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Semple JW, Schifferli A, Cooper N, Saad H, Mytych DT, Chea LS, Newland A. Immune thrombocytopenia: Pathophysiology and impacts of Romiplostim treatment. Blood Rev 2024:101222. [PMID: 38942688 DOI: 10.1016/j.blre.2024.101222] [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: 04/21/2024] [Revised: 06/04/2024] [Accepted: 06/18/2024] [Indexed: 06/30/2024]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune bleeding disease caused by immune-mediated platelet destruction and decreased platelet production. ITP is characterized by an isolated thrombocytopenia (<100 × 109/L) and increased risk of bleeding. The disease has a complex pathophysiology wherein immune tolerance breakdown leads to platelet and megakaryocyte destruction. Therapeutics such as corticosteroids, intravenous immunoglobulins (IVIg), rituximab, and thrombopoietin receptor agonists (TPO-RAs) aim to increase platelet counts to prevent hemorrhage and increase quality of life. TPO-RAs act via stimulation of TPO receptors on megakaryocytes to directly stimulate platelet production. Romiplostim is a TPO-RA that has become a mainstay in the treatment of ITP. Treatment significantly increases megakaryocyte maturation and growth leading to improved platelet production and it has recently been shown to have additional immunomodulatory effects in treated patients. This review will highlight the complex pathophysiology of ITP and discuss the usage of Romiplostim in ITP and its ability to potentially immunomodulate autoimmunity.
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Affiliation(s)
- John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden, Clinical Immunology and Transfusion Medicine, Office of Medical Services, Region Skåne, Lund, Sweden; Departments of Pharmacology, Medicine and Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, USA.
| | - Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | | | | | | | | | - Adrian Newland
- Barts and The London School of Medicine and Dentistry, London, UK.
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2
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Yassin MA, Al-Rasheed M, Al-Khaboori M, Marashi M, Osman H, Wali Y, Al Kindi S, Alsayegh F, Provan D. Thrombopoietin-receptor agonists for adult patients with immune thrombocytopenia: a narrative review and an approach for managing patients fasting intermittently. Front Cardiovasc Med 2023; 10:1260487. [PMID: 38162126 PMCID: PMC10755910 DOI: 10.3389/fcvm.2023.1260487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Thrombopoietin-receptor agonist (TPO-RAs) currently represent the state of art for treating immune thrombocytopenia. Their different molecular structures contribute to the difference in their pharmacodynamics and pharmacokinetics. This narrative review aims to provide an overview of the current TPO-RAs approved for primary immune thrombocytopenia (romiplostim, eltrombopag, avatrombopag) and the effect of intermittent fasting in adult patients receiving TPO-RAs. Areas covered Literature was searched with no limits on date or language, using various combinations of keywords. Data on the pharmacokinetics, pharmacodynamics, efficacy, and safety of TPO-RAs and the effect of intermittent fasting were summarized. Expert opinion Switching between TPO-RAs is a useful strategy to tackle some associated limitations. Romiplostim and avatrombopag have an advantage over eltrombopag as they do not require any dietary restrictions. In cases where romiplostim and avatrombopag are unavailable, patients should be educated on the appropriate administration, possible interactions, and dietary restrictions before initiating eltrombopag.
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Affiliation(s)
- Mohamed A. Yassin
- National Center for Cancer Care and Research, Hematology Section, Hamad Medical Corporation, Doha, Qatar
| | - Mona Al-Rasheed
- Hematology Unit, Department of Medicine, Al-Adan Hospital, Hadiya, Kuwait
| | | | - Mahmoud Marashi
- Dubai Academic Health Corporation, Dubai, United Arab Emirates
| | - Hani Osman
- Hematology-Oncology Department, Tawam Hospital, Abu Dhabi, United Arab Emirates
| | - Yasser Wali
- Department of Child Health, Sultan Qaboos University, Muscat, Oman
| | - Salam Al Kindi
- Department of Hematology, Sultan Qaboos University, Muscat, Oman
| | - Faisal Alsayegh
- Faculty of Medicine, Department of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, United Kingdom
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3
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Merjaneh N, Young J, Mangoli A, Olsen M, Setty B, Lane A, Nagarajan R, Pressey JG, Turpin B. Chemotherapy-induced thrombocytopenia in Ewing sarcoma: Implications and potential for romiplostim supportive care. Pediatr Blood Cancer 2022; 69:e29548. [PMID: 34962714 DOI: 10.1002/pbc.29548] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/24/2021] [Accepted: 12/08/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Maintaining dose-dense, interval-compressed chemotherapy improves survival in patients with Ewing sarcoma but is limited by myelosuppression. Romiplostim is a thrombopoietin receptor agonist that may be useful in the treatment of chemotherapy-induced thrombocytopenia (CIT). METHODS Patients aged between 3 and 33 years with Ewing sarcoma from 2010 to 2020 were reviewed. CIT was defined as a failure to achieve 75,000 platelets per microliter by day 21 after the start of any chemotherapy cycle. Fisher's exact test was used for univariate analysis and Pearson's correlation coefficient was used for the association between continuous variables. RESULTS Twenty-seven out of 42 patients (64%) developed isolated CIT, delaying one to four chemotherapy cycles per patient. CIT occurred during consolidation therapy in 24/27(88.9%) and with ifosfamide/etoposide cycles in 24/27 (88.9%). Univariate analysis failed to identify risk factors for CIT. The use of radiation approached significance (p-value = .056). Ten patients received romiplostim. The median starting dose was 3 μg/kg (range 1-5). Doses were escalated weekly by 1-2 to 4-10 μg/kg and continued throughout chemotherapy. A higher romiplostim dose was associated with a higher change in average platelet counts from baseline, r = .73 (p = .04). No romiplostim-related adverse events were identified aside from mild headache. CONCLUSIONS CIT is the primary reason for the inability to maintain treatment intensity in Ewing sarcoma. The concurrent use of romiplostim with chemotherapy was safe and feasible, and efficacy was associated with higher romiplostim doses.
