without ITP MDS/CMML-associated ITP have a particular outcome with more severe bleeding and multirefractory profile than primary ITP, similar response profile to primary ITP therapy except for IVIg, and less progression toward acute myeloid leukemia than MDS/CMML without ITP.
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MESH Headings
- Humans
- Leukemia, Myeloid, Acute
- Leukemia, Myelomonocytic, Chronic/complications
- Leukemia, Myelomonocytic, Chronic/diagnosis
- Leukemia, Myelomonocytic, Chronic/therapy
- Myelodysplastic Syndromes/complications
- Myelodysplastic Syndromes/diagnosis
- Myelodysplastic Syndromes/therapy
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Thrombocytopenia
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Affiliation(s)
- Vincent Jachiet
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris
| | - Guillaume Moulis
- Service de médecine interne, CHU de Toulouse, France; CIC 1436, CHU de Toulouse, France; UMR 1027 Inserm-Université de Toulouse
| | - Jérome Hadjadj
- Imagine Institute, laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM UMR 1163, Université de Paris, F-75015, Paris ; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Assistance Publique Hôpitaux de Paris-Centre (APHP-CUP), Université de Paris, F-75014
| | - Julie Seguier
- Département de médecine interne, Hôpital de la Timone, AP-HM, Aix Marseille Université, Marseille
| | - Kamel Laribi
- Department of Hematology, Centre hospitalier Le Mans, Le Mans
| | - Nicolas Schleinitz
- Département de médecine interne, Hôpital de la Timone, AP-HM, Aix Marseille Université, Marseille
| | - Norbert Vey
- Haematology Department, Institut Paoli-Calmettes, Aix-Marseille Université, Marseille
| | - Karim Sacre
- Departement de Médecine Interne, Hôpital Bichat, APHP, Université de Paris, INSERM U1149, Paris
| | - Bertrand Godeau
- Hôpitaux de Paris, Hôpital Henri Mondor, Médecine Interne, Centre de Référence des Cytopénies Autoimmunes de L'Adulte, Université Paris-Est Créteil, F-94010, Créteil
| | - Odile Beyne-Rauzy
- Department of internal medicine, Toulouse University Hospital, Institut universitaire du cancer de Toulouse, and University of Toulouse, F-31059, Toulouse
| | - Romain Bouvet
- Médecine interne et maladies systémiques, CHU Dijon Bourgogne, 21000 Dijon
| | - Jonathan Broner
- Internal Médicine Department, Nîmes University Hospital, University of Montpellier, Nîmes
| | - Natacha Brun
- Service de Médecine Interne, Centre Hospitalier de Rodez, Rodez
| | - Thibault Comont
- Department of internal medicine, Toulouse University Hospital, Institut universitaire du cancer de Toulouse, and University of Toulouse, F-31059, Toulouse
| | - Clément Gaudin
- Department of oncogeriatric medicine, University Hospital Purpan, Toulouse
| | - Olivier Lambotte
- Hôpitaux de Paris, Hôpital Bicêtre, Médecine Interne et Immunologie Clinique, F-94275, Le Kremlin-Bicêtre, France; INSERM U1184, Immunology of Viral Infections and Autoimmune Diseases, F-94276, Le Kremlin-Bicêtre, France; Université Paris Sud, UMR 1184, F-94276, Le Kremlin-Bicêtre, France; CEA, DSV/iMETI, IDMIT, F-92265, Fontenay-aux-Roses
| | - Lenaïg Le Clech
- Department of Internal Medicine, Infectious Diseases and Haematology, Cornouaille Hospital Quimper
| | | | - Frédérique Roy-Peaud
- Service de médecine interne, maladies infectieuses et tropicales, CHU de Poitiers, Poitiers
| | | | | | - Françoise Isnard
- Department of Clinical Hematology, Saint-Antoine Hospital, AP-HP, Paris
| | | | - Delphine Gobert
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris
| | - Lionel Adès
- Hopital Saint-Louis (APHP) and Paris University and INSERM U944, Paris
| | - Pierre Fenaux
- Hopital Saint-Louis (APHP) and Paris University and INSERM U944, Paris
| | - Olivier Fain
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris
| | - Arsène Mekinian
- Sorbonne Université, AP-HP, Hôpital Saint-Antoine, Service de Médecine Interne and Inflammation-Immunopathology-Biotherapy Department (DMU 3iD), F-75012, Paris.
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19
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Qanash H, Li Y, Smith RH, Linask K, Young-Baird S, Hakami W, Keyvanfar K, Choy JS, Zou J, Larochelle A. Eltrombopag Improves Erythroid Differentiation in a Human Induced Pluripotent Stem Cell Model of Diamond Blackfan Anemia. Cells 2021; 10:734. [PMID: 33810313 PMCID: PMC8065708 DOI: 10.3390/cells10040734] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/17/2021] [Accepted: 03/22/2021] [Indexed: 12/15/2022] Open
Abstract
Diamond Blackfan Anemia (DBA) is a congenital macrocytic anemia associated with ribosomal protein haploinsufficiency. Ribosomal dysfunction delays globin synthesis, resulting in excess toxic free heme in erythroid progenitors, early differentiation arrest, and pure red cell aplasia. In this study, DBA induced pluripotent stem cell (iPSC) lines were generated from blood mononuclear cells of DBA patients with inactivating mutations in RPS19 and subjected to hematopoietic differentiation to model disease phenotypes. In vitro differentiated hematopoietic cells were used to investigate whether eltrombopag, an FDA-approved mimetic of thrombopoietin with robust intracellular iron chelating properties, could rescue erythropoiesis in DBA by restricting the labile iron pool (LIP) derived from excessive free heme. DBA iPSCs exhibited RPS19 haploinsufficiency, reduction in the 40S/60S ribosomal subunit ratio and early erythroid differentiation arrest in the absence of eltrombopag, compared to control isogenic iPSCs established by CRISPR/Cas9-mediated correction of the RPS19 point mutation. Notably, differentiation of DBA iPSCs in the presence of eltrombopag markedly improved erythroid maturation. Consistent with a molecular mechanism based on intracellular iron chelation, we observed that deferasirox, a clinically licensed iron chelator able to permeate into cells, also enhanced erythropoiesis in our DBA iPSC model. In contrast, erythroid maturation did not improve substantially in DBA iPSC differentiation cultures supplemented with deferoxamine, a clinically available iron chelator that poorly accesses LIP within cellular compartments. These findings identify eltrombopag as a promising new therapeutic to improve anemia in DBA.
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Affiliation(s)
- Husam Qanash
- Cellular and Molecular Therapeutics Branch, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD 20892, USA; (H.Q.); (Y.L.); (R.H.S.); (W.H.)
- Department of Biology, Catholic University of America, Washington, DC 20064, USA;
- Department of Medical Laboratory Science, College of Applied Medical Sciences, The University of Hail, Hail 55476, Saudi Arabia
| | - Yongqin Li
- Cellular and Molecular Therapeutics Branch, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD 20892, USA; (H.Q.); (Y.L.); (R.H.S.); (W.H.)
| | - Richard H. Smith
- Cellular and Molecular Therapeutics Branch, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD 20892, USA; (H.Q.); (Y.L.); (R.H.S.); (W.H.)
| | - Kaari Linask
- iPSC Core Facility, NHLBI, NIH, Bethesda, MD 20892, USA; (K.L.); (J.Z.)
| | - Sara Young-Baird
- Eunice Kennedy Shriver, National Institute of Child Health and Human Development, NIH, Bethesda, MD 20892, USA;
- National Institute of General Medical Sciences (NIGMS), NIH, Bethesda, MD 20892, USA
| | - Waleed Hakami
- Cellular and Molecular Therapeutics Branch, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD 20892, USA; (H.Q.); (Y.L.); (R.H.S.); (W.H.)
- Department of Biology, Catholic University of America, Washington, DC 20064, USA;
- Department of Medical Laboratories Technology, College of Applied Medical Sciences, Jazan University, Jazan 45142, Saudi Arabia
| | - Keyvan Keyvanfar
- Clinical Flow Core Facility, NHLBI, NIH, Bethesda, MD 20892, USA;
| | - John S. Choy
- Department of Biology, Catholic University of America, Washington, DC 20064, USA;
| | - Jizhong Zou
- iPSC Core Facility, NHLBI, NIH, Bethesda, MD 20892, USA; (K.L.); (J.Z.)
| | - Andre Larochelle
- Cellular and Molecular Therapeutics Branch, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD 20892, USA; (H.Q.); (Y.L.); (R.H.S.); (W.H.)
