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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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Li Y, Kong F, Bai G, Jiang Y, Zhang W, Sun X, Sui X, Li Y, Ding M, Yuan D, Wang X, Fang X. Eltrombopag can promote platelet implantation after allogeneic hematopoietic stem cell transplantation as safely and similarly to thrombopoietin. Front Immunol 2024; 15:1340908. [PMID: 38650933 PMCID: PMC11033304 DOI: 10.3389/fimmu.2024.1340908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/25/2024] [Indexed: 04/25/2024] Open
Abstract
Background Eltrombopag has demonstrated efficacy in treating low platelet (PLT) levels, but it remains unclear whether eltrombopag can promote PLT engraftment after hematopoietic stem cell transplantation (HSCT). Methods Forty-one HSCT patients received eltrombopag 50 mg/d from +1 day until PLT >50 × 109/L or 1 month after HSCT. Fifty-one patients in the same period received thrombopoietin (TPO) to promote PLT graft after HSCT and served as a control group. Results A total of 51 patients who applied TPO during the same period were treated as a control. In the eltrombopag group, the median time to white blood cells (WBC) graft was 12 days (range, 10-17 days) and the PLT graft was 15 days (range, 10-30 days), whereas for the patients in the TPO group, the median time to WBC and PLT graft was 12 days (range, 9-23 days) and 15.5 days (range, 9-41 days), respectively. In the first month after HSCT, the median WBC count in the eltrombopag group was 4.41 × 109/L (range, 0.87-40.01 × 109/L) and the median PLT was 89x109/L (range, 30-401 × 109/L); the median WBC and PLT \counts in the TPO group were 4.65 × 109/L (range, 0.99-23.63 × 109/L) and 86 × 109/L (range, 5-512 × 109/L), respectively. Patients in the TPO or eltrombopag group did not experience serious side effects after drug administration, and the difference in side effects on liver and kidney function between the two groups was not statistically significant. Conclusion Eltrombopag is safe and similarly promotes platelet engraftment to thrombopoietin after allogeneic HSCT.
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Affiliation(s)
- Yahan Li
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Fansheng Kong
- Department of Hematology, The Affiliated Hospital of Shandong University of Traditional Chinese Medical, Jinan, Shandong, China
| | - Guanchen Bai
- Department of Hematology, The Affiliated Taian City Centeral Hospital of Qingdao University, Taian, Shandong, China
| | - Yujie Jiang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Wenlu Zhang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xue Sun
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiaohui Sui
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Ying Li
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Mei Ding
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Dai Yuan
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- Department of Hematology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, China
- Branch of National Clinical Research Center for Hematologic Diseases, Jinan, Shandong, China
- National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaosheng Fang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Gunji Y, Yagasaki H, Kanezawa K, Shimozawa K, Ueno M, Yoda T, Mochizuki S, Morioka I. T-cell-replete retransplantation in children with severe aplastic anemia who developed late graft failure. Pediatr Blood Cancer 2024; 71:e30733. [PMID: 37849231 DOI: 10.1002/pbc.30733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/14/2023] [Accepted: 10/10/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Yuki Gunji
- Department of Pediatrics, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Hiroshi Yagasaki
- Department of Pediatrics, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Koji Kanezawa
- Department of Pediatrics, Nihon University Itabashi Hospital, Tokyo, Japan
| | | | - Masaru Ueno
- Department of Pediatrics, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takanao Yoda
- Department of Pediatrics, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Shinji Mochizuki
- Department of Pediatrics, Center Hospital, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ichiro Morioka
- Department of Pediatrics, Nihon University Itabashi Hospital, Tokyo, Japan
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Arslan Davulcu E, Akad Soyer N, Vural F. Eltrombopag for the Treatment of Allogeneic Hematopoietic Stem Cell Transplantation-Related Poor Graft Function. Cureus 2023; 15:e44555. [PMID: 37790070 PMCID: PMC10544786 DOI: 10.7759/cureus.44555] [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: 09/01/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Allogeneic stem cell transplantation (ASCT) is a crucial therapeutic strategy for hematological and non-hematological disorders. Poor graft function (PGF) after ASCT presents a critical challenge that does not have a standardized treatment approach. A thrombopoietin-mimetic oral drug eltrombopag shows promise in some bone failure syndromes. This study aimed to analyze the efficacy of eltrombopag in treating PGF after ASCT. METHODS Patients receiving eltrombopag for PGF after ASCT between 2017 and 2020 were retrospectively evaluated. Patients' characteristics, details for ASCT, timing, treatment, and possible contributors for PGF, response to eltrombopag treatment, and overall response rate (ORR) were analyzed. Results: Eighteen patients were assessed. Eltrombopag treatment yielded a favorable response in 11 patients, resulting in an ORR of 61%. The ORR in secondary PGF was better than that in primary PGF (83% and 17% respectively). There was a marked enhancement in platelet and hemoglobin levels following eltrombopag treatment (p=0.001 and p=0.030, respectively), while neutrophil values exhibited no significant change (p=0.8). Among the responding patients, four individuals (22%) underwent a tapering and discontinuation of eltrombopag. No toxicity was observed above grade one, and no patient discontinued eltrombopag because of intolerability or adverse events. CONCLUSION Our findings affirm that eltrombopag can treat poor graft function after allogeneic stem cell transplantation without significant toxicities. These results contribute to the growing body of evidence supporting the use of eltrombopag in poor graft function after allogeneic stem cell transplantation, providing insights into its potential benefits and limitations.
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Affiliation(s)
- Eren Arslan Davulcu
- Department of Hematology, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, TUR
| | - Nur Akad Soyer
- Department of Hematology, Faculty of Medicine, Ege University, Izmir, TUR
| | - Filiz Vural
- Department of Hematology, Faculty of Medicine, Ege University, Izmir, TUR
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Müskens KF, Lindemans CA, Dandis R, Nierkens S, Belderbos ME. Definitions, incidence and outcome of poor graft function after hematopoietic cell transplantation: A systematic review and meta-analysis. Blood Rev 2023; 60:101076. [PMID: 36990959 DOI: 10.1016/j.blre.2023.101076] [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: 01/30/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Poor graft function (PGF) after allogeneic hematopoietic stem cell transplantation (HCT) is a serious complication with high morbidity and mortality. The reported incidence of PGF, its risk factors and outcome vary substantially between studies. This variability may be explained by heterogeneity in patient cohorts and HCT strategies, differences in the underlying causes of cytopenia, as well as by differences in PGF definition. In this systematic review and meta-analysis, we provide an overview of the various PGF definitions used and determined the impact of this variability on the reported incidence and outcome. We searched MEDLINE, EMBASE and Web of Science up to July 2022, for any study on PGF in HCT recipients. We performed random-effect meta-analyses for incidence and outcome and subgroup analyses based on different PGF criteria. Among 69 included studies (14.265 HCT recipients), we found 63 different PGF definitions, using various combinations of 11 common criteria. The median incidence of PGF was 7% (IQR: 5-11%, 22 cohorts). The pooled survival of PGF patients was 53% (95% CI: 45-61%, 23 cohorts). The most commonly reported risk factors associated with PGF were history of cytomegalovirus infection and prior graft-versus-host disease. Incidence was lower in studies with strict cytopenic cutoffs, while survival was lower for primary compared to secondary PGF. This work indicates that a standardized, quantitative definition of PGF is needed to facilitate clinical guideline development and to advance scientific progress.