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Affiliation(s)
- Nawal Merjaneh
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Jennifer Young
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Avani Mangoli
- Division of Pediatric Hematology-Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Mallery Olsen
- Division of Pediatric Hematology, Oncology and BMT, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Bhuvana Setty
- Division of Pediatric Hematology, Oncology and BMT, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Adam Lane
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Rajaram Nagarajan
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Joseph G Pressey
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Brian Turpin
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
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Sheng XY, Liu ZY, Zhao J, Song L, Zhao WM, Zhao X, Cui YM. Safety, tolerance, pharmacokinetic and pharmacodynamic properties of thrombopoietin mimetic peptide for injection in Chinese healthy volunteers: a randomized, placebo-controlled, double-blind study. Platelets 2022; 33:1185-1191. [PMID: 35549802 DOI: 10.1080/09537104.2022.2073344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The thrombopoietin mimetic peptide for injection is a second-generation thrombopoietin receptor agonist (TPO-RA) used in the treatment of patients with immune thrombocytopenia. The aim of the present study was to assess the safety, tolerance, pharmacokinetic and pharmacodynamic properties of thrombopoietin mimetic peptide for injection in Chinese healthy volunteers. A randomized, placebo-controlled, double-blind, dose-escalation study was conducted in healthy Chinese subjects aged 18-50 years. Thirty subjects received single subcutaneous injection of 0.3 μg/kg, 1.0 μg/kg, 2.0 μg/kg thrombopoietin mimetic peptide or placebo. Thrombopoietin mimetic peptide was safe and well tolerated at doses of 0.3-2.0 μg/kg. There was no significant change in mean platelet count (PLT) from baseline at the 0.3 μg/kg or placebo groups. The mean PLT of subjects in the 1.0 μg/kg and 2.0 μg/kg groups peaked at day 12 (± 1), began to decline around day 17, and returned to the baseline level at day 28 (± 1). Platelet aggregation rates of the three dose groups showed no significant change before and after administration. Serum concentrations of thrombopoietin mimetic peptide in all subjects were below the quantization limit. This was the first study to demonstrate that subcutaneous injection of thrombopoietin mimetic peptide at doses of 0.3-2.0 μg/kg was safe and well tolerated in Chinese healthy subjects. As a second-generation TPO-RA, thrombopoietin mimetic peptide is effective at improving PLT after single subcutaneous injection at dose of ≥1 μg/kg.Plain language summaryWhat is the context?● Immune thrombocytopenia (ITP) is a rare, serious autoimmune disorder characterized by low platelet count (PLT) without an alternate cause. The treatment goal of ITP is to increase the platelet count to a safe level that can stop active bleeding and reduce the risks of future bleeding.● Thrombopoietin receptor agonists (TPO-RAs, e.g. eltrombopag, avatrombopag, hetrombopag, and romiplostim) have shown high response rates in stimulating platelet production and reducing the risk of bleeding. TPO-RAs provide ITP patients with well-tolerated, long-term treatment choices.What is new?● The thrombopoietin mimetic peptide for injection is a new TPO-RAs developed by Shandong Quangang Pharmaceutical Co., Ltd. (China).● This study showed that thrombopoietin mimetic peptide is effective at improving PLT after a single subcutaneous injection.● The thrombopoietin mimetic peptide is safe and well-tolerated in Chinese healthy subjects.What is the impact?● This study provides evidence for the further development potential of the thrombopoietin mimetic peptide.