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20
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Nevil G, Roth M, Gill J, Zhang W, Teicher B, Erickson SW, Gatto G, Smith M, Kolb EA, Gorlick R. Initial in vivo testing of TPO-receptor agonist eltrombopag in osteosarcoma patient-derived xenograft models by the pediatric preclinical testing consortium. Pediatr Hematol Oncol 2021; 38:8-13. [PMID: 32804009 PMCID: PMC8670012 DOI: 10.1080/08880018.2020.1802539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Eltrombopag is a small molecule, thrombopoietin receptor agonist approved for the treatment of patients with aplastic anemia and chronic immune thrombocytopenia. It is also a polyvalent cation chelator and inhibits leukemia cell proliferation via reduction of intracellular iron. The in vivo efficacy of eltrombopag was tested against a panel of six Pediatric Preclinical Testing Consortium osteosarcoma xenografts at doses of 5 mg/kg/day (moderate dose) and 50 mg/kg/day (high dose). Eltrombopag, at moderate doses, failed to significantly improve event-free survival (EFS) in 6/6 models. At high doses, eltrombopag significantly prolonged EFS in 2/2 models, though the effect size was small. All models tested demonstrated progressive disease. While eltrombopag did not meaningfully inhibit osteosarcoma growth, it also did not stimulate tumor growth, suggesting it may be safely investigated as a supportive care agent to enhance platelet recovery post chemotherapy.
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Affiliation(s)
- Grace Nevil
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Roth
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jonathan Gill
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wendong Zhang
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Gregory Gatto
- RTI International, Research Triangle Park, North Carolina, USA
| | - Malcom Smith
- National Cancer Institute, Bethesda, maryland, USA
| | - E. Anders Kolb
- Division of Pediatric Hematology/Oncology, A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Richard Gorlick
- Division of Pediatric Oncology, MD Anderson Children’s Cancer Hospital, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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21
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Mina A, Platanias LC. Increasing megakaryopoiesis without promoting the malignant clone in myeloid malignancies. Leuk Lymphoma 2020; 61:2289-2291. [PMID: 32779514 DOI: 10.1080/10428194.2020.1802453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Alain Mina
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.,Department of Medicine, Division of Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Leonidas C Platanias
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA.,Department of Medicine, Division of Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Medicine, Jesse Brown Veterans Affairs Medical Center, Chicago, IL, USA
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22
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Adrianzen-Herrera D, Choudhary G, Gordon-Mitchell S, Ramachandra N, Bhagat T, Zhang H, Aluri S, Shastri A, Steidl U, Will B, Yang WL, Mahler M, Eichenbaum G, Guha C, Verma A. The thrombopoietin mimetic JNJ-26366821 increases megakaryopoiesis without affecting malignant myeloid proliferation. Leuk Lymphoma 2020; 61:2453-2465. [PMID: 32578476 DOI: 10.1080/10428194.2020.1775213] [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: 12/19/2022]
Abstract
Thrombocytopenia remains a challenge in myeloid malignancies, needing safer and more effective therapies. JNJ-26366821, a pegylated synthetic peptide thrombopoietin (TPO) mimetic not homologous to endogenous TPO, has an in-vitro EC50 of 0.2 ng/mL for the TPO receptor and dose dependently elevates platelets in volunteers. We demonstrate that JNJ-26366821 increases megakaryocytic differentiation and megakaryocytic colony formation in healthy controls and samples from myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). JNJ-26366821 had no effect on proliferation of malignant myeloid cell lines at doses up to 1000 ng/mL and malignant patient-derived mononuclear cells showed no increased cell growth or leukemic colony formation capacity at concentrations between 0.2 ng/mL and 10 ng/mL. Furthermore, JNJ-26366821 did not enhance in-vivo engraftment of leukemic cells in an AML xenotransplantation murine model. Our results show that JNJ-26366821 stimulates megakaryopoiesis without causing proliferation of the malignant myeloid clones in MDS/AML and provides the rationale for clinical testing of JNJ-26366821 in myeloid malignancies.
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Affiliation(s)
- Diego Adrianzen-Herrera
- Division of Hematology and Oncology, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Gaurav Choudhary
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Shanisha Gordon-Mitchell
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Nandini Ramachandra
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Tushar Bhagat
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Hui Zhang
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Srinivas Aluri
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Aditi Shastri
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Ulrich Steidl
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Britta Will
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Weng-Lang Yang
- Department of Radiation Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Michelle Mahler
- Department of the Chief Medical Officer, Johnson & Johnson Global Service, New Brunswick, NJ, USA
| | - Gary Eichenbaum
- Department of the Chief Medical Officer, Johnson & Johnson Global Service, New Brunswick, NJ, USA
| | - Chandan Guha
- Department of Radiation Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
| | - Amit Verma
- Department of Oncology, Albert Einstein College of Medicine - Montefiore Medical Center, Bronx, NY, USA
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23
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Lassandro G, Palladino V, Vecchio GCD, Palmieri VV, Corallo PC, Faienza MF, Giordano P. Thrombopoietin Receptor Agonists in Children with Immune Thrombocytopenia: A New Therapeutic Era. Endocr Metab Immune Disord Drug Targets 2020; 21:397-406. [PMID: 32473624 DOI: 10.2174/1871530320666200531142244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/03/2020] [Accepted: 04/23/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVE Immune thrombocytopenia (ITP) is a common bleeding disorder in childhood. The management of ITP in children is controversial, requiring personalized assessment of patients and therapeutic choices. Thrombopoietin receptor agonists (TPO-RAs), eltrombopag and romiplostim, have been shown to be safe and effective for the treatment of pediatric ITP. The aim of our research is to define the role of thrombopoietin receptor agonists in the management of pediatric ITP. METHODS This review focuses on the use of TPO-RAs in pediatric ITP, in randomized trials and in clinical routine, highlighting their key role in the management of the disease. RESULTS Eltrombopag and romiplostim appear effective treatment options for children with ITP. Several clinical studies have assessed that the use of TPO-RAs increases platelet count, decreases bleeding symptoms and improves health-related quality of life. Moreover, TPO-RAs are well tolerated with minor side effects. CONCLUSION Although long term efficacy and safety of TPO-RAs still require further investigations, their use is gradually expanding in the clinical practice of children with ITP.
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Affiliation(s)
- Giuseppe Lassandro
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Valentina Palladino
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Giovanni C D Vecchio
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Viviana V Palmieri
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Paola C Corallo
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Maria F Faienza
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Paola Giordano
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
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24
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Strickland SA, Wang XV, Cerny J, Rowe JM, Rybka W, Tallman MS, Litzow M, Lazarus HM. A novel PrECOG (PrE0901) dose-escalation trial using eltrombopag: enhanced platelet recovery during consolidation therapy in acute myeloid leukemia. Leuk Lymphoma 2020; 61:2191-2199. [DOI: 10.1080/10428194.2020.1762878] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Stephen A. Strickland
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Jan Cerny
- University of Massachusetts Medical Center, Worcester, MA, USA
| | - Jacob M. Rowe
- Institute of Hematology, Rambam Medical Center, Haifa, Israel
| | | | - Martin S. Tallman
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Hillard M. Lazarus
- Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
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25
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Duong VH, Al Ali N, Zhang L, Padron E, Sallman D, Lancet JE, List AF, Komrokji RS. A sequential two-stage dose escalation study of eltrombopag in patients with myelodysplastic syndrome and thrombocytopenia after hypomethylating agent failure. Leuk Lymphoma 2020; 61:1901-1907. [PMID: 32306798 DOI: 10.1080/10428194.2020.1751841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Thrombocytopenia occurs frequently in patients with myelodysplastic syndromes (MDS), and the survival of patients after failure of hypomethylating agents (HMAs) is poor. We conducted a trial of eltrombopag in patients with MDS, MDS/myeloproliferative neoplasm (MPN) or acute myeloid leukemia (AML) with 20-30% myeloblasts after HMA failure and mean baseline platelet count ≤ 50 × 109/L. Eltrombopag was escalated from 50 mg daily up to 200 mg daily. The primary objective was to determine the maximally tolerated dose (MTD). 37 patients were enrolled, and MTD was not reached. Responses were observed in 9 patients (24%), 2 achieving marrow CR with hematologic improvement (HI), 1 marrow CR without HI, and 6 HI. Median overall survival was 7.5 months. Eltrombopag was well-tolerated and yielded modest responses in heavily treated, predominantly higher-risk MDS patients after HMA failure. Future studies should focus on determining characteristics that predict response.