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Affiliation(s)
- Konradin F Müskens
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Caroline A Lindemans
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Wilhelmina Children's Hospital, University Medical Center Utrecht, Lundlaan 6, 3584 EA Utrecht, the Netherlands
| | - Rana Dandis
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Stefan Nierkens
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Center for Translational Immunology, Utrecht University, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Mirjam E Belderbos
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
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Kırcalı E, Cengiz Seval G, Öztürk C, Yılmaz H, Koyun D, Civriz Bozdağ S, Toprak SK, Topçuoğlu P, Arslan Ö, Özcan M, Demirer T, İlhan O, Gürman G, Beksaç M, Kurt Yüksel M. Eltrombopag for the Treatment of Poor Graft Function Following Haematopoietic Cell Transplantation: Real-Life Data. Balkan Med J 2023; 40:51-56. [PMID: 36571427 PMCID: PMC9874246 DOI: 10.4274/balkanmedj.galenos.2022.2022-2-48] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background Eltrombopag has an off-label indication for haematopoietic cell transplantation in patients experiencing delayed thrombocyte recovery and/or thrombocytopaenia. Aims To present our centre’s experience of using this agent not only for post- haematopoietic cell transplantation thrombocytopaenia but also for poor graft functioning in the post-haematopoietic cell transplantation setting. Study Design Retrospective cross-sectional study. Methods Thirty-nine patients who had persistent cytopaenia following haematopoietic cell transplantation and treated with eltrombopag at our centre between October 2011 and December 2021 were retrospectively identified. During this period, 9 (23.1%) and 30 (76.9%) patients who underwent allogeneic transplantations, respectively, received eltrombopag. Results The female-to-male ratio was 12:27, and the median transplant age was 49 (18-70) years. Eight (20.5%) patients had isolated thrombocytopaenia, 19 (49.4%) had bi-lineage cytopaenia and 12 (30.1%) had pancytopaenia. Patients received a median of 50 mg/day (25-150 mg/day) of eltrombopagfor a median duration of 82 (24-386) days. Nine (23.1%) patients had autologous haematopoietic cell transplantation, and 30 (76.9%) had allogeneic haematopoietic cell transplantation (14 unrelated, 9 sibling and 7 haploidentical). The median donor age was 32 (20-67) years. The median follow-up was 16.4 (1.8-84.3) months. The median pre-treatment platelet count was 11x109/l (1-23), which increased to 41x109/l (6-150). The median platelet count increment was 29.5x109/l (p = 0.001). The pre-treatment median neutrophil count was 1.19x109/l (0.39-5.1), which increased to 2.35 x109/l (0.1-5.33) (p = 0.05), and the pre-treatment median haemoglobin was 8.3 (6.2-14) g/dl, which increased to 10 (6.2-14) g/dl (p = 0.001) with eltrombopag. No eltrombopag-related hepatotoxicity occurred; however, 1 (2.6%) patient failed to continue treatment because of two consecutive episodes of deep venous thrombosis. Six (15.4%) patients were unresponsive to eltrombopag and dependent on blood product transfusions. After a median time of 82 days, 61.5% of the patients discontinued eltrombopag successfully. Conclusion The results confirmed that eltrombopag could provide a rapid, sustained response in patients with poor graft functioning after haematopoietic cell transplantation. This finding is essential given the high rate of non-relapse mortality caused by poor graft functioning after haematopoietic cell transplantation.
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Affiliation(s)
- Ekin Kırcalı
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey,* Address for Correspondence: Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey E-mail:
| | | | - Cemaleddin Öztürk
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Hülya Yılmaz
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Derya Koyun
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Sinem Civriz Bozdağ
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Selami Koçak Toprak
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Pervin Topçuoğlu
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Önder Arslan
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Muhit Özcan
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Osman İlhan
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Günhan Gürman
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Meral Beksaç
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Meltem Kurt Yüksel
- Department of Hematology, Ankara University Faculty of Medicine, Ankara, Turkey
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Abstract
Hematopoietic stem cell transplantation (HSCT) is a highly effective and unique medical procedure for the treatment of most hematological malignancies. The first allogeneic transplantation was performed by E. Donnall Thomas in 1957. Since then, the field has evolved and expanded worldwide. The first successful allogenic HSCT (allo-HSCT) in China was conducted in 1981. Although the development of allo-HSCT in China lagged, China has since made considerable contributions to the process of HSCT worldwide, with more than 10,000 HSCTs performed annually. In particular, haploid HSCT (haplo-HSCT) technology represented in the Beijing Protocol has demonstrated similar efficacy to human leukocyte antigen-matched HSCT and has gradually become the pre-dominant choice for allo-HSCT in China. Currently, the number of haplo-HSCT procedures exceeds 5000 per year, and the Beijing Protocol has been greatly improved by implementing updated individualized strategies for controlling complications, relapse, and infection management. In addition, innovative haplo-HSCT technologies developed by different medical transplantation centers, such as Soochow, Zhejiang, Fujian, Chongqing, and Anhui, have emerged, providing inspiration for the refinement of global practice. This review will focus on the current activity in this field and highlight important trends that are vital in China's allo-HSCT process, examining the current viewpoint and future directions.