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Affiliation(s)
- Xiao-Yan Sheng
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhi-Yan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Jing Zhao
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Lei Song
- Research and Development Center, Shandong Quangang Pharmaceutical Co. Ltd., Jinan, China
| | - Wen-Ming Zhao
- Research and Development Center, Shandong Quangang Pharmaceutical Co. Ltd., Jinan, China
| | - Xia Zhao
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yi-Min Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,Institute of Clinical Pharmacology, Peking University, Beijing, China
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Mareddy C, Kalra M, Sachdeva A. Generic romiplostim for children with persistent or chronic immune thrombocytopenia: Experience from a tertiary care centre in North India. Br J Haematol 2022; 197:618-626. [PMID: 35467751 DOI: 10.1111/bjh.18126] [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: 12/01/2021] [Revised: 02/11/2022] [Accepted: 02/21/2022] [Indexed: 11/29/2022]
Abstract
Thrombopoietin receptor agonists are important therapeutic option in children with immune thrombocytopenia (ITP). We evaluated the response, efficacy, safety of a generic form of romiplostim manufactured in India for treating children with persistent/chronic ITP at our centre. Study of 45 children with persistent/chronic ITP was conducted of which 5 discontinued and 40 were included between 2019-2020. Patients received romiplostim for 20 weeks, at a dose of 5 mcg/kg/week. Platelet count at week 1, 3, 20 and 26 was assessed. Predesigned algorithm was used for dose adjustment. After 20 weeks, patients who had platelet count of 50 × 109/L or above were tapered off medication and monitored till 26 weeks. Median platelet count at enrolment was 11 x 109/L (IQR 23 X 109/L). 13/40 children had received >/= three lines of prior ITP therapy. Platelet response (platelet count rise to more than 50×109/L without rescue medications) observed in 26 (65%) patients at week 20. Rescue medication was used in 12/40 children. Sustained platelet response after tapering and stopping romiplostim observed in 22/40 children. No adverse events were considered serious or led to discontinuation of treatment. Our data demonstrated generic romiplostim is well tolerated and efficacious in children with persistent/chronic ITP.
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Affiliation(s)
- Chandana Mareddy
- Paediatric Haematology, Oncology and BMT Unit, Sir Ganga Ram Hospital, India
| | - Manas Kalra
- Paediatric Haematology, Oncology and BMT Unit, Sir Ganga Ram Hospital, India
| | - Anupam Sachdeva
- Paediatric Haematology, Oncology and BMT Unit, Department of Paediatrics, Sir Ganga Ram Hospital, India
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A single-arm, long-term efficacy and safety study of subcutaneous romiplostim in children with immune thrombocytopenia. Blood Adv 2022; 7:396-405. [PMID: 35413092 PMCID: PMC9979726 DOI: 10.1182/bloodadvances.2021006014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 02/24/2022] [Accepted: 03/27/2022] [Indexed: 02/02/2023] Open
Abstract
Romiplostim is a thrombopoietin (TPO) receptor agonist approved for children and adults with immune thrombocytopenia (ITP) for ≥6 months, recommended as second-line treatment. This phase 3b, single-arm, multicenter study investigated long-term efficacy and safety of romiplostim in children ≥1 to <18 years old with ≥6 months' ITP duration and platelet counts ≤30 × 109/L. Children received weekly subcutaneous romiplostim (1 μg/kg titrated to 10 μg/kg) to maintain platelets within 50 to 200 × 109/L. A subset underwent bone marrow examinations. The primary end point was percentage of time with platelet response during the first 6 months' treatment (counts ≥50 × 109/L without rescue medication within the preceding 4 weeks). Overall, 203 patients (median age, 10.0 years) received ≥1 dose of romiplostim, median treatment duration was ∼3 years, and median average weekly dose was 6.9 μg/kg. Ninety-five (46.8%) discontinued (lack of efficacy, n = 43 [21.2%]). Platelet responses were achieved a median (interquartile range) of 50.0% (16.7%-83.3%) of the time during the first 6 months, increasing to 78.2% (26.7%-90.4%) during the overall 36-month treatment period. Eleven patients (5.4%) achieved sustained responses (consecutive counts ≥50 × 109/L without ITP medications for ≥24 weeks). Treatment-related adverse events (AEs) occurred in 56 patients (27.6%), with 8 (3.9%) experiencing serious treatment-related AEs; all of these led to discontinuation, including 4 cases of neutralizing antibodies (romiplostim, n = 3; TPO, n = 1). Bleeding occurred in 141 patients (69.5%), decreasing over time; grade ≥3 bleeding events occurred in 20 (9.9%). At year 2, eight of 63 evaluable patients (12.7%) had grade 2 reticulin. Long-term romiplostim resulted in sustained on-treatment platelet responses with an overall safety profile consistent with previous studies. This trial was registered at www.clinicaltrials.gov as #NCT02279173.
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de Paula JI, Lopes-Torres EJ, Jacobs-Lorena M, Paes MC, Cha SJ. The Screen of a Phage Display Library Identifies a Peptide That Binds to the Surface of Trypanosoma cruzi Trypomastigotes and Impairs Their Infection of Mammalian Cells. Front Microbiol 2022; 13:864788. [PMID: 35359712 PMCID: PMC8960960 DOI: 10.3389/fmicb.2022.864788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/15/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundChagas is a neglected tropical disease caused by the protozoan parasite Trypanosoma cruzi. On the order of seven million people are infected worldwide and current therapies are limited, highlighting the urgent need for new interventions. T. cruzi trypomastigotes can infect a variety of mammalian cells, recognition and adhesion to the host cell being critical for parasite entry. This study focuses on trypomastigote surface ligands involved in cell invasion.MethodsThree selection rounds of a phage peptide display library for isolation of phages that bind to trypomastigotes, resulted in the identification of the N3 dodecapeptide. N3 peptide binding to T. cruzi developmental forms (trypomastigotes, amastigotes and epimastigotes) was evaluated by flow cytometry and immunofluorescence assays. Parasite invasion of Vero cells was assessed by flow cytometry and immunofluorescence assays.ResultsPhage display screening identified the N3 peptide that binds preferentially to the surface of the trypomastigote and amastigote infective forms as opposed to non-infective epimastigotes. Importantly, the N3 peptide, but not a control scrambled peptide, inhibits trypomastigote invasion of Vero cells by 50%.ConclusionThe N3 peptide specifically binds to T. cruzi, and by doing so, inhibits Vero cell infection. Follow-up studies will identify the molecule on the parasite surface to which the N3 peptide binds. This putative T. cruzi ligand may advance chemotherapy design and vaccine development.