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Affiliation(s)
- Vu H Duong
- Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Najla Al Ali
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ling Zhang
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Eric Padron
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - David Sallman
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jeffrey E Lancet
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Alan F List
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rami S Komrokji
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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26
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D'Alò F, Zangrilli I, Cupelli E, Fianchi L, Criscuolo M, Falconi G, Fabiani E, Pagano L, Hohaus S, De Stefano V. In vitro effect of eltrombopag alone and in combination with azacitidine on megakaryopoiesis in patients with myelodysplastic syndrome. Platelets 2020; 32:378-382. [PMID: 32268817 DOI: 10.1080/09537104.2020.1742312] [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: 10/24/2022]
Abstract
Thrombocytopenia is a severe complication for patients with myelodysplastic syndrome (MDS). Eltrombopag increases platelet count in MDS patients but its combination with azacitidine elicited controversial results. We aimed to quantify the colony forming units of megakaryocytes (CFU-Mk) obtained from CD34+ bone marrow cells isolated from patients with MDS and from healthy donors that were cultured in vitro in the presence or absence of azacitidine and with or without the sequential addition of eltrombopag to the culture medium. CD34+ bone marrow cells from 6 MDS patients and 3 controls were expanded in vitro and cultured for 3 days with or without azacitidine. Subsequently, a CFU-Mk assay was performed in presence or absence of eltrombopag. The addition of eltrombopag in the CFU-Mk assay after mock treatment of CD34+ cells increased the number of CFU-Mk in both controls and patients. On the contrary, using azacitidine pretreated CD34+ cells, eltrombopag minimally increased CFU-Mk in controls and produced heterogeneous response in MDS patients with no change in two patients and CFU-Mk increase in four patients. In vitro CFU-Mk assay suggest that some MDS patients are likely to benefit from the sequential addition of eltrombopag after azacitidine treatment, in the context of a personalized medicine.
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Affiliation(s)
- Francesco D'Alò
- Dipartimento Di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Sezione Di Ematologia, Dipartimento Di Scienze Radiologiche Ed Ematologiche, Università Cattolica Del Sacro Cuore, Roma, Italy
| | - Ilaria Zangrilli
- Dipartimento Di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Elisa Cupelli
- Dipartimento Di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Luana Fianchi
- Dipartimento Di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Marianna Criscuolo
- Dipartimento Di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Giulia Falconi
- Dipartimento Di Biomedicina E Prevenzione, Università Di Roma Tor Vergata, Roma, Italy
| | - Emiliano Fabiani
- Dipartimento Di Biomedicina E Prevenzione, Università Di Roma Tor Vergata, Roma, Italy
| | - Livio Pagano
- Dipartimento Di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Sezione Di Ematologia, Dipartimento Di Scienze Radiologiche Ed Ematologiche, Università Cattolica Del Sacro Cuore, Roma, Italy
| | - Stefan Hohaus
- Dipartimento Di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Sezione Di Ematologia, Dipartimento Di Scienze Radiologiche Ed Ematologiche, Università Cattolica Del Sacro Cuore, Roma, Italy
| | - Valerio De Stefano
- Dipartimento Di Diagnostica per Immagini, Radioterapia Oncologica Ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Sezione Di Ematologia, Dipartimento Di Scienze Radiologiche Ed Ematologiche, Università Cattolica Del Sacro Cuore, Roma, Italy
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Vasudevan Nampoothiri R, Kumar R. Eltrombopag: Role in Cytopenias Following Hematopoietic Stem Cell Transplantation. Indian J Hematol Blood Transfus 2020; 36:238-245. [PMID: 32425372 PMCID: PMC7229069 DOI: 10.1007/s12288-019-01194-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/16/2019] [Indexed: 12/22/2022] Open
Abstract
Eltrombopag is a small molecule oral agonist of the thrombopoietin receptor. Initially used for improving thrombocytopenia in chronic immune thrombocytopenia (ITP), it was later found to be efficacious in various other etiologies of thrombocytopenia as well as inherited marrow failure syndromes. Lately, it has been used for thrombocytopenia and poor graft function after allogeneic hematopoietic stem cell transplantation (HSCT) without any severe adverse events. Although prospective evidence of the efficacy is limited, there are increasing reports on the safety and efficacy with Eltrombopag in post HSCT thrombocytopenia and poor graft function. This provides an exciting opportunity for further research to evaluate both efficacy and cost-effectiveness of the use of Eltrombopag in this scenario. Here we review the current evidence on the indications for the use of Eltrombopag in the post allogeneic hematopoietic stem cell transplant setting.
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Affiliation(s)
- Ram Vasudevan Nampoothiri
- Messner Allogeneic Transplant Program, University of Toronto, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON M5G 2M9 Canada
| | - Rajat Kumar
- Messner Allogeneic Transplant Program, University of Toronto, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON M5G 2M9 Canada
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28
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Mahat U, Rotz SJ, Hanna R. Use of Thrombopoietin Receptor Agonists in Prolonged Thrombocytopenia after Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:e65-e73. [DOI: 10.1016/j.bbmt.2019.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 01/09/2023]
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29
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Cilloni D, Andreani G, Dragani M, De Gobbi M, Saglio G. Synergistic effect of eltrombopag and deferasirox in aplastic anemia: a clinical case and review of the literature. Leuk Lymphoma 2020; 61:234-236. [DOI: 10.1080/10428194.2019.1660969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Daniela Cilloni
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giacomo Andreani
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Matteo Dragani
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Marco De Gobbi
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giuseppe Saglio
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
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30
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Hematopoietic Stem Cell Transplantation Without the Use of Blood Components by the Patient's Choice: Experience of 2 Brazilian Centers. Biol Blood Marrow Transplant 2019; 26:458-462. [PMID: 31669397 DOI: 10.1016/j.bbmt.2019.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 10/11/2019] [Accepted: 10/16/2019] [Indexed: 11/21/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) has been used to treat many malignant and nonmalignant hematologic conditions; however, the use of HSCT in patients who refuse blood transfusions has rarely been described in the literature, and no data have been published concerning haploidentical HSCT without the use of blood products. The aim of this study is to describe the experience of a Brazilian group in performing 21 HSCTs without the use of blood components in the first 100 days after transplantation, which is the period corresponding to the greatest risk of toxicity for this procedure. We developed 21 HSCTs without transfusion support in 19 patients admitted to 2 Brazilian transplantation centers. The patients were subjected to stem cell mobilization and different conditioning regimens. No mortality related to the procedure occurred among the transplant recipients. The global survival rate after 100 days, which is the period related to the immediate toxicity of HSCT, was 94.7%, and the median duration of follow-up was 980 days, with an overall survival rate of 68.4%. Thus, refusal of blood transfusion is not an absolute contraindication for HSCT. This therapy is feasible in specific situations when the patient clearly expresses a desire to avoid blood transfusions and when favorable clinical conditions are achievable with strict, specialized medical monitoring.
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31
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Bussel J, Kulasekararaj A, Cooper N, Verma A, Steidl U, Semple JW, Will B. Mechanisms and therapeutic prospects of thrombopoietin receptor agonists. Semin Hematol 2019; 56:262-278. [PMID: 31836033 DOI: 10.1053/j.seminhematol.2019.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
The second-generation thrombopoietin (TPO) receptor agonists eltrombopag and romiplostim are potent activators of megakaryopoiesis and represent a growing treatment option for patients with thrombocytopenic hematological disorders. Both TPO receptor agonists have been approved worldwide for the treatment of children and adults with chronic immune thrombocytopenia. In the EU and USA, eltrombopag is approved for the treatment of patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy and in the USA for the first-line treatment of severe aplastic anemia in combination with immunosuppressive therapy. Eltrombopag has also shown efficacy in several other disease settings, for example, chemotherapy-induced thrombocytopenia, selected inherited thrombocytopenias, and myelodysplastic syndromes. While both TPO receptor agonists stimulate TPO receptor signaling and enhance megakaryopoiesis, their vastly different biochemical structures bestow upon them markedly different molecular and functional properties. Here, we review and discuss results from preclinical and clinical studies on the functional and molecular mechanisms of action of this new class of drug.
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Affiliation(s)
- James Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY.
| | | | | | - Amit Verma
- Albert Einstein College of Medicine, New York, NY
| | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Britta Will
- Albert Einstein College of Medicine, New York, NY.