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8
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Man Y, Lu Z, Yao X, Gong Y, Yang T, Wang Y. Recent Advancements in Poor Graft Function Following Hematopoietic Stem Cell Transplantation. Front Immunol 2022; 13:911174. [PMID: 35720412 PMCID: PMC9202575 DOI: 10.3389/fimmu.2022.911174] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/06/2022] [Indexed: 01/05/2023] Open
Abstract
Poor graft function (PGF) is a life-threatening complication that occurs after transplantation and has a poor prognosis. With the rapid development of haploidentical hematopoietic stem cell transplantation, the pathogenesis of PGF has become an important issue. Studies of the pathogenesis of PGF have resulted in some success in CD34+-selected stem cell boosting. Mesenchymal stem cells, N-acetyl-l-cysteine, and eltrombopag have also been investigated as therapeutic strategies for PGF. However, predicting and preventing PGF remains challenging. Here, we propose that the seed, soil, and insect theories of aplastic anemia also apply to PGF; CD34+ cells are compared to seeds; the bone marrow microenvironment to soil; and virus infection, iron overload, and donor-specific anti-human leukocyte antigen antibodies to insects. From this perspective, we summarize the available information on the common risk factors of PGF, focusing on its potential mechanism. In addition, the safety and efficacy of new strategies for treating PGF are discussed to provide a foundation for preventing and treating this complex clinical problem.
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Affiliation(s)
- Yan Man
- Department of Hematology, National Key Clinical Specialty of Hematology, Yunnan Blood Disease Clinical Medical Center, Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Zhixiang Lu
- Department of Hematology, National Key Clinical Specialty of Hematology, Yunnan Blood Disease Clinical Medical Center, Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Xiangmei Yao
- Department of Hematology, National Key Clinical Specialty of Hematology, Yunnan Blood Disease Clinical Medical Center, Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China
| | - Yuemin Gong
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Tonghua Yang
- Department of Hematology, National Key Clinical Specialty of Hematology, Yunnan Blood Disease Clinical Medical Center, Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China,*Correspondence: Tonghua Yang, ; Yajie Wang,
| | - Yajie Wang
- Department of Hematology, National Key Clinical Specialty of Hematology, Yunnan Blood Disease Clinical Medical Center, Yunnan Blood Disease Hospital, The First People’s Hospital of Yunnan Province, Kunming, China,*Correspondence: Tonghua Yang, ; Yajie Wang,
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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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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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Chen J, Pang A, Zhao Y, Liu L, Ma R, Wei J, Chen X, He Y, Yang D, Zhang R, Zhai W, Ma Q, Jiang E, Han M, Zhou J, Feng S. Primary graft failure following allogeneic hematopoietic stem cell transplantation: risk factors, treatment and outcomes. Hematology 2022; 27:293-299. [PMID: 35192779 DOI: 10.1080/16078454.2022.2042064] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Graft failure (GF) is an intractable complication of transplantation, which can severely affect the efficacy of the graft; however, the characteristics, incidence, and risk factors of primary GF have not been well described. This study aimed to analyze the risk factors and outcomes of primary GF to swiftly identify high-risk patients for GF. METHODS We performed a case-control study with a case-control ratio of 1:4 with 869 patients who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) between January 2015 and December 2019 at our center. RESULTS Nineteen (2.19%) patients experienced primary poor graft function (PGF), while eleven (1.27%) patients developed primary graft rejection (GR). Univariate and multivariate logistic analyses identified two independent risk factors for primary PGF: splenomegaly [P = 0.030; odds ratio (OR), 3.486; 95% confidence interval (CI), 1.139 to 13.109], and donor type [non-matched sibling donor (non-MSD)] (P = 0.018; OR, 4.475; 95% CI, 1.289 to 15.537). However, only donor type (non-MSD) was statistically significant (P = 0.020; OR, 19.432; 95% CI, 1.595 to 236.691) for primary GR. The overall survival was significantly lower in the primary PGF (P = 0.001) and GR group (P = 0.000), respectively, compared to the control group. CONCLUSION GF can significantly affect the overall survival of patients who underwent allo-HSCT, despite its considerably low incidence. A human leukocyte antigen-matched sibling donor should be the first choice for patients undergoing allo-HSCT for the prevention of GF. Moreover, splenomegaly is an independent risk factor for PGF, and caution must be exercised while treating such patients.
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Affiliation(s)
- Juan Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Aiming Pang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Yuanqi Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Li Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Runzhi Ma
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Xin Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Yi He
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Donglin Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Rongli Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Weihua Zhai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Qiaoling Ma
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Jiaxi Zhou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
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12
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Ahn HJ, Byun JM, Kim I, Youk J, Koh Y, Shin DY, Hong J, Yoon SS. Eltrombopag for Post-Transplant Poor Graft Function in East Asian Patients. J Korean Med Sci 2022; 37:e48. [PMID: 35166084 PMCID: PMC8845101 DOI: 10.3346/jkms.2022.37.e48] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/10/2022] [Indexed: 11/20/2022] Open
Abstract
Poor graft function (PGF) is a serious, potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation. Eltrombopag has shown multilineage responses in patients with refractory severe aplastic anemia, supporting the idea that it may improve cytopenia in patients with PGF. This retrospective, single center analysis included 8 Korean patients receiving eltrombopag for PGF. Median interval between transplant and eltrombopag treatment was 73 days, and the median duration treatment was 3.5 weeks. With median maximum daily dose of 50 mg, the time to best response was 93 days. Median hemoglobin increased from 8.2 g/dL to 10.9 g/dL, platelet from 18.5 × 109/L to 54 × 109/L, and absolute neutrophil count from 1.25 × 109/L to 3.32 × 109/L. In conclusion, eltrombopag is a good option for PGF in Korean patients, even at a lower dose compared to western patients.
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Affiliation(s)
- Hyun Jin Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Inho Kim
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea.
| | - Jeonghwan Youk
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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13
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Cell-based therapeutics for the treatment of hematologic diseases inside the bone marrow. J Control Release 2021; 339:1-13. [PMID: 34536449 DOI: 10.1016/j.jconrel.2021.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/12/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022]
Abstract
Cell-based therapies could overcome the limitations of traditional drugs for the treatment of refractory diseases. Cell exchange between the bone marrow and blood is bidirectional. Several kinds of cells in the blood have the capability to enter the bone marrow by interacting with sinusoidal cells under specific physiological or pathological conditions. These cells are the potential living therapeutics or delivery vehicles to treat or prevent bone marrow-related hematologic diseases. In this review, we summarized the in vivo molecular mechanisms and kinetics of these cells in entering the bone marrow. The advances in the fabrication of living cell drugs and the strategies to design cell-based carriers into the bone marrow were discussed. The latest studies on how to use blood cells as living drugs or as drug carriers to improve therapeutic outcomes of hematologic diseases inside the bone marrow were highlighted.