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Affiliation(s)
- Jéssica I. de Paula
- Laboratório de Interação Tripanossomatídeos e Vetores – Departamento de Bioquímica, IBRAG – UERJ, Rio de Janeiro, Brazil
| | - Eduardo J. Lopes-Torres
- Laboratório de Helmintologia Romero Lascasas Porto, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo Jacobs-Lorena
- Johns Hopkins Bloomberg School of Public Health, Department of Molecular Microbiology and Immunology and Malaria Research Institute, Baltimore, MD, United States
| | - Marcia Cristina Paes
- Laboratório de Interação Tripanossomatídeos e Vetores – Departamento de Bioquímica, IBRAG – UERJ, Rio de Janeiro, Brazil
- Instituto Nacional de Ciência e Tecnologia - Entomologia Molecular (INCT-EM), Rio de Janeiro, Brazil
- Marcia Cristina Paes,
| | - Sung-Jae Cha
- Johns Hopkins Bloomberg School of Public Health, Department of Molecular Microbiology and Immunology and Malaria Research Institute, Baltimore, MD, United States
- *Correspondence: Sung-Jae Cha,
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Assessment of romiplostim immunogenicity in pediatric patients in clinical trials and in a global postmarketing registry. Blood Adv 2021; 5:4969-4979. [PMID: 34638135 PMCID: PMC9153015 DOI: 10.1182/bloodadvances.2021005105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/16/2021] [Indexed: 11/20/2022] Open
Abstract
Development of first-generation thrombopoietins (TPOs) was halted due to antibodies that neutralized endogenous TPO, causing protracted thrombocytopenia in some patients. The second-generation TPO receptor agonist romiplostim, having no homology to TPO, was developed to circumvent potential immunogenicity. We examined the development of binding and neutralizing antibodies to romiplostim and TPO among pediatric patients with primary immune thrombocytopenia (ITP) in 5 clinical trials and a global postmarketing registry. In the trials, 25 of 280 (8.9%) patients developed anti-romiplostim binding antibodies. The first positive result was detected 67 weeks (median) after romiplostim treatment was initiated. The median romiplostim dose was 8 µg/kg, and the median platelet count was 87 × 109/L. Most patients who developed anti-romiplostim binding antibodies (18 of 25 [72%]) had ≥90% of platelet assessments showing a response. Anti-romiplostim neutralizing antibodies developed in 8 of 280 (2.9%) patients. The development of anti-romiplostim neutralizing antibodies was unrelated to the romiplostim dose, and most patients who developed the antibodies (7 of 8 [88%]) had platelet response. Nine of 279 (3.2%) patients developed anti-TPO binding antibodies, and 1 (0.4%) developed transient anti-TPO neutralizing antibodies. In 8 patients who developed anti-romiplostim neutralizing antibodies, no TPO cross-reactivity was observed. In the postmarketing registry, 3 of 19 (15.8%) patients developed anti-romiplostim binding antibodies; 1 (5.3%) patient developed anti-romiplostim neutralizing antibodies. These results suggest that immunogenicity to romiplostim occurs infrequently in pediatric patients with ITP and is generally not associated with loss of platelet response or other negative clinical sequelae.
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Grainger JD, Kühne T, Hippenmeyer J, Cooper N. Romiplostim in children with newly diagnosed or persistent primary immune thrombocytopenia. Ann Hematol 2021; 100:2143-2154. [PMID: 34308495 PMCID: PMC8310729 DOI: 10.1007/s00277-021-04590-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/28/2021] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a disease of heterogenous origin characterized by low platelet counts and an increased bleeding tendency. Three disease phases have been described: newly diagnosed (≤ 3 months after diagnosis), persistent (> 3-12 months after diagnosis), and chronic (> 12 months after diagnosis). The majority of children with ITP have short-lived disease and will not need treatment. For children with newly diagnosed ITP, who have increased bleeding symptoms, short courses of steroids are recommended. In children who do not respond to first-line treatment or who become steroid dependent, thrombopoietin receptor agonists (TPO-RAs) are recommended because of their efficacy and safety profiles. In this narrative review, we evaluate the available evidence on the use of the TPO-RA romiplostim to treat children with newly diagnosed or persistent ITP and identify data from five clinical trials, five real-world studies, and a case report. While the data are more limited for children with newly diagnosed ITP than for persistent ITP, the collective body of evidence suggests that romiplostim is efficacious in increasing platelet counts in children with newly diagnosed or persistent ITP and may result in long-lasting treatment-free responses in some patients. Furthermore, romiplostim was found to be well tolerated in the identified studies. Collectively, the data suggest that earlier treatment with romiplostim may help children to avoid the side effects associated with corticosteroid use and reduce the need for subsequent treatment.