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32
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Shi M, Xu F, Yang X, Bai Y, Niu J, Drokow EK, Chen M, Chen Y, Sun K. The synergistic antileukemic effects of eltrombopag and decitabine in myeloid leukemia cells. Cancer Manag Res 2019; 11:8229-8238. [PMID: 31564981 PMCID: PMC6735651 DOI: 10.2147/cmar.s213931] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/05/2019] [Indexed: 12/18/2022] Open
Abstract
Background Hypomethylating agents (HMAs), such as decitabine (DAC), are currently used as first-line therapy for patients with high-risk myelodysplastic syndromes (MDS) and acute myelogenous leukemia (AML) not eligible for standard chemotherapies. Exacerbation of thrombocytopenia is one of the prevalent complications after HMA treatment. Eltrombopag (EP), an oral thrombopoietin receptor agonist, can efficiently stimulate megakaryopoiesis and elevate platelet counts in MDS/AML patients. However, the significance of combining EP with HMAs in patients with high-risk MDS/AML has not been determined. Purpose To explore the impacts and mechanisms of EP and/or DAC on leukemia cell growth and to explore whether EP exhibits antileukemic effects in the context of DAC treatment in human myeloid leukemia cell lines. Methods In our study, we assessed the anti-leukemic effect of EP in the context of DAC treatment by measuring cell proliferation, apoptosis, cell-cycle distribution, and intracellular reactive oxygen species (ROS) levels. Results Our results showed that the combination of EP and DAC had a more obvious antiproliferative effect than that of DAC as a single agent. EP mainly induced S or G0/G1 phase cell cycle arrest, and DAC arrested the cell cycle in the S or G2/M phase. The combination of EP and DAC had a synergistic effect on cell cycle arrest. Furthermore, single-agent treatment with EP or DAC induced a change in intracellular ROS levels, and the combination of EP and DAC had a synergistic effect on ROS levels, exacerbating leukemia cell death. Conclusion Our study provides in vitro evidence of the synergistic antileukemic effect and potential mechanisms of the combination of DAC and EP on myeloid leukemia cells.
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Affiliation(s)
- Mingyue Shi
- Division of Graduate, Department of Hematology, The Second Clinical Medical School and the Second Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China.,Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China.,Department of Pathology and Laboratory Medicine, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Fangfang Xu
- Department of Research and Discipline Development, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Xiawan Yang
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Yanliang Bai
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Junwei Niu
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Emmanuel Kwateng Drokow
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Mingyi Chen
- Department of Pathology and Laboratory Medicine, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Yuqing Chen
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Kai Sun
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
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Ghanima W, Cooper N, Rodeghiero F, Godeau B, Bussel JB. Thrombopoietin receptor agonists: ten years later. Haematologica 2019; 104:1112-1123. [PMID: 31073079 PMCID: PMC6545830 DOI: 10.3324/haematol.2018.212845] [Citation(s) in RCA: 212] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/11/2019] [Indexed: 01/19/2023] Open
Abstract
The two thrombopoietin receptor agonists (TPO-RA), eltrombopag and romiplostim, were licensed in the US for treatment of immune thrombocytopenia (ITP) in 2008 and, since then, their use has progressively increased around the world; they are currently used in more than 100 countries. The six largest randomized controlled trials conducted in ITP have used one of these two agents. All studies have demonstrated a platelet response rate between 50-90%, depending on the criteria used, with good safety and tolerability. TPO-RA were shown to be effective in reducing bleeding and the need for concomitant or rescue medication. Many other investigations of their mechanism of effect, prospective and retrospective trials, and studies focusing on toxicity have been performed widening our knowledge of these two agents. Initial concerns on issues such as myelofibrosis have not been confirmed. Only a small number of patients develop moderate-severe reticulin fibrosis and/or collagen fibrosis; however, these are usually reversed after discontinuation of TPO-RA. Studies indicate, however, that TPO-RA may increase the risk of venous thromboembolism. Both TPO-RA are currently approved in patients with chronic ITP aged >1-year who are refractory to at least one other treatment. Eltrombopag has acquired two additional indications: severe aplastic anemia refractory to first-line treatment and hepatitis C patients undergoing treatment with interferon-ribavirin. Despite these wide-ranging studies, important questions still need to be answered. This summary review on TPO-RA will summarize what is known regarding efficacy in ITP, evaluate safety concerns in more depth, and focus on the questions that remain.
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MESH Headings
- Animals
- Benzoates/chemistry
- Benzoates/pharmacology
- Benzoates/therapeutic use
- Biomarkers
- Blood Coagulation/drug effects
- Clinical Trials as Topic
- Disease Susceptibility
- Humans
- Hydrazines/chemistry
- Hydrazines/pharmacology
- Hydrazines/therapeutic use
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/complications
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Pyrazoles/chemistry
- Pyrazoles/pharmacology
- Pyrazoles/therapeutic use
- Receptors, Fc/chemistry
- Receptors, Fc/therapeutic use
- Receptors, Thrombopoietin/agonists
- Receptors, Thrombopoietin/chemistry
- Receptors, Thrombopoietin/metabolism
- Recombinant Fusion Proteins/chemistry
- Recombinant Fusion Proteins/pharmacology
- Recombinant Fusion Proteins/therapeutic use
- Signal Transduction/drug effects
- Thrombopoietin/chemistry
- Thrombopoietin/pharmacology
- Thrombopoietin/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Waleed Ghanima
- Departments of Medicine, Hematology-Oncology and Research, Østfold Hospital Trust, Norway
- Department of Hematology, Institute of Clinical Medicine, University of Oslo, Norway
| | - Nichola Cooper
- Department of Medicine, Hammersmith Hospital, Imperial College, London, UK
| | - Francesco Rodeghiero
- Hematology Project Foundation and Department of Cell Therapy and Hematology, S. Bortolo Hospital, Vicenza, Italy
| | - Bertrand Godeau
- Department of Internal Medicine, Henri Mondor University Hospital, Assistance Publique-Hopitaux de Paris, UPEC, Créteil, France
| | - James B Bussel
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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Swaminathan M, Borthakur G, Kadia TM, Ferrajoli A, Alvarado Y, Pemmaraju N, Bodden K, Yearby B, Konopleva M, Khoury J, Bueso-Ramos C, Garcia-Manero G, DiNardo CD. A phase 2 clinical trial of eltrombopag for treatment of patients with myelodysplastic syndromes after hypomethylating-agent failure. Leuk Lymphoma 2019; 60:2207-2213. [DOI: 10.1080/10428194.2019.1576873] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Mahesh Swaminathan
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M. Kadia
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Yesid Alvarado
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Kristy Bodden
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Brittany Yearby
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Khoury
- Department of Hematopathology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Carlos Bueso-Ramos
- Department of Hematopathology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Courtney D. DiNardo
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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35
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Eltrombopag use in higher risk myeloid cancers: fitting a square "pag" into a round hole? LANCET HAEMATOLOGY 2019; 6:e111-e112. [PMID: 30704924 DOI: 10.1016/s2352-3026(19)30010-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 01/17/2023]
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36
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Yuan C, Boyd AM, Nelson J, Patel RD, Varela JC, Goldstein SC, Ahmad S, Zhu X, Mori S. Eltrombopag for Treating Thrombocytopenia after Allogeneic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1320-1324. [PMID: 30710685 DOI: 10.1016/j.bbmt.2019.01.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/22/2019] [Indexed: 01/18/2023]
Abstract
Thrombocytopenia after allogeneic hematopoietic stem cell transplantation (allo-SCT) can pose significant problems in management of patients. Eltrombopag is a small-molecule thrombopoietin receptor agonist that has been approved for use in immune thrombocytopenic purpura and aplastic anemia; but its use after allo-SCT is limited. Between 2014 and 2017, we treated 13 patients with eltrombopag for poor platelet engraftment without evidence of relapse at the time of initiation, including 6 patients with primary platelet engraftment failure and 7 with secondary platelet engraftment failure. Eltrombopag was started at an initial dose of 25 or 50 mg per day, and dose adjustments were made in accordance with the manufacturer's recommendation. The cumulative incidence of platelet recovery to ≥50,000/μL without the need for transfusion for at least 7 days was defined as response. The overall response rate was 62% (n = 8). Of the 6 patients with primary isolated platelet failure, 3 (50%) responded, and of the 7 patients with secondary platelet failure, 5 (71%) responded. The median time to response was 33 days (range, 11 to 68 days). In addition, no significant differences in platelet recovery were noted in patients with adequate and decreased bone marrow megakaryocytic reserve (60% and 67%, respectively). Although eltrombopag was well tolerated, and no patient discontinued treatment because of adverse events, only 3 patients were alive at the end of the observation period, with relapse and graft-versus-host disease accounting for majority of the deaths. This suggested that despite the relatively good overall response rate to eltrombopag, inadequate platelet engraftment is a harbinger of poor outcome in allo-SCT.
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Affiliation(s)
- Cai Yuan
- Department of Hematology and Oncology, University of Florida, Gainesville, Florida
| | - Angela M Boyd
- Pharmacy Department, Florida Hospital, Orlando, Florida
| | - Jan Nelson
- Pharmacy Department, Florida Hospital, Orlando, Florida
| | - Rushang D Patel
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida
| | - Juan C Varela
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida
| | - Steven C Goldstein
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida
| | - Sarfraz Ahmad
- Department of Gynecologic Oncology, Florida Hospital Cancer Institute, Orlando, Florida
| | - Xiang Zhu
- Center for Collaborative Research, Florida Hospital, Orlando, Florida
| | - Shahram Mori
- Blood and Marrow Transplant Center, Florida Hospital Cancer Institute, Orlando, Florida.