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14
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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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15
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Capecchi M, Serpenti F, Giannotta J, Pettine L, Reda G, Martinelli I, Artoni A, Barcellini W, Fattizzo B. Off-Label Use of Thrombopoietin Receptor Agonists: Case Series and Review of the Literature. Front Oncol 2021; 11:680411. [PMID: 34650908 PMCID: PMC8505995 DOI: 10.3389/fonc.2021.680411] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 09/06/2021] [Indexed: 12/15/2022] Open
Abstract
Since their license in 2008, studies on thrombopoietin receptor agonists (TPO-RAs) are proceeding at a fast pace. Their favorable efficacy and safety profile makes them good candidates for the management of thrombocytopenia in different settings, even beyond their current indications. In the last 10 years, we faced patients with refractory thrombocytopenia that required treatment with off-label TPO-RA, despite the paucity of data in the literature and the possible risks, particularly that of thrombosis. We hereby report our 10-year real-life single-center experience of TPO-RA used off-label. Fourteen patients were divided into three groups according to the etiology of thrombocytopenia: myelodysplastic syndromes, post-transplantation, and lymphoproliferative diseases. Clinical features and results are reported within each group. Overall, TPO-RA proved effective in all these conditions achieving responses also in heavily pretreated patients. The overall response rate (ORR) was 100% in patients with thrombocytopenia after transplantation and in those with lymphoproliferative diseases and 75% in patients with myelodysplastic syndromes. The median duration of therapy was 285 days (range 93–1,513 days). Four patients (29%) discontinued treatment because of lack of response (n=2) or a sustained response (n=2). No grade 3–4 adverse events occurred, particularly no thrombosis. In our real-life experience, TPO-RAs were effective and safe and proved of value in the challenging management of patients with refractory thrombocytopenia associated with different conditions.
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Affiliation(s)
- Marco Capecchi
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Fabio Serpenti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Oncology and Onco-hematology, Università degli Studi di Milano, Milan, Italy
| | - Juri Giannotta
- Department of Oncology and Onco-hematology, Università degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Loredana Pettine
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Gianluigi Reda
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Ida Martinelli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Andrea Artoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Wilma Barcellini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
| | - Bruno Fattizzo
- Department of Oncology and Onco-hematology, Università degli Studi di Milano, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Hematology Unit, Milan, Italy
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16
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Berger M, Faraci M, Saglio F, Giardino S, Ernestina Vassallo E, Prete A, Fagioli F. CD34+ selected peripheral blood Stem Cell Boost (SCB) for Poor Graft Function (PGF) or mixed chimerism in pediatric patients, after hematopoietic stem cell transplantation: Results of a retrospective multicenter study. Pediatr Transplant 2021; 25:e13909. [PMID: 33141997 DOI: 10.1111/petr.13909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/22/2020] [Accepted: 10/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND PGF is historically associated with high morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). METHODS In this study, we report our multicenter experience on stem cell boost (SCB) for PGF, or incomplete donor engraftment, in 16 pediatric patients. Donors were HLA-matched siblings (n = 4), unrelated donors (n = 11), or haploidentical family members (n = 1). Ten patients had two-lineage cytopenia, 5 had one-lineage cytopenia, and 1 had poor immunological reconstitution together with a low percentage of donor cell engraftment. A median of 6.6x106 selected CD34+/Kg was infused after 194 days from allo-HSCT (48-607). RESULTS In 4 out of 5 patients, one-lineage cytopenia was resolved, while among the 10 patients with two-lineage cytopenia, 4 resolved both cytopenia, 5 resolved one-lineage, and one did not respond. All patients reverted their mixed chimera to full donor chimera. OS was 56%, transplant-related mortality (TRM) 32%, and RI 12%. The main causes of failure were related to infections with 4 out of 7 deaths caused by this. CONCLUSIONS SCB may rescue over 50% of patients with PGF after allo-HSCT. An earlier treatment may reduce the infectious complications and improve survival.
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Affiliation(s)
- Massimo Berger
- Pediatric Onco-Hematology, Regina Margherita Children Hospital, City of Health and Science, University of Turin, Turin, Italy
| | - Maura Faraci
- Hematopoietic Stem Cell transplantation Unit IRCSS, Istituto G. Gaslini, Genova, Italy
| | - Francesco Saglio
- Pediatric Onco-Hematology, Regina Margherita Children Hospital, City of Health and Science, University of Turin, Turin, Italy
| | - Stefano Giardino
- Hematopoietic Stem Cell transplantation Unit IRCSS, Istituto G. Gaslini, Genova, Italy
| | - Elena Ernestina Vassallo
- Pediatric Onco-Hematology, Regina Margherita Children Hospital, City of Health and Science, University of Turin, Turin, Italy
| | - Arcangelo Prete
- Paediatric Oncology and Hematology Unit 'Lalla Seràgnoli', Department of Paediatrics, Sant'Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Franca Fagioli
- Pediatric Onco-Hematology, Regina Margherita Children Hospital, City of Health and Science, University of Turin, Turin, Italy
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17
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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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18
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Uria-Oficialdegui ML, Alonso L, Benitez-Carabante MI, Renedo B, Oliveras M, Diaz-de-Heredia C. Use of eltrombopag for the treatment of poor graft function after hematopoietic stem cell transplantation in children. Pediatr Transplant 2021; 25:e14010. [PMID: 33742757 DOI: 10.1111/petr.14010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/18/2021] [Accepted: 03/02/2021] [Indexed: 01/09/2023]
Abstract
The main objective of this study was to determine whether Eltrombopag, a synthetic thrombopoietin receptor agonist, could improve peripheral blood counts in the three hematopoietic lineages and achieve transfusion independence in children with poor graft function (PGF) after allogenic hematopoietic stem cell transplantation (HSCT). Retrospective study of patients under 18 years who developed PGF post-HSCT in a large tertiary institution between January 2013 and March 2019. Out of 198 allogeneic HSCT, five patients met PGF criteria and were treated with eltrombopag. Median time from HSCT to eltrombopag initiation was 120 days. The median starting dose was 50 mg/day and the maximum dose reached was 75 mg/day. Median treatment duration was 9 months. Three patients achieved complete response and one partial response. The median dose among responders was 75 mg/day and the median time to response 8 weeks. Responses were sustained in three patients and two required a booster dose of CD34+ -selected cells from the original donor. None of the patients had to stop treatment due to adverse effects. The use of eltrombopag in children with PGF achieved responses in 80% of cases and demonstrated to be an effective and safe therapeutic option in pediatric patients with PGF.