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Affiliation(s)
- John D Grainger
- Department of Haematology, University of Manchester, Royal Manchester Children's Hospital, Manchester, UK.
| | - Thomas Kühne
- Oncology/Hematology, University Children's Hospital Basel, Basel, Switzerland
| | | | - Nichola Cooper
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
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Chen F, McDonald V, Newland A. Experts' review: the emerging roles of romiplostim in immune thrombocytopenia (ITP). Expert Opin Biol Ther 2021; 21:1383-1393. [PMID: 34313512 DOI: 10.1080/14712598.2021.1960979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The management of ITP has in recent years been transformed from reliance on immunosuppressants and splenectomy to targeted therapy with thrombopoietin receptor agonists (TPO-RA) that directly stimulate platelet production in the bone marrow. This has reduced the long-term infective complications and toxicities associated with the use of potent immunosuppressants and splenectomy. The welltolerated romiplostim, itself a novel drug construct called peptibody, has established itself, alongside other TPO-RA as the preferred 2nd line therapy in major international guidelines on treatment of ITP. AREAS COVERED This review summarizes the data from early licensing trials of romiplostim and discusses the real-world experience to date, the unexpected emerging data on treatment-free long-term remission achieved using TPO-RA, and the case for its early introduction in the therapeutic pathway. The emerging risk of thrombosis is also discussed. EXPERT OPINION The use of romiplostim and other TPO-RA will be increasingly brought forward in the management pathway of ITP with the prospect of modifying the long-term outcome of the disease by increasing sustained treatment-free remission. With the prospect of several new targeted therapies been introduced into clinical practice, TPO-RA will likely be a key component of future combination therapies for difficult cases.
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Affiliation(s)
- Frederick Chen
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Genomics and Child Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Vickie McDonald
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK.,Centre for Immunobiology, Blizard Institute, Barts and The London School of Medicine and Dentistry,QMUL, London, UK
| | - Adrian Newland
- Department of Clinical Haematology, the Royal London Hospital, Barts Health NHS Trust, London, UK.,Academic Haematology Unit, Barts & the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Schneider CW, Penney SW, Helfrich AM, Hartman KR, Lieuw K. A Novel Use of Romiplostim for SARS-CoV-2-induced Thrombocytopenia. J Pediatr Hematol Oncol 2021; 43:e788-e790. [PMID: 33003146 DOI: 10.1097/mph.0000000000001961] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/04/2020] [Indexed: 01/10/2023]
Abstract
The literature regarding coronavirus disease of 2019 (COVID-19) infection in pediatrics indicates that children have less severe clinical presentations and lower mortality rates. There remains limited data regarding hematologic sequelae in pediatric patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Romiplostim has shown a platelet response in pediatric patients with chronic immune thrombocytopenic purpura, and eltrombopag is proven to increase platelet counts in patients with inherited thrombocytopenia. We review SARS-CoV-2-associated thrombocytopenia and present a pediatric patient with acute on chronic thrombocytopenia in the setting of COVID-19 with subsequent platelet recovery using romiplostim.
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Affiliation(s)
| | | | - Alison M Helfrich
- Pediatric Infectious Disease, Walter Reed National Military Medical Center, Bethesda, MD
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Shah RM, Trehan A. ASH 2019 guidelines for immune thrombocytopenia: “Old wine in a new bottle with added spices”. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2021. [DOI: 10.1016/j.phoj.2021.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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13
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Bussel JB, Soff G, Balduzzi A, Cooper N, Lawrence T, Semple JW. A Review of Romiplostim Mechanism of Action and Clinical Applicability. Drug Des Devel Ther 2021; 15:2243-2268. [PMID: 34079225 PMCID: PMC8165097 DOI: 10.2147/dddt.s299591] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/06/2021] [Indexed: 12/17/2022] Open
Abstract
Thrombocytopenia results from a variety of conditions, including radiation, chemotherapy, autoimmune disease, bone marrow disorders, pathologic conditions associated with surgical procedures, hematopoietic stem cell transplant (HSCT), and hematologic disorders associated with severe aplastic anemia. Immune thrombocytopenia (ITP) is caused by immune reactions that accelerate destruction and reduce production of platelets. Thrombopoietin (TPO) is a critical component of platelet production pathways, and TPO receptor agonists (TPO-RAs) are important for the management of ITP by increasing platelet production and reducing the need for other treatments. Romiplostim is a TPO-RA approved for use in patients with ITP in the United States, European Union, Australia, and several countries in Africa and Asia, as well as for use in patients with refractory aplastic anemia in Japan and Korea. Romiplostim binds to and activates the TPO receptor on megakaryocyte precursors, thus promoting cell proliferation and viability, resulting in increased platelet production. Through this mechanism, romiplostim reduces the need for other treatments and decreases bleeding events in patients with thrombocytopenia. In addition to its efficacy in ITP, studies have shown that romiplostim is effective in improving platelet counts in various settings, thereby highlighting the versatility of romiplostim. The efficacy of romiplostim in such disorders is currently under investigation. Here, we review the structure, mechanism, pharmacokinetics, and pharmacodynamics of romiplostim. We also summarize the clinical evidence supporting its use in ITP and other disorders that involve thrombocytopenia, including chemotherapy-induced thrombocytopenia, aplastic anemia, acute radiation syndrome, perisurgical thrombocytopenia, post-HSCT thrombocytopenia, and liver disease.