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37
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Frey N, Jang JH, Szer J, Illés Á, Kim HJ, Ram R, Chong BH, Rowe JM, Borisenkova E, Liesveld J, Winer ES, Cherfi A, Aslanis V, Ghaznawi F, Strickland S. Eltrombopag treatment during induction chemotherapy for acute myeloid leukaemia: a randomised, double-blind, phase 2 study. LANCET HAEMATOLOGY 2019; 6:e122-e131. [PMID: 30704923 DOI: 10.1016/s2352-3026(18)30231-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with acute myeloid leukaemia frequently have thrombocytopenia during induction chemotherapy. Eltrombopag, an oral thrombopoietin receptor agonist, stimulates platelet production by a similar mechanism to endogenous thrombopoietin. This study investigated safety and efficacy of eltrombopag versus placebo during anthracycline-based induction treatment of patients with acute myeloid leukaemia. METHODS In this randomised, double-blind, phase 2 study, treatment-naive patients were recruited from clinical centres across 10 countries (Australia, Belgium, Canada, Greece, Hungary, Israel, South Korea, Poland, Russia, and the USA). Patients with acute myeloid leukaemia of any subtype except M3 and M7 were stratified by antecedent malignant haematological disorder (yes or no) and age (18-60 years or >60 years) and were then randomly assigned (1:1) using an automated interactive voice-response system randomisation schedule. Investigators and patients were blinded to study treatment. Starting on day 4, patients received standard induction chemotherapy (daunorubicin bolus intravenous infusion on days 1-3 [90 mg/m2 for patients aged 18-60 years or 60 mg/m2 for patients aged >60 years], plus cytarabine continuous intravenous infusion on days 1-7 [100 mg/m2]), with eltrombopag 200 mg (100 mg for east Asians) or placebo once daily, until platelet counts were 200 × 109/L or higher, until remission, or after 42 days from the start of induction chemotherapy. The primary objective of the study was safety and tolerability assessed by adverse events, changes in left ventricular ejection fraction (LVEF), and clinical laboratory parameters in all treated patients. This study has been completed and is registered with ClinicalTrials.gov, number NCT01890746. FINDINGS Between Sept 7, 2013, and Jan 30, 2015, 149 patients were assessed for eligibility and 148 were then randomly assigned to receive eltrombopag (n=74) and placebo (n=74). Groups were matched in mean (SD) age (56·7 years [12·3] in the eltrombopag group vs 56·6 years [11·6] in the placebo group), mean (SD) initial platelet count (59·5 × 109/L [43·3] vs 63·7 × 109/L [48·0]), and poor-risk karyotype (16 [22%] of 74 patients in both groups). The most common grade 3-4 adverse events (≥10% in either group) were febrile neutropenia (31 [42%] vs 28 [39%]), decreased white blood cell count (8 [11%] vs 5 [7%]), and hypophosphataemia (3 [4%] vs 9 [13%]). Serious adverse events occurred in 24 (32%) patients in the eltrombopag group compared with 14 (20%) patients in the placebo group. 39 (53%) patients in the eltrombopag group died versus 29 (41%) patients in the placebo group. Thromboembolic events (5 [7%] vs 4 [6%]) and mean (SD) change in LVEF (-2·5% [7·8] vs -4·3% [8·5]) were similar. INTERPRETATION Data from this trial do not support combining eltrombopag with induction chemotherapy in patients with acute myeloid leukaemia. FUNDING Novartis Pharma AG.
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Affiliation(s)
- Noelle Frey
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Jun Ho Jang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeff Szer
- The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Árpád Illés
- Faculty of Medicine, Department of Hematology, University of Debrecen, Debrecen, Hungary
| | - Hee-Je Kim
- Seoul St Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ron Ram
- Tel-Aviv Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Beng H Chong
- St George Hospital, University of New South Wales, Sydney, NSW, Australia
| | | | | | - Jane Liesveld
- University of Rochester Medical Center, Rochester, NY, USA
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38
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Thrombopoietin Receptor Agonists. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00061-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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39
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Azacitidine with or without eltrombopag for first-line treatment of intermediate- or high-risk MDS with thrombocytopenia. Blood 2018; 132:2629-2638. [PMID: 30305280 DOI: 10.1182/blood-2018-06-855221] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 09/24/2018] [Indexed: 12/27/2022] Open
Abstract
Azacitidine treatment of myelodysplastic syndromes (MDSs) generally exacerbates thrombocytopenia during the first treatment cycles. A Study of Eltrombopag in Myelodysplastic Syndromes Receiving Azacitidine (SUPPORT), a phase 3, randomized, double-blind, placebo-controlled study, investigated the platelet supportive effects of eltrombopag given concomitantly with azacitidine. International Prognostic Scoring System intermediate-1, intermediate-2, or high-risk MDS patients with baseline platelets <75 × 109/L were randomized 1:1 to eltrombopag (start, 200 mg/d [East Asians, 100 mg/d], maximum, 300 mg/d [East Asians, 150 mg/d]) or placebo, plus azacitidine (75 mg/m2 subcutaneously once daily for 7 days every 28 days). The primary end point was the proportion of patients platelet transfusion-free during cycles 1 through 4 of azacitidine therapy. Based on planned interim analyses, an independent data monitoring committee recommended stopping the study prematurely because efficacy outcomes crossed the predefined futility threshold and for safety reasons. At termination, 28/179 (16%) eltrombopag and 55/177 (31%) placebo patients met the primary end point. Overall response (International Working Group criteria; complete, marrow, or partial response) occurred in 20% and 35% of eltrombopag and placebo patients, respectively, by investigator assessment. There was no difference in hematologic improvement in any cell lineage between the 2 arms. There was no improvement in overall or progression-free survival. Adverse events with ≥10% occurrence in the eltrombopag vs placebo arm were febrile neutropenia and diarrhea. Compared with azacitidine alone, eltrombopag plus azacitidine worsened platelet recovery, with lower response rates and a trend toward increased progression to acute myeloid leukemia. This trial was registered at www.clinicaltrials.gov as #NCT02158936.
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40
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Kao YR, Chen J, Narayanagari SR, Todorova TI, Aivalioti MM, Ferreira M, Ramos-Marques P, Pallaud C, Mantzaris I, Shastri A, Bussel JB, Verma A, Steidl U, Will B. Thrombopoietin receptor-independent stimulation of hematopoietic stem cells by eltrombopag. Sci Transl Med 2018; 10:10/458/eaas9563. [PMID: 30209246 PMCID: PMC9899005 DOI: 10.1126/scitranslmed.aas9563] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/13/2018] [Accepted: 08/22/2018] [Indexed: 02/06/2023]
Abstract
Eltrombopag (EP), a small-molecule thrombopoietin receptor (TPO-R) agonist and potent intracellular iron chelator, has shown remarkable efficacy in stimulating sustained multilineage hematopoiesis in patients with bone marrow failure syndromes, suggesting an effect at the most immature hematopoietic stem and multipotent progenitor level. Although the functional and molecular effects of EP on megakaryopoiesis have been studied in the past, mechanistic insights into its effects on the earliest stages of hematopoiesis have been limited. We investigated the effects of EP treatment on hematopoietic stem cell (HSC) function using purified primary HSCs in separation-of-function mouse models, including a TPO-R-deficient strain, and stem cells isolated from patients undergoing TPO-R agonist treatment. Our mechanistic studies showed a stimulatory effect on stem cell self-renewal independently of TPO-R. Human and mouse HSCs responded to acute EP treatment with metabolic and gene expression alterations consistent with a reduction of intracellular labile iron pools that are essential for stem cell maintenance. Iron preloading prevented the stem cell stimulatory effects of EP. Moreover, comparative analysis of stem cells in the bone marrow of patients receiving EP showed a marked increase in the number of functional stem cells compared to patients undergoing therapy with romiplostim, another TPO-R agonist lacking an iron-chelating ability. Together, our study demonstrates that EP stimulates hematopoiesis at the stem cell level through iron chelation-mediated molecular reprogramming and indicates that labile iron pool-regulated pathways can modulate HSC function.