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Affiliation(s)
- M Luz Uria-Oficialdegui
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Laura Alonso
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | | | - Berta Renedo
- Department of Pharmacy, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Maria Oliveras
- Department of Pharmacy, Hospital Universitari Vall d´Hebron, Barcelona, Spain
| | - Cristina Diaz-de-Heredia
- Department of Pediatric Hematology and Oncology, Hospital Universitari Vall d´Hebron, Barcelona, Spain
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19
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Abboud R, Slade M, Abboud C, DiPersio JF. Can planned CD34+ stem cell boost prevent poor graft function after peripheral blood haploidentical hematopoietic transplantation? Leuk Lymphoma 2020; 62:749-751. [PMID: 33135522 DOI: 10.1080/10428194.2020.1839657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Ramzi Abboud
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Slade
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Camille Abboud
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - John F DiPersio
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
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20
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Cuadrado MM, Szydlo RM, Watts M, Patel N, Renshaw H, Dorman J, Lowdell M, Ings S, Anthias C, Madrigal A, Mackinnon S, Kottaridis P, Carpenter B, Hough R, Morris E, Thomson K, Peggs KS, Chakraverty R. Predictors of recovery following allogeneic CD34+-selected cell infusion without conditioning to correct poor graft function. Haematologica 2020; 105:2639-2646. [PMID: 33131253 PMCID: PMC7604618 DOI: 10.3324/haematol.2019.226340] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 11/20/2019] [Indexed: 11/09/2022] Open
Abstract
Poor graft function is a serious complication following allogeneic hematopoietic stem cell transplantation. Infusion of CD34+-selected stem cells without pre-conditioning has been used to correct poor graft function, but predictors of recovery are unclear. We report the outcome of 62 consecutive patients who had primary or secondary poor graft function who underwent a CD34+-selected stem cell infusion from the same donor without further conditioning. Forty-seven of 62 patients showed hematological improvement and became permanently transfusion and growth factor-independent. In multivariate analysis, parameters significantly associated with recovery were shared CMV seronegative status for recipient/donor, the absence of active infection and matched recipient/donor sex. Recovery was similar in patients with mixed and full donor chimerism. Five -year overall survival was 74.4% (95% CI 59-89) in patients demonstrating complete recovery, 16.7% (95% CI 3-46) in patients with partial recovery and 22.2% (CI 95% 5-47) in patients with no response. In patients with count recovery, those with poor graft function in 1-2 lineages had superior 5-year overall survival (93.8%, 95% CI 82-99) than those with tri-lineage failure (53%, 95% CI 34-88). New strategies including cytokine or agonist support, or second transplant need to be investigated in patients who do not recover.
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Affiliation(s)
| | - Richard M. Szydlo
- Anthony Nolan Research Institute
- Department of Haematology, Imperial College London
| | - Mike Watts
- Wolfson Cellular Therapy Unit, University College Hospital London NHS Trust
| | - Nishil Patel
- Department of Haematology, Royal Free London NHS Trust
| | - Hanna Renshaw
- Department of Haematology, Royal Free London NHS Trust
| | - Jude Dorman
- Department of Haematology, University College Hospital NHS Trust
| | - Mark Lowdell
- Centre for Cell, Gene & Tissue Therapeutics, Royal Free London NHS Trust
| | - Stuart Ings
- Wolfson Cellular Therapy Unit, University College Hospital London NHS Trust
| | | | | | | | | | - Ben Carpenter
- Department of Haematology, University College Hospital NHS Trust
| | - Rachael Hough
- Department of Haematology, University College Hospital NHS Trust
| | - Emma Morris
- Department of Haematology, University College Hospital NHS Trust
| | - Kirsty Thomson
- Department of Haematology, University College Hospital NHS Trust
| | - Karl S. Peggs
- Department of Haematology, University College Hospital NHS Trust
- Department of Hematology, Cancer Institute, University College London, London, UK
| | - Ronjon Chakraverty
- Department of Haematology, University College Hospital NHS Trust
- Department of Hematology, Cancer Institute, University College London, London, UK
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21
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Hama A, Muramatsu H, Narita A, Nishikawa E, Kawashima N, Nishio N, Kojima S, Takahashi Y. Risk factors for secondary poor graft function after bone marrow transplantation in children with acquired aplastic anemia. Pediatr Transplant 2020; 24:e13828. [PMID: 32876388 DOI: 10.1111/petr.13828] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 06/30/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Abstract
In patients with acquired AA, PGF is a major cause of cytopenia after hematopoietic stem cell transplantation. An increased incidence of PGF, especially sPGF, has been noted after the introduction of the FLU/CY regimen in children with acquired AA. To clarify the risk factors for sPGF, the clinical data of 49 patients (median age, 11 years; range, 1-19 years) with AA who received allogeneic BMT at Nagoya University Hospital from 1997 to 2016 were analyzed. Out of the 49 patients, 7 developed sPGF, and the 5-year CI was 0.15 (95% CI, 0.04-0.25). Five received the FLU/CY regimen, and the 5-year CI of sPGF was significantly higher in patients who received the regimen (0.36; 95% CI, 0.12-0.62) than in those who were conditioned with the non-FLU/CY regimen (0.06; 95% CI, 0.01-0.17; P = .01). The multivariate analysis confirmed that the FLU/CY regimen (hazard ratio, 6.12; 95% CI, 1.16-32.4; P = .03) was a significant risk factor for sPGF. sPGF improved spontaneously without stem cell boost infusions in 5 patients, ranging from 460 to 3539 days after BMT. The 10-year CI of the spontaneous trilineage recovery was 0.83 (95% CI, 0.00-0.97), and all 7 patients are alive. The FLU/CY regimen was identified as a risk factor for the sPGF development in patients with AA. The establishment of the optimal conditioning regimens for children with AA is warranted.