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Affiliation(s)
- James B Bussel
- Department of Pediatrics, Division of Hematology, Weill Cornell Medicine, New York, NY, USA
| | - Gerald Soff
- Department of Medicine, Hematology Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Adriana Balduzzi
- Clinica Pediatrica Università degli Studi di Milano Bicocca, Ospedale San Gerardo, Monza, Italy
| | | | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
- Department of Pharmacology, University of Toronto, Toronto, ON, Canada
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Up-front Treatment With Romiplostim in Children With Acquired Bone Marrow Failure: A Single Institutional Pediatric Case Series. J Pediatr Hematol Oncol 2021; 43:e431-e435. [PMID: 32341259 DOI: 10.1097/mph.0000000000001810] [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] [Received: 10/22/2019] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Thrombopoietin receptor agonists are emerging as a therapeutic option for patients with aplastic anemia (AA) and myelodysplastic syndrome (MDS). We report our experience of treating children with AA/MDS with romiplostim, thrombopoietin receptor agonist. OBSERVATIONS Three children (AA, 2; MDS, 1) received romiplostim treatment at a median dose of 10 μg/kg/week (starting dose: 5 μg/kg/wk; 2.5 μg/kg/wk increment). Trilineage hematopoietic recovery occurred at a median of 13 weeks (range: 13 to 16 wk) without adverse events. Hematopoiesis continued to improve after therapy discontinuation (median follow-up: 2.8 y; range: 0.5 to 3.0). CONCLUSION Our experience supports the short-term safety and efficacy of romiplostim in children with AA/MDS.
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15
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Kuter DJ, Tarantino MD, Lawrence T. Clinical overview and practical considerations for optimizing romiplostim therapy in patients with immune thrombocytopenia. Blood Rev 2021; 49:100811. [PMID: 33781612 DOI: 10.1016/j.blre.2021.100811] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 12/23/2020] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
The fundamental treatment goal for patients with immune thrombocytopenia (ITP) is reduced or ameliorated bleeding. Although various treatment options exist for the management of ITP, recent advances have led to the approval of three thrombopoietin receptor agonists (TPO-RAs; romiplostim, eltrombopag, and avatrombopag) in the United States and European Union. Current treatment guidelines for ITP indicate that medical therapy is preferred over surgical therapy and support the use of TPO-RAs as early as 3 months after disease onset. More recent data are available on the use of romiplostim in patients who have had ITP for <1 year, and romiplostim is now indicated for the treatment of adults who have not responded adequately to initial treatment, as well as children aged ≥1 year who have had ITP for ≥6 months. Here we review the role of romiplostim in the management of ITP, with a focus on efficacy and safety data, emerging data on early use (beginning within 3 months of disease onset) and treatment-free remission, and practical considerations for optimal management of ITP.
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Affiliation(s)
- David J Kuter
- Hematology Division, Massachusetts General Hospital, Suite 118, Room 110, Zero Emerson Place, Boston, MA 02114, USA.
| | - Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, 9128 North Lindbergh Drive, Peoria, IL 61615, USA.
| | - Tatiana Lawrence
- Amgen Inc., One Amgen Center Drive, Thousand Oaks, CA 91320, USA.
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16
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Tarantino MD, Despotovic J, Roy J, Grainger J, Cooper N, Beam D, Raj A, Maschan A, Kim J, Eisen M. Romiplostim treatment for children with immune thrombocytopenia: Results of an integrated database of five clinical trials. Pediatr Blood Cancer 2020; 67:e28630. [PMID: 32902132 DOI: 10.1002/pbc.28630] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treatment for chronic immune thrombocytopenia (cITP) in children is largely limited to immunosuppressive agents. Thrombopoietin receptor agonists (TRAs) have been used to treat cITP in adults for over a decade. The objective of this integrated analysis was to examine the safety and efficacy of the TRA romiplostim in children with ITP. METHODS We examined efficacy and safety in children with ITP across five romiplostim trials: final data from two double-blind placebo-controlled trials and two open-label extensions, and interim data from an ongoing single-arm trial. RESULTS Patients (n = 24 initially placebo; n = 262 initially romiplostim) had a median age of 10.0 years (Q1: 6.0, Q3: 13.0), ITP duration of 1.9 years (Q1: 1.0, Q3: 4.0), and baseline platelet count of 14.3 × 109 /L (Q1: 7.5, Q3: 23.0). Among 282 patients receiving romiplostim, median treatment duration was 65 weeks (range 8-471 weeks) and median weekly dose was 6.6 μg/kg (range 0.1-9.7 μg/kg). Overall, 89% of romiplostim-treated patients had platelet responses. Nineteen patients (7%) maintained treatment-free responses for ≥6 months while withholding all ITP therapy. Grade 3 and 4 adverse events of bleeding occurred in 10% and <1% of romiplostim-treated patients, respectively. Twenty-five percent of patients had a serious adverse event, most commonly epistaxis (6%). Seven patients (2%) had neutralizing antibodies against romiplostim postbaseline and none had neutralizing antibodies against endogenous thrombopoietin. Efficacy and safety results appeared similar between children with ITP for ≤12 months and >12 months at baseline. CONCLUSIONS Across five pediatric clinical trials, romiplostim was well tolerated. Most patients had a platelet response; some maintained responses for at least 6 months while withholding all ITP therapy.