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Affiliation(s)
- Yun-Ruei Kao
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Jiahao Chen
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | | | - Tihomira I. Todorova
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Maria M. Aivalioti
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Mariana Ferreira
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461
| | | | | | - Ioannis Mantzaris
- Department of Oncology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Aditi Shastri
- Department of Oncology, Albert Einstein College of Medicine, Bronx, NY 10461
| | - James B. Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY 10065
| | - Amit Verma
- Department of Medicine, Albert Einstein College, Bronx, NY 10461,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY 10461
| | - Ulrich Steidl
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461,Department of Medicine, Albert Einstein College, Bronx, NY 10461,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY 10461,Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, Bronx, NY 10461,Corresponding authors: Britta Will or Ulrich Steidl
| | - Britta Will
- Department of Cell Biology, Albert Einstein College of Medicine, Bronx, NY 10461,Department of Medicine, Albert Einstein College, Bronx, NY 10461,Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY 10461,Institute for Stem Cell and Regenerative Medicine Research, Albert Einstein College of Medicine, Bronx, NY 10461,Corresponding authors: Britta Will or Ulrich Steidl
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41
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Rodeghiero F, Pecci A, Balduini CL. Thrombopoietin receptor agonists in hereditary thrombocytopenias. J Thromb Haemost 2018; 16:1700-1710. [PMID: 29956472 DOI: 10.1111/jth.14217] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Indexed: 12/15/2022]
Abstract
Hereditary thrombocytopenias (HTPs) constitute a heterogeneous group of diseases characterized by a reduction in platelet count and a potential bleeding risk. As a result of advances in diagnostic methods, HTPs are increasingly being identified, and appear to be less rare than previously thought. Most HTPs do not have effective treatments, except for platelet transfusion when bleeding occurs and in preparation for procedures associated with a risk of bleeding. Preliminary clinical evidence suggests that thrombopoietin receptor agonists (TPO-RAs) with an established use in the treatment of certain acquired thrombocytopenias are well tolerated and provide clinical benefits in patients with some forms of HTP. These drugs may therefore be considered for the treatment of HTPs in clinical practice. However, caution and close monitoring are recommended, owing to the absence of long-term safety data and the potential risks posed by prolonged bone marrow stimulation in certain HTPs. In this review, we summarize the available clinical data on TPO-RAs in the treatment of HTPs, and discuss their use in patients with these disorders. We believe that TPO-RAs will play a major role in the treatment of HTPs, particularly myosin heavy chain 9-related disease, Wiskott-Aldrich syndrome, X-linked thrombocytopenia, and thrombocytopenia caused by THPO mutations.
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Affiliation(s)
- F Rodeghiero
- Hematology Project Foundation, Affiliated to the Department of Haematology, S. Bortolo Hospital, Vicenza, Italy
| | - A Pecci
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
| | - C L Balduini
- Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation and University of Pavia, Pavia, Italy
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42
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Bussel J, Arnold DM, Grossbard E, Mayer J, Treliński J, Homenda W, Hellmann A, Windyga J, Sivcheva L, Khalafallah AA, Zaja F, Cooper N, Markovtsov V, Zayed H, Duliege A. Fostamatinib for the treatment of adult persistent and chronic immune thrombocytopenia: Results of two phase 3, randomized, placebo-controlled trials. Am J Hematol 2018; 93:921-930. [PMID: 29696684 PMCID: PMC6055608 DOI: 10.1002/ajh.25125] [Citation(s) in RCA: 206] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 04/17/2018] [Accepted: 04/22/2018] [Indexed: 01/19/2023]
Abstract
Spleen tyrosine kinase (Syk) signaling is central to phagocytosis-based, antibody-mediated platelet destruction in adults with immune thrombocytopenia (ITP). Fostamatinib, an oral Syk inhibitor, produced sustained on-treatment responses in a phase 2 ITP study. In two parallel, phase 3, multicenter, randomized, double-blind, placebo-controlled trials (FIT1 and FIT2), patients with persistent/chronic ITP were randomized 2:1 to fostamatinib (n = 101) or placebo (n = 49) at 100 mg BID for 24 weeks with a dose increase in nonresponders to 150 mg BID after 4 weeks. The primary endpoint was stable response (platelets ≥50 000/μL at ≥4 of 6 biweekly visits, weeks 14-24, without rescue therapy). Baseline median platelet count was 16 000/μL; median duration of ITP was 8.5 years. Stable responses occurred in 18% of patients on fostamatinib vs. 2% on placebo (P = .0003). Overall responses (defined retrospectively as ≥1 platelet count ≥50 000/μL within the first 12 weeks on treatment) occurred in 43% of patients on fostamatinib vs. 14% on placebo (P = .0006). Median time to response was 15 days (on 100 mg bid), and 83% responded within 8 weeks. The most common adverse events were diarrhea (31% on fostamatinib vs. 15% on placebo), hypertension (28% vs. 13%), nausea (19% vs. 8%), dizziness (11% vs. 8%), and ALT increase (11% vs. 0%). Most events were mild or moderate and resolved spontaneously or with medical management (antihypertensive, anti-motility agents). Fostamatinib produced clinically-meaningful responses in ITP patients including those who failed splenectomy, thrombopoietic agents, and/or rituximab. Fostamatinib is a novel ITP treatment option that targets an important mechanism of ITP pathogenesis.
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Affiliation(s)
| | - Donald M. Arnold
- McMaster University, Michael G. DeGroote School of Medicine, and Canadian Blood ServicesHamiltonOntarioCanada
| | | | - Jiří Mayer
- Fakultni nemocnice BrnoBrnoCzech Republic
| | - Jacek Treliński
- Wojewódzki Szpital Specjalistyczny im. M. Kopernika w ŁodziLodzPoland
| | - Wojciech Homenda
- Wojewódzki Szpital Specjalistyczny im. J. Korczaka i Akademia Pomorska w SłupskuSlupskPoland
| | - Andrzej Hellmann
- University Clinical Center, Medical University of GdańskGdańskPoland
| | - Jerzy Windyga
- Instytut Hematologii i TransfuzjologiiWarszawaPoland
| | - Liliya Sivcheva
- First Internal DepartmentMHAT Hristo Botev, AD, VratsaVratsaBulgaria
| | | | - Francesco Zaja
- Clinica Ematologica, DAME, University of UdineUdineItaly
| | | | | | - Hany Zayed
- Rigel PharmaceuticalsSouth San FranciscoCalifornia
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43
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Raslova H, Vainchenker W, Plo I. Eltrombopag, a potent stimulator of megakaryopoiesis. Haematologica 2018; 101:1443-1445. [PMID: 27903709 DOI: 10.3324/haematol.2016.153668] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Hana Raslova
- INSERM, UMR1170, Gustave Roussy, Villejuif, France
| | | | - Isabelle Plo
- INSERM, UMR1170, Gustave Roussy, Villejuif, France
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44
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Nishimura CD, Brenner DA, Mukherjee M, Hirsch RA, Ott L, Wu MF, Liu H, Dakhova O, Orange JS, Brenner MK, Lin CY, Arber C. c-MPL provides tumor-targeted T-cell receptor-transgenic T cells with costimulation and cytokine signals. Blood 2017; 130:2739-2749. [PMID: 29079582 PMCID: PMC5746163 DOI: 10.1182/blood-2017-02-769463] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 10/20/2017] [Indexed: 12/13/2022] Open
Abstract
Adoptively transferred T-cell receptor (TCR)-engineered T cells depend on host-derived costimulation and cytokine signals for their full and sustained activation. However, in patients with cancer, both signals are frequently impaired. Hence, we developed a novel strategy that combines both essential signals in 1 transgene by expressing the nonlymphoid hematopoietic growth factor receptor c-MPL (myeloproliferative leukemia), the receptor for thrombopoietin (TPO), in T cells. c-MPL signaling activates pathways shared with conventional costimulatory and cytokine receptor signaling. Thus, we hypothesized that host-derived TPO, present in the tumor microenvironment, or pharmacological c-MPL agonists approved by the US Food and Drug Administration could deliver both signals to c-MPL-engineered TCR-transgenic T cells. We found that c-MPL+ polyclonal T cells expand and proliferate in response to TPO, and persist longer after adoptive transfer in immunodeficient human TPO-transgenic mice. In TCR-transgenic T cells, c-MPL activation enhances antitumor function, T-cell expansion, and cytokine production and preserves a central memory phenotype. c-MPL signaling also enables sequential tumor cell killing, enhances the formation of effective immune synapses, and improves antileukemic activity in vivo in a leukemia xenograft model. We identify the type 1 interferon pathway as a molecular mechanism by which c-MPL mediates immune stimulation in T cells. In conclusion, we present a novel immunotherapeutic strategy using c-MPL-enhanced transgenic T cells responding to either endogenously produced TPO (a microenvironment factor in hematologic malignancies) or c-MPL-targeted pharmacological agents.