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Affiliation(s)
- Asahito Hama
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Hematology and Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Hideki Muramatsu
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Narita
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eri Nishikawa
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nozomu Kawashima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuhiro Nishio
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Seiji Kojima
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
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22
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Aydin S, Dellacasa C, Manetta S, Giaccone L, Godio L, Iovino G, Bruno B, Busca A. Rescue treatment with eltrombopag in refractory cytopenias after allogeneic stem cell transplantation. Ther Adv Hematol 2020; 11:2040620720961910. [PMID: 33194161 PMCID: PMC7594218 DOI: 10.1177/2040620720961910] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Patients with post-transplant cytopenias due to poor graft function or
primary engraftment failure show poor prognosis with a high mortality rate
mainly because of graft versus host disease (GVHD),
infection and/or bleeding. Treatment options are scarce and a CD34+ stem
cell boost or a second bone marrow transplantation may be required to
restore adequate haematopoiesis. Methods: In the present study patients with primary engraftment failure
(n = 1) and refractory poor graft function
(n = 11) were treated with eltrombopag in a single
centre. The reason for eltrombopag treatment was trilineage cytopenia in six
patients, bilineage cytopenia in three patients and single lineage cytopenia
in three patients. Eltrombopag was initiated at a median of 214 (range:
120–877) days after haematopoietic stem cell transplantation (HCST) and
administered for a median time of 114 (range: 12 days to >490) days. In
8/12 patients eltrombopag was introduced at a dose of 75 mg/day and then
increased to 150 mg/day after 1 week; 1 patient was given 50 mg eltrombopag
per day, and 3 patients received 75 mg daily. Results: In 10/12 patients eltrombopag significantly enhanced blood count values and
patients became transfusion independent. Once stable haematological response
was obtained, treatment was tapered until final discontinuation in 9/10
responding patients. No grade 3 or 4 toxicities were observed. At time of
last follow up, 3/12 patients were dead, 2 due to disease relapse, 1 due to
GVHD and pneumonia. All patients except one maintained their complete
response and remain transfusion independent at a median of 858 (range:
429–1119) days. Conclusion: These preliminary data confirm that eltrombopag is able to rescue
multilineage haematopoiesis in patients with treatment-refractory cytopenias
after allogeneic HSCT.
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Affiliation(s)
- Semra Aydin
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, Ematologia, Corso Bramante 88, Turin, 10126, Italy
| | - Chiara Dellacasa
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, SSD Trapianto allogenico di cellule staminali, Turin, Italy
| | - Sara Manetta
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, SSD Trapianto allogenico di cellule staminali, Turin, Italy
| | - Luisa Giaccone
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, SSD Trapianto allogenico di cellule staminali, Turin, Italy
| | - Laura Godio
- A.O.U. Città della Salute e della Scienza, Anatomia Patologica, Turin, and University of Turin, Italy
| | - Giorgia Iovino
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, Ematologia, Turin, Italy
| | - Benedetto Bruno
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, SSD Trapianto allogenico di cellule staminali, Turin, Italy
| | - Alessandro Busca
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, SSD Trapianto allogenico di cellule staminali, Turin, Italy
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23
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The Successful Sequential Use of Plerixafor and Eltrombopag For Hematopoietic Cell Transplantation in a Child With High-risk Neuroblastoma. J Pediatr Hematol Oncol 2020; 42:e680-e682. [PMID: 31306338 DOI: 10.1097/mph.0000000000001551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
High-dose chemotherapy with autologous hematopoietic stem cell transplantation improves event-free survival in patients with high-risk neuroblastoma. However, in heavily pretreated patients, poor marrow function can be an obstacle in the successful proceeding of therapy. Priming with plerixafor plus filgrastim is an option for effective mobilization and collection of stem cells. In addition, thrombopoietin agonist eltrombopag can improve the outcome of posttransplantation thrombocytopenia and poor graft function in the posttransplant setting. We describe a case of a child with high-risk neuroblastoma, for whom plerixafor and eltrombopag were used as an effective and safe supportive therapy.
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24
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Chen J, Wang H, Zhou J, Feng S. Advances in the understanding of poor graft function following allogeneic hematopoietic stem-cell transplantation. Ther Adv Hematol 2020; 11:2040620720948743. [PMID: 32874483 PMCID: PMC7436797 DOI: 10.1177/2040620720948743] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/14/2020] [Indexed: 12/13/2022] Open
Abstract
Poor graft function (PGF) following allogeneic hematopoietic stem-cell transplantation (allo-HSCT) is a life-threatening complication and is characterized by bilineage or trilineage blood cell deficiency and hypoplastic marrow with full chimerism. With the rapid development of allo-HSCT, especially haploidentical-HSCT, PGF has become a growing concern. The most common risk factors illustrated by recent studies include low dose of infused CD34+ cells, donor-specific antibody, cytomegalovirus infection, graft versus host disease (GVHD), iron overload and splenomegaly, among others. Because of the poor prognosis of PGF, it is crucial to uncover the underlying mechanism, which remains elusive. Recent studies have suggested that the bone marrow microenvironment may play an important role in the pathogenesis of PGF. Deficiency and dysfunction of endothelial cells and mesenchymal stem cells, elevated reactive oxygen species (ROS) levels, and immune abnormalities are believed to contribute to PGF. In this review, we also discuss recent clinical trials that evaluate the safety and efficacy of new strategies in patients with PGF. CD34+-selected stem-cell boost (SCB) is effective with an acceptable incidence of GVHD, despite the need for a second donation. Alternative strategies including the applications of mesenchymal stem cells, N-acetyl-l-cysteine (NAC), and eltrombopag have shown favorable outcomes, but further large-scale studies are needed due to the small sample sizes of the recent clinical trials.
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Affiliation(s)
- Juan Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Department of Stem Cells and Regenerative Medicine, Peking Union Medical College, Tianjin, China
| | - Hongtao Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Department of Stem Cells and Regenerative Medicine, Peking Union Medical College, Tianjin, China
| | - Jiaxi Zhou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
- Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Department of Stem Cells and Regenerative Medicine, Peking Union Medical College, Tianjin, 300020, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 288 Nanjing Road, Heping District, Tianjin, 300020, China
- Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Department of Stem Cells and Regenerative Medicine, Peking Union Medical College, Tianjin, 300020, China
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25
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Kwon M, Bailén R, Díez-Martín JL. Evolution of the role of haploidentical stem cell transplantation: past, present, and future. Expert Rev Hematol 2020; 13:835-850. [PMID: 32749913 DOI: 10.1080/17474086.2020.1796621] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The accessibility to haplo-donors has led to an increase in the number of haplo-HSCT worldwide. A systematic search of the PubMed database between 2000 to present was performed. AREAS COVERED In this review, the authors discussed the most used approaches to perform haplo-HSCT and its results: T-cell depletion (TCD, including Perugia platform and its modifications) and T-cell repleted haplo (TCR, including the high-dose post-transplant cyclophosphamide strategy (Baltimore protocol) and the Beijing protocol). The improvements and modifications made to the different strategies have increased the indications of haplo-HSCT, including both malignant and nonmalignant disorders. Focusing on the Baltimore protocol, the authors review the results of the retrospective studies that have compared it to other donor transplants. The limitations of this strategy in terms of toxicity, graft complications, and GVHD are also discussed in detail. Finally, possible approaches to improve the outcomes of TCR haplo-HSCT are presented. EXPERT OPINION The recent advances in the field of haplo-HSCT have allowed a large number of patients with incurable diseases to benefit from this procedure despite not having a matched donor. With all available strategies, virtually no patient who needs an allogeneic transplant should be excluded by the absence of a donor.