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Affiliation(s)
- Michael D Tarantino
- The Bleeding and Clotting Disorders Institute and University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | | | - John Roy
- Children's Health Queensland & Pathology Queensland, The University of Queensland, Saint Lucia, Brisbane, Queensland, Australia
| | - John Grainger
- Royal Manchester Children's Hospital, University of Manchester, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Nichola Cooper
- Hammersmith Hospital, Imperial College London, London, UK
| | - Donald Beam
- Cook Children's Medical Center, Fort Worth, Texas
| | - Ashok Raj
- Pediatric Cancer and Blood Disorders Clinic, Louisville, Kentucky
| | - Alexey Maschan
- Dmitry Rogachev National Research Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - June Kim
- Amgen Inc., Thousand Oaks, California
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17
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Khoreva A, Abramova I, Deripapa E, Rodina Y, Roppelt A, Pershin D, Larin S, Voronin K, Maschan A, Novichkova G, Shcherbina A. Efficacy of romiplostim in treatment of thrombocytopenia in children with Wiskott-Aldrich syndrome. Br J Haematol 2020; 192:366-374. [PMID: 33131064 DOI: 10.1111/bjh.17174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/31/2020] [Indexed: 01/21/2023]
Abstract
Wiskott-Aldrich syndrome (WAS) is a life-threatening primary immunodeficiency associated with bleeding of variable severity due to thrombocytopenia. Correction of the thrombocytopenia is of paramount importance for most WAS patients. We report a retrospective analysis of the safety and efficacy of romiplostim treatment in reducing thrombocytopenia and bleeding tendency in 67 children (median age 1·3 years) with genetically confirmed WAS, followed in eight months (range, 1-12 months). Complete or partial primary responses regarding platelet counts were observed in 22 (33%) and 18 (27%) subjects, respectively. Yet, even in the non-responder group, the risk of haemorrhagic events decreased significantly, to 21%, after the first month of treatment. The responses tended to be durable and stable over time, with no significant fluctuations in platelets counts. The results of this retrospective study of a large cohort of WAS patients demonstrates that romiplostim can be used to increase platelet counts and reduce the risks of life-threatening bleeding in WAS patients awaiting haematopoietic stem cell transplantation or forgoing the procedure for various reasons.
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Affiliation(s)
- Anna Khoreva
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Irina Abramova
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Elena Deripapa
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Yulia Rodina
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Roppelt
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Dmitry Pershin
- Laboratory of Hematopoietic Stem Cell Transplantation and Immunotherapy, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Sergey Larin
- Laboratory of Molecular Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Kirill Voronin
- Department of Bioinformatics and Medical Statistics, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Alexey Maschan
- Department of Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Galina Novichkova
- Department of Pediatric Hematology and Oncology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Shcherbina
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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18
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Lim HJ, Lim YT, Hah JO, Lee JM. Delayed treatment-free response after romiplostim discontinuation in pediatric chronic immune thrombocytopenia. Yeungnam Univ J Med 2020; 38:165-168. [PMID: 32891076 PMCID: PMC8016626 DOI: 10.12701/yujm.2020.00493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/18/2020] [Indexed: 12/19/2022] Open
Abstract
We report the case of a 16-month-old patient with chronic immune thrombocytopenia (ITP) patient who experienced delayed treatment-free response (TFR) after romiplostim treatment. He received intravenous immunoglobulin every month to maintain a platelet count above 20,000/μL for 2 years. Thereafter, he received rituximab and cyclosporine as second-line therapy, with no response, followed by romiplostim. After 4 weeks of treatment, the platelet count was maintained above 50,000/μL. Following 7 months of treatment, he discontinued romiplostim, and the platelet count decreased. His platelet counts remained above 50,000/μL, without any bleeding symptoms, 2 years after romiplostim discontinuation. This is the first report of TFR after romiplostim treatment in pediatric chronic ITP.