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Affiliation(s)
- Christopher D Nishimura
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, TX; and
| | - Daniel A Brenner
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, TX; and
- Center for Human Immunobiology
| | - Malini Mukherjee
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, TX; and
- Center for Human Immunobiology
| | | | - Leah Ott
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, TX; and
| | - Meng-Fen Wu
- Department of Biostatistics, Dan L. Duncan Comprehensive Cancer Center
| | - Hao Liu
- Department of Biostatistics, Dan L. Duncan Comprehensive Cancer Center
| | - Olga Dakhova
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, TX; and
| | | | - Malcolm K Brenner
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, TX; and
- Department of Molecular and Human Genetics
- Department of Pediatrics, and
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | | | - Caroline Arber
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children's Hospital, Houston, TX; and
- Department of Medicine, Baylor College of Medicine, Houston, TX
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45
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Eltrombopag reduces clinically relevant thrombocytopenic events in higher risk MDS and AML. LANCET HAEMATOLOGY 2017; 5:e6-e7. [PMID: 29241763 DOI: 10.1016/s2352-3026(17)30229-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
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46
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Mittelman M, Platzbecker U, Afanasyev B, Grosicki S, Wong RSM, Anagnostopoulos A, Brenner B, Denzlinger C, Rossi G, Nagler A, Garcia-Delgado R, Portella MSO, Zhu Z, Selleslag D. Eltrombopag for advanced myelodysplastic syndromes or acute myeloid leukaemia and severe thrombocytopenia (ASPIRE): a randomised, placebo-controlled, phase 2 trial. LANCET HAEMATOLOGY 2017; 5:e34-e43. [PMID: 29241762 DOI: 10.1016/s2352-3026(17)30228-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/09/2017] [Accepted: 11/10/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Thrombocytopenia is a life-threatening complication in patients with advanced myelodysplastic syndromes (MDS) and acute myeloid leukaemia (AML). In this study (ASPIRE), we aimed to assess eltrombopag, an oral thrombopoietin receptor agonist, for thrombocytopenia (grade 4) treatment in adult patients with advanced MDS or AML. METHODS ASPIRE consisted of an open-label, double-blind phase for 8 weeks and a randomised, double-blind phase (parts 1 and 2, reported here) for 12 weeks, and an open-label extension (part 3). Eligible patients were men and women aged 18 years or older, with intermediate-2 or high-risk MDS or AML, with bone marrow blasts of 50% or less, and had either grade 4 thrombocytopenia due to bone marrow insufficiency (platelet counts <25 × 109 per L) or grade 4 thrombocytopenia before platelet transfusion, with 25 × 109 platelets per L or greater after transfusion. Additionally, eligible patients had at least one of the following within the screening period of 4 weeks: platelet transfusion, symptomatic bleeding, or platelet count of less than 10 × 109 per L. During part 1, patients received eltrombopag, and dose-escalation criteria for part 2 were determined. In part 2, we randomly allocated patients 2:1 using an interactive voice-response system to eltrombopag or placebo, stratified by baseline platelet count (<10 × 109 platelets per L vs ≥10 × 109 platelets per L) and disease (MDS vs AML). In parts 1 and 2, patients received supportive standard of care and initiated eltrombopag or placebo at 100 mg per day (50 mg per day for patients of east-Asian heritage) to a maximum of 300 mg per day (150 mg per day for patients of east-Asian heritage). The part 2 primary objective was assessed by a composite primary endpoint of clinically relevant thrombocytopenic events (CRTE) during weeks 5-12, defined as one of the following events, either alone or in combination: grade 3 or worse haemorrhagic adverse events; platelet counts of less than 10 × 109 per L; or platelet transfusions. Efficacy analyses were based on intention to treat; clinically meaningful efficacy was defined as 30% absolute difference between groups. This trial is registered with ClinicalTrials.gov, number NCT01440374. FINDINGS In part 1, 17 patients received eltrombopag and 11 patients completed treatment; four experienced significantly increased platelet counts, and ten had reduced platelet transfusion requirements. In part 2 we randomly allocated 145 patients to receive supportive care plus eltrombopag (n=98) or placebo (n=47); similar proportions had MDS (50 [51%] patients to eltrombopag, 22 (47%) patients to placebo) or AML (48 [49%] patients to eltrombopag, 25 [53%] patients to placebo). Average weekly CRTE proportions from weeks 5-12 were significantly lower with eltrombopag (54% [95% CI 43-64]) than with placebo (69% [57-80], odds ratio [OR] 0·20, 95% CI 0·05-0·87; p=0·032) although the difference between treatment groups was less than 30%. The most common grade 3 and grade 4 adverse events were fatigue (six [6%] in the eltrombopag group and one [2%] in the placebo group), hypokalaemia (six [6%] and two [4%]), pneumonia (five [5%] and five [11%]), and febrile neutropenia (five [5%] and six [13%]). Serious adverse events were reported in 56 (58%) eltrombopag-treated patients and 32 (68%) placebo-treated patients. Seven eltrombopag recipients and two placebo recipients had serious adverse events that were suspected to be study drug-related (eltrombopag: acute kidney injury, arterial thrombosis, bone pain, diarrhoea, myocardial infarction, pyrexia, retinal vein occlusion, n=1 each; placebo: vomiting, white blood cell count increased, n=1 each). Two eltrombopag recipients (arterial thrombosis n=1; myocardial infarction n=1) and no placebo recipients experienced fatal serious adverse events suspected to be study drug-related. INTERPRETATION No new safety concerns were noted with eltrombopag and the trial met the primary objective of a reduction in CRTEs; eltrombopag might be a treatment option for thrombocytopenic patients with AML or MDS who are ineligible for other treatment and who are not receiving disease-modifying treatment. FUNDING Novartis Pharma AG.
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Affiliation(s)
- Moshe Mittelman
- Tel Aviv Sourasky Medical Center, Sackler Medical Faculty, Tel Aviv University, Tel Aviv, Israel.
| | | | | | | | - Raymond S M Wong
- Sir YK Pao Centre for Cancer & Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China
| | | | - Benjamin Brenner
- Rambam Medical Center, Technion, Israel Institute of Technology, Haifa, Israel
| | | | | | - Arnon Nagler
- Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Zewen Zhu
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Gao Y, Gong M, Zhang C, Kong X, Ma Y. Successful eltrombopag treatment of severe refractory thrombocytopenia in chronic myelomonocytic leukemia: Two cases reports: A CARE-compliant article. Medicine (Baltimore) 2017; 96:e8337. [PMID: 29069007 PMCID: PMC5671840 DOI: 10.1097/md.0000000000008337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Thrombocytopenia in chronic myelomonocytic leukemia (CMML) is usually attributed to impaired marrow production resulting from cytotoxic drug use or CMML itself ("CMML-induced thrombocytopenia"). In very rare cases, immune thrombocytopenia (ITP) can be a complication of CMML ("CMML-associated ITP"). However, treatment of severe thrombocytopenia in patients with CMML is still a challenge. PATIENT CONCERNS Case 1 was a 61-year-old female patient admitted to our hospital because of skin petechiae and purpura for 6 days. She had increased monocyte cell count (1.82 × 10/L), markedly decreased platelet count (2 × 10/L), hypercellularity of the megakaryocyte lineage with many immature megakaryocytes, and ZRSR2(zinc finger CCCH-type, RNA binding motif and serine/arginine rich 2) mutation. She failed to the treatment of corticosteroids, intravenous immunoglobulin (IVIg), TPO (thrombopoietin), and cyclosporin A (CsA). Case 2 was a 72-year-old female patient with thrombocytosis and monocytosis for 4 years, and thrombocytopenia for 6 months. After 10 courses of decitabine therapy, she had a persistent severe thrombocytopenia and decreased number of megakaryocytes, TET2 (tet methylcytosine dioxygenase 2) and SRSF2 (serine and arginine rich splicing factor 2) mutations were detected. She was dependent on platelet transfusion. DIAGNOSES Case 1 was diagnosed as CMML-associated ITP, and case 2 as CMML with decitabine therapy-induced thrombocytopenia. INTERVENTIONS Both patients were treated with eltrombopag. OUTCOMES In both patients, the platelet counts returned to the normal within 1 week after eltrombopag therapy. The platelet count in case 1 patient remained stable at 141-200 × 10/L for 20 months with stopping therapy for 3 months. In case 2 patient, eltrombopag was stopped 1 month later. Her platelet count decreased to 41 × 10/L, but was stable at ∼30 × 10/L for 3 months with platelet transfusion independency for 12 months. Both patients had no adverse effects with eltrombopag. LESSONS CMML-associated ITP is very rare and easily misdiagnosed. To the best of our knowledge, case 1 is the first reported case of the successful treatment of CMML-associated ITP with eltrombopag. Both CMML-associated ITP and decitabine therapy-induced thrombocytopenia in these 2 patients were highly sensitive and safe to eltrombopag therapy.