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Affiliation(s)
- Mi Kwon
- Department of Hematology, Hospital General Universitario Gregorio Marañón , Madrid, Spain.,Departement of Translational Oncology, Institute of Health Research Gregorio Marañón , Madrid, Spain
| | - Rebeca Bailén
- Department of Hematology, Hospital General Universitario Gregorio Marañón , Madrid, Spain.,Departement of Translational Oncology, Institute of Health Research Gregorio Marañón , Madrid, Spain
| | - José Luis Díez-Martín
- Department of Hematology, Hospital General Universitario Gregorio Marañón , Madrid, Spain.,Departement of Translational Oncology, Institute of Health Research Gregorio Marañón , Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid , Madrid, Spain
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26
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Outcomes of allogeneic haematopoietic stem cell transplantation for patients with severe aplastic anaemia using the porcine antilymphocyte globulin-containing conditioning regimen. Ann Hematol 2020; 99:1863-1871. [PMID: 32556453 DOI: 10.1007/s00277-020-04111-5] [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] [Received: 10/11/2019] [Accepted: 06/01/2020] [Indexed: 10/24/2022]
Abstract
Antithymocyte globulin (ATG) is widely used for allogeneic haematopoietic stem cell transplantation (allo-HSCT) in severe aplastic anaemia (SAA). Only rabbit-ATG (r-ATG) and porcine-antilymphocyte globulin (p-ALG) are available in China, but the p-ALG-containing conditioning regimen for allo-HSCT in SAA has seldom been reported. In this study, we retrospectively evaluated the outcomes of 41 SAA patients receiving allo-HSCT with a p-ALG-containing conditioning regimen in our transplantation centre. All patients engrafted, and no death during conditioning was observed. The actuarial 3-year overall survival (OS) rates were 95.1 ± 3.4%. The actuarial 3-year disease-free survival (DFS) rates were 85.0 ± 5.7%. Acute graft-versus-host disease (aGVHD) predicted inferior OS (p < 0.05). The interval from diagnosis to transplantation for more than 100 days predicted an inferior DFS rate (p < 0.05) and a higher graft rejection/poor graft function (GR/PGF) rate (p < 0.01). In conclusion, the p-ALG-containing regimen showed satisfactory effects and safety in allo-HSCT for SAA patients. P-ALG could be a potential alternative preparation for r-ATG in SAA allo-HSCT.
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27
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Romiplostim in patients undergoing hematopoietic stem cell transplantation: results of a phase 1/2 multicenter trial. Blood 2020; 135:227-229. [PMID: 31805185 DOI: 10.1182/blood.2019000358] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Persisting severe thrombocytopenia more than 6 weeks after allogeneic stem cell transplantation is a common problem associated with adverse prognosis. Peffault de Latour et al report the results of the first trial of the thrombopoietin mimetic, romiplostim, in this setting, demonstrating recovery of platelet counts in 18 of 24 patients.
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28
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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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29
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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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30
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Abstract
Eltrombopag (ELT) is a thrombopoietin receptor activator that has shown efficacy in chronic immune thrombocytopenia. We report the outcome of ELT therapy in 4 children who were treated for rare hematologic disorders, including Pearson syndrome, DiGeorge syndrome, posttransplant allogeneic poor graft function (PGF), and Wiskott-Aldrich syndrome. The ELT tolerance in the analyzed group was good, with the exception of the child with Pearson syndrome, who experienced an exacerbation of cataracts and had to discontinue treatment. Thromboembolic events were observed in one child, who continued ELT therapy despite achieving normalized platelet counts. Independence from PLT transfusions was observed at the 4-week timepoint of therapy in patients with DiGeorge syndrome and PGF who responded to ELT. Discontinuation of therapy was successful in one child, who sustained the normal CBC values afterward. In 2 patients, an increase in neutrophil counts was observed during ELT therapy without additional intervention, and a positive correlation between neutrophil and platelet values during ELT therapy was observed in the child with PGF. ELT is effective in rare pediatric disorders, but response patterns are determined by the underlying disease. ELT shows promising results in patients, but constitutional hematopoiesis defects reduce the chances of a response.
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31
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Vogel JU, Schmidt S, Schmidt D, Rothweiler F, Koch B, Baer P, Rabenau H, Michel D, Stamminger T, Michaelis M, Cinatl J. The Thrombopoietin Receptor Agonist Eltrombopag Inhibits Human Cytomegalovirus Replication Via Iron Chelation. Cells 2019; 9:cells9010031. [PMID: 31861948 PMCID: PMC7017049 DOI: 10.3390/cells9010031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/12/2019] [Accepted: 12/18/2019] [Indexed: 02/07/2023] Open
Abstract
The thrombopoietin receptor agonist eltrombopag was successfully used against human cytomegalovirus (HCMV)-associated thrombocytopenia refractory to immunomodulatory and antiviral drugs. These effects were ascribed to the effects of eltrombopag on megakaryocytes. Here, we tested whether eltrombopag may also exert direct antiviral effects. Therapeutic eltrombopag concentrations inhibited HCMV replication in human fibroblasts and adult mesenchymal stem cells infected with six different virus strains and drug-resistant clinical isolates. Eltrombopag also synergistically increased the anti-HCMV activity of the mainstay drug ganciclovir. Time-of-addition experiments suggested that eltrombopag interfered with HCMV replication after virus entry. Eltrombopag was effective in thrombopoietin receptor-negative cells, and the addition of Fe3+ prevented the anti-HCMV effects, indicating that it inhibits HCMV replication via iron chelation. This may be of particular interest for the treatment of cytopenias after hematopoietic stem cell transplantation, as HCMV reactivation is a major reason for transplantation failure. Since therapeutic eltrombopag concentrations are effective against drug-resistant viruses, and synergistically increase the effects of ganciclovir, eltrombopag is also a drug-repurposing candidate for the treatment of therapy-refractory HCMV disease.
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Affiliation(s)
- Jens-Uwe Vogel
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Sophie Schmidt
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Daniel Schmidt
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Florian Rothweiler
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Benjamin Koch
- Medizinische Klinik III, Nephrologie, Klinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (B.K.); (P.B.)
| | - Patrick Baer
- Medizinische Klinik III, Nephrologie, Klinikum der Goethe-Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany; (B.K.); (P.B.)
| | - Holger Rabenau
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
| | - Detlef Michel
- Institut für Virologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (D.M.); (T.S.)
| | - Thomas Stamminger
- Institut für Virologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany; (D.M.); (T.S.)
| | - Martin Michaelis
- Industry Biotechnology Centre and School of Biosciences, University of Kent, Canterbury CT2 7NJ, UK
- Correspondence: (J.C.); (M.M.); Tel.: +49-69-678665-72 (J.C.); +44-1227-82-7804 (M.M.)
| | - Jindrich Cinatl
- Institut für Medizinische Virologie, Universitätsklinikum, Goethe-Universität, Paul Ehrlich-Str. 40, 60596 Frankfurt am Main, Germany; (J.-U.V.); (S.S.); (D.S.); (F.R.); (H.R.)