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MESH Headings
- Aged
- Antimetabolites, Antineoplastic/adverse effects
- Azacitidine/adverse effects
- Azacitidine/analogs & derivatives
- Benzoates/administration & dosage
- DNA-Binding Proteins/genetics
- Decitabine
- Dioxygenases
- Drug Monitoring
- Female
- Hematologic Agents/administration & dosage
- Humans
- Hydrazines/administration & dosage
- Leukemia, Myelomonocytic, Chronic/blood
- Leukemia, Myelomonocytic, Chronic/complications
- Leukemia, Myelomonocytic, Chronic/diagnosis
- Leukemia, Myelomonocytic, Chronic/drug therapy
- Middle Aged
- Mutation
- Nuclear Proteins/genetics
- Platelet Count/methods
- Proto-Oncogene Proteins/genetics
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Purpura, Thrombocytopenic, Idiopathic/etiology
- Purpura, Thrombocytopenic, Idiopathic/physiopathology
- Pyrazoles/administration & dosage
- Ribonucleoproteins/genetics
- Serine-Arginine Splicing Factors/genetics
- Thrombocytopenia/chemically induced
- Thrombocytopenia/diagnosis
- Thrombocytopenia/drug therapy
- Thrombocytopenia/physiopathology
- Thrombopoietin/agonists
- Treatment Outcome
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Affiliation(s)
| | | | | | - Xudong Kong
- Department of Pharmacology, China-Japan Friendship Hospital, Beijing, China
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48
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Dodillet H, Kreuzer K, Monsef I, Skoetz N. Thrombopoietin mimetics for patients with myelodysplastic syndromes. Cochrane Database Syst Rev 2017; 9:CD009883. [PMID: 28962071 PMCID: PMC6483680 DOI: 10.1002/14651858.cd009883.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Myelodysplastic syndrome (MDS) is one of the most frequent haematologic malignancies of the elderly population and characterised by progenitor cell dysplasia with ineffective haematopoiesis and a high rate of transformation to acute myeloid leukaemia (AML). Thrombocytopenia represents a common problem for patients with MDS. ranging from mild to serious bleeding events and death. To manage thrombocytopenia, the current standard treatment includes platelet transfusion, unfortunately leading to a range of side effects. Thrombopoietin (TPO) mimetics represent an alternative treatment option for MDS patients with thrombocytopenia. However, it remains unclear, whether TPO mimetics influence the increase of blast cells and therefore to premature progression to AML. OBJECTIVES To evaluate the efficacy and safety of thrombopoietin (TPO) mimetics for patients with MDS. SEARCH METHODS We searched for randomised controlled trials in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 2000 to August 2017), trials registries (ISRCTN, EU clinical trials register and clinicaltrials.gov) and conference proceedings. We did not apply any language restrictions. Two review authors independently screened search results, disagreements were solved by discussion. SELECTION CRITERIA We included randomised controlled trials comparing TPO mimetics with placebo, no further treatment or another TPO mimetic in patients with MDS of all risk groups, without gender, age or ethnicity restrictions. Additional chemotherapeutic treatment had to be equal in both arms. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the quality of trials, disagreements were resolved by discussion. Risk ratio (RR) was used to analyse mortality during study, transformation to AML, incidence of bleeding events, transfusion requirement, all adverse events, adverse events >= grade 3, serious adverse events and platelet response. Overall survival (OS) and progression-free survival (PFS) have been extracted as hazard ratios, but could not be pooled as results were reported in heterogenous ways. Health-related quality of life and duration of thrombocytopenia would have been analysed as standardised mean differences, but no trial reported these outcomes. MAIN RESULTS We did not identify any trial comparing one TPO mimetic versus another. We analysed six eligible trials involving 746 adult patients. All trials were reported as randomised and double-blind trials including male and female patients. Two trials compared TPO mimetics (romiplostim or eltrombopag) with placebo, one trial evaluated eltrombopag in addition to the hypomethylating agent azacitidine, two trials analysed romiplostim additionally to a hypomethylating agent (azacitidine or decitabine) and one trial evaluated romiplostim in addition to the immunomodulatory drug lenalidomide. There are more data on romiplostim (four included, completed, full-text trials) than on eltrombopag (two trials included: one full-text publication, one abstract publication). Due to small sample sizes and imbalances in baseline characteristics in three trials and premature termination of two studies, we judged the potential risk of bias of all included trials as high.Due to heterogenous reporting, we were not able to pool data for OS. Instead of that, we analysed mortality during study. There is little or no evidence for a difference in mortality during study for thrombopoietin mimetics compared to placebo (RR 0.97, 95% confidence interval (CI) 0.73 to 1.27, N = 6 trials, 746 patients, low-quality evidence). It is unclear whether the use of TPO mimetics induces an acceleration of transformation to AML (RR 1.02, 95% CI 0.59 to 1.77, N = 5 trials, 372 patients, very low-quality evidence).Thrombopoietin mimetics probably improve the incidence of all bleeding events (RR 0.92, 95% CI 0.86 to 0.99, N = 5 trials, 390 patients, moderate-quality evidence). This means that in the study population, 713 out of 1000 in the placebo arm will have a bleeding event, compared to 656 of 1000 (95% CI 613 to 699) in the TPO mimetics arm. There is little or no evidence for a difference that TPO mimetics significantly diminish the rate of transfusion requirement (RR 0.83, 95% CI 0.66 to 1.05, N = 4 trials, 358 patients, low-quality evidence). No studies were found that looked at quality of life or duration of thrombocytopenia.There is no evidence that patients given TPO mimetics suffer more all adverse events (RR 1.01, 95% CI 0.96 to 1.07, N = 5 trials, 390 patients, moderate-quality evidence). There is uncertainty whether the number of serious adverse events decrease under therapy with TPO mimetics (RR 0.89, 95% CI 0.54 to 1.46, N = 4 trials, 356 patients, very low-quality evidence).We identified one ongoing study and one study marked as completed (March 2015), but without publication of results for MDS patients (only results reported for AML and MDS patients together). Both studies evaluate MDS patients receiving eltrombopag in comparison to placebo. AUTHORS' CONCLUSIONS No trial evaluated one TPO mimetic versus another.Six trials including adult patients analysed one TPO mimetic versus placebo, sometimes combined with standard therapy in both arms. Given the uncertainty of the quality of evidence, meta-analyses show that there is little or no evidence for a difference in mortality during study and premature progress to AML. However, these assumptions have to be further explored. Treatment with TPO mimetics resulted in a lower number of MDS patients suffering from bleeding events.There is no evidence for a difference between study groups regarding transfusion requirement. Enlarged sample sizes and a longer follow-up of future trials should improve the estimate of safety and efficacy of TPO mimetics, moreover health-related quality of life should be evaluated. As two ongoing studies currently investigate eltrombopag (one already completed, but without published results), we are awaiting results for this drug.
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Affiliation(s)
- Helga Dodillet
- University Hospital of CologneDepartment I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Karl‐Anton Kreuzer
- University Hospital of CologneDepartment I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Ina Monsef
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Nicole Skoetz
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50924
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Bal G, Fabian D, Maia D, Ringel F, Salama A. Effect of thrombopoietin receptor agonists on leukocyte and haematopoietic stem and progenitor cells in the peripheral blood of patients with immune thrombocytopenic purpura. Ann Hematol 2017; 96:2045-2056. [DOI: 10.1007/s00277-017-3131-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 09/15/2017] [Indexed: 11/29/2022]
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Beyond immune thrombocytopenia: the evolving role of thrombopoietin receptor agonists. Ann Hematol 2017; 96:1421-1434. [PMID: 28275823 DOI: 10.1007/s00277-017-2953-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/13/2017] [Indexed: 01/19/2023]
Abstract
Since its discovery, the thrombopoietin (TPO) pathway has been an important pharmaceutical target for the treatment of thrombocytopenia. The first generation of TPO mimetics included peptide agents sharing homology with endogenous TPO, but these introduced a risk of antibody formation to endogenous TPO and were not successful. However, second-generation TPO mimetics or TPO receptor agonists (RAs) are currently being used to treat thrombocytopenia associated with a number of conditions, such as immune thrombocytopenia (ITP), severe aplastic anaemia (SAA), and hepatitis C virus-associated chronic liver disease. Accumulating efficacy and safety data suggest that the role of TPO-RAs in the treatment of thrombocytopenia may evolve in the near future with broader use of these agents in ITP and SAA, as well as approval in other indications, potentially including myelodysplastic syndromes, chemotherapy-associated thrombocytopenia, and post-transplant thrombocytopenia. This review provides an overview of clinical data on the efficacy and safety of TPO-RAs, emphasising recent findings that may expand their clinical utility.
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