- Correspondence: (J.C.); (M.M.); Tel.: +49-69-678665-72 (J.C.); +44-1227-82-7804 (M.M.)
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32
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Chang YJ, Zhao XY, Huang XJ. Granulocyte Colony-Stimulating Factor-Primed Unmanipulated Haploidentical Blood and Marrow Transplantation. Front Immunol 2019; 10:2516. [PMID: 31749802 PMCID: PMC6842971 DOI: 10.3389/fimmu.2019.02516] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 10/09/2019] [Indexed: 12/25/2022] Open
Abstract
Granulocyte colony-stimulating factor (G-CSF), a growth factor for neutrophils, has been successfully used for stem cell mobilization and T cell immune tolerance induction. The establishment of G-CSF-primed unmanipulated haploidentical blood and marrow transplantation (The Beijing Protocol) has achieved outcomes for the treatment of acute leukemia, myelodysplastic syndrome, and severe aplastic anemia with haploidentical allografts comparable to those of human leukocyte antigen (HLA)-matched sibling donor transplantation. Currently, G-CSF-mobilized bone marrow and/or peripheral blood stem cell sources have been widely used in unmanipulated haploidentical transplant settings. In this review, we summarize the roles of G-CSF in inducing T cell immune tolerance. We discuss the recent advances in the Beijing Protocol, mainly focusing on strategies that have been used to improve transplant outcomes in cases of poor graft function, virus infections, and relapse. The application of G-CSF-primed allografts in other haploidentical modalities is also discussed.
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Affiliation(s)
- Ying-Jun Chang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Xiang-Yu Zhao
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China
| | - Xiao-Jun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Peking University Institute of Hematology, Peking University People's Hospital, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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33
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Eltrombopag maintains human hematopoietic stem and progenitor cells under inflammatory conditions mediated by IFN-γ. Blood 2019; 133:2043-2055. [PMID: 30803992 DOI: 10.1182/blood-2018-11-884486] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/12/2019] [Indexed: 12/15/2022] Open
Abstract
The proinflammatory cytokine interferon-γ (IFN-γ) has been implicated in human hematopoietic stem and progenitor cell (HSPC) depletion in immune-mediated bone marrow failure syndromes. We show that IFN-γ specifically prevents full engagement of thrombopoietin (TPO), a primary positive regulator of HSPC survival, to its receptor (c-MPL) via steric occlusion of the low-affinity binding site, contributing to perturbation of TPO-induced signaling pathways and decreased survival of human HSPCs. Eltrombopag, a synthetic small molecule mimetic of TPO that interacts with c-MPL at a position distinct from the extracellular binding site of TPO, bypasses this inhibition, providing an explanation for its clinical activity in bone marrow failure, despite already elevated endogenous TPO levels. Thus, IFN-γ-mediated perturbation of TPO:c-MPL complex formation and the resulting inhibition of a critical pathway of growth factor cell signaling may represent a general mechanism by which IFN-γ impairs the function of human HSPCs. This understanding could have broad therapeutic implications for various disorders of chronic inflammation.
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34
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Eltrombopag for post-transplant cytopenias due to poor graft function. Bone Marrow Transplant 2019; 54:1346-1353. [PMID: 30679824 DOI: 10.1038/s41409-019-0442-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 01/06/2023]
Abstract
Persistent cytopenia due to poor graft function (PoGF) is a relatively common complication which may affect up to 20% of patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT). Treatment options for PoGF remain limited, and reinfusion of additional HSC is often the only way to rescue hematopoiesis. Here we describe a retrospective single-center experience with the thrombopoietin-mimetic agent eltrombopag for the treatment of PoGF. Thirteen patients have received eltrombopag for either PoGF (n = 12) or primary graft failure (n = 1). In the 12 PoGF patients eltrombopag was started at the median time of 79 days after HSCT, due to persistent thrombocytopenia, with concomitant anemia and neutropenia in 7 and 3 patients, respectively. The treatment was started at the dose of 50 mg per day, and eventually increased up to 150 mg in case of lack of response. Hematological response was seen in 7 patients, with 6 complete responses. Hematological responses were seen both in patients with evidence of immune-mediated pathophysiology, and with possible infectious/iatrogenic causes. In responding patients, eltrombopag was discontinued in 6/7 patients without further relapse. These results suggest that eltrombopag is safe and possibly effective in the setting of the treatment of PoGF, and pave the way for future prospective studies.
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Eltrombopag is an effective and safe therapy for refractory thrombocytopenia after haploidentical hematopoietic stem cell transplantation. Bone Marrow Transplant 2019; 54:1310-1318. [PMID: 30664724 DOI: 10.1038/s41409-019-0435-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/20/2018] [Accepted: 12/23/2018] [Indexed: 12/13/2022]
Abstract
Refractory thrombocytopenia is a frequent and severe complication after haploidentical allogeneic hematopoietic stem cell transplantation (haplo-HSCT) and lacks effective treatment strategies. Eltrombopag has shown promising results in several thrombocytopenia disorders. We report 38 patients treated with eltrombopag for refractory thrombocytopenia after haplo-HSCT. Eight patients had delayed platelet engraftment, 15 patients had secondary failure of platelet recovery, and 15 patients had poor graft function (PGF). Eltrombopag was initiated at 25 or 50 mg daily, and the dosage was adjusted to a maximum of 50-100 mg daily to maintain platelet between 50 × 109/L and 100 × 109/L. The cumulative incidence of platelet recovery to transfusion independence was 63.2% and to ≥50 × 109/L without transfusion support was 52.3%. Furthermore, neutrophil counts and hemoglobin were also increased in the nine responders with PGF. Nineteen (79.2%) of the 24 responders were able to taper off eltrombopag, and the remaining 5 patients were able to begin a taper. The median duration of treatment was 64 (range 14-195) days. The presence of megakaryocyte before initiation was the only independent factor influencing the efficacy of eltrombopag (P = 0.044). Eltrombopag was well tolerated in all patients. In summary, eltrombopag was a safe and effective therapy for refractory thrombocytopenia after haplo-HSCT.
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