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Affiliation(s)
- Hyun Ji Lim
- Department of Pediatrics, Yeungnam University Hospital, Daegu, Korea
| | - Young Tae Lim
- Department of Pediatrics, Yeungnam University Hospital, Daegu, Korea
| | - Jeong Ok Hah
- Department of Pediatrics, Daegu Fatima Hospital, Daegu, Korea
| | - Jae Min Lee
- Department of Pediatrics, Yeungnam University College of Medicine, Daegu, Korea
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19
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Romiplostim for the management of pediatric immune thrombocytopenia: drug development and current practice. Blood Adv 2020; 3:1907-1915. [PMID: 31239245 DOI: 10.1182/bloodadvances.2019000279] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/29/2019] [Indexed: 12/13/2022] Open
Abstract
Since successful cloning of thrombopoietin (TPO) in 1994, significant advances have been made in the development of recombinant TPO receptor agonists. The US Food and Drug Administration (FDA) has approved 2 agents for use in patients with immune thrombocytopenia (ITP): eltrombopag and romiplostim. Romiplostim is a once-weekly subcutaneous injection that has been shown to increase the platelet count, lessen bleeding, and reduce concurrent medication use in adults with ITP. In December 2018, the US FDA approved romiplostim for use in pediatric patients ≥1 year of age with ITP of >6 months' duration and insufficient response to corticosteroids, immunoglobulins, or splenectomy, based on similarly favorable clinical trial data. In addition, romiplostim is well tolerated, making it an attractive option for the treatment of children. Expansion of off-label romiplostim use is being reported in children for ITP <6 months, neonatal thrombocytopenia, hereditary thrombocytopenias, and chemotherapy- and bone marrow transplant-associated thrombocytopenia. We review here the development of romiplostim with a focus on pediatric use.
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20
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Lassandro G, Palladino V, Vecchio GCD, Palmieri VV, Corallo PC, Faienza MF, Giordano P. Thrombopoietin Receptor Agonists in Children with Immune Thrombocytopenia: A New Therapeutic Era. Endocr Metab Immune Disord Drug Targets 2020; 21:397-406. [PMID: 32473624 DOI: 10.2174/1871530320666200531142244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/03/2020] [Accepted: 04/23/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVE Immune thrombocytopenia (ITP) is a common bleeding disorder in childhood. The management of ITP in children is controversial, requiring personalized assessment of patients and therapeutic choices. Thrombopoietin receptor agonists (TPO-RAs), eltrombopag and romiplostim, have been shown to be safe and effective for the treatment of pediatric ITP. The aim of our research is to define the role of thrombopoietin receptor agonists in the management of pediatric ITP. METHODS This review focuses on the use of TPO-RAs in pediatric ITP, in randomized trials and in clinical routine, highlighting their key role in the management of the disease. RESULTS Eltrombopag and romiplostim appear effective treatment options for children with ITP. Several clinical studies have assessed that the use of TPO-RAs increases platelet count, decreases bleeding symptoms and improves health-related quality of life. Moreover, TPO-RAs are well tolerated with minor side effects. CONCLUSION Although long term efficacy and safety of TPO-RAs still require further investigations, their use is gradually expanding in the clinical practice of children with ITP.
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Affiliation(s)
- Giuseppe Lassandro
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Valentina Palladino
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Giovanni C D Vecchio
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Viviana V Palmieri
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Paola C Corallo
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Maria F Faienza
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
| | - Paola Giordano
- Department of Biomedical Science and Human Oncology-Pediatric Unit, University of Bari "Aldo Moro", Bari, Italy
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21
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Al-Samkari H, Grace RF, Kuter DJ. The role of romiplostim for pediatric patients with immune thrombocytopenia. Ther Adv Hematol 2020; 11:2040620720912992. [PMID: 32523658 PMCID: PMC7236573 DOI: 10.1177/2040620720912992] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/18/2020] [Indexed: 01/19/2023] Open
Abstract
The thrombopoietin receptor agonists (TPO-RAs) are a class of platelet growth factors used to treat immune thrombocytopenia (ITP) in children and adults. Romiplostim is a peptide TPO-RA approved for over a decade to treat adults with ITP but was just recently US Food and Drug Administration approved to manage ITP in children 1 year of age and older who have had an inadequate response to corticosteroids, intravenous immunoglobulin, or splenectomy. Like the small molecule TPO-RA eltrombopag, romiplostim offers a high clinical response rate in pediatric patients with ITP, but requires use over an extended, and possibly indefinite, duration. This review is a critical appraisal of the role of romiplostim in pediatric ITP, discussing the safety and efficacy of this agent in clinical trials of children and adults and defining the patients most likely to benefit from romiplostim treatment. The treating hematologist is additionally provided guidance with treatment goals, dosing strategies, toxicity management, and indications for discontinuation.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical chool, Suite 118, Room 112, Zero Emerson Place, Boston, MA 02114, USA
| | - Rachael F Grace
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA
| | - David J Kuter
- Division of Hematology, Harvard Medical School, Boston, MA, USA
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22
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Singh G, Bansal D, Wright NAM. Immune Thrombocytopenia in Children: Consensus and Controversies. Indian J Pediatr 2020; 87:150-157. [PMID: 31927692 DOI: 10.1007/s12098-019-03155-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/05/2019] [Indexed: 01/19/2023]
Abstract
Newly diagnosed immune thrombocytopenia (ITP) is a relatively common disorder of childhood that does not require an exhaustive laboratory workup for diagnosis. A history and physical exam with a review of the peripheral smear are crucial for excluding secondary causes of thrombocytopenia. Several guidelines have been published to guide physicians in the management of ITP. However, the decision for treatment can be arduous. The management strategy should not be focussed on the platelet count but the severity of bleeding symptoms. Agents for treating acute ITP, including corticosteroids, immunoglobulin and anti-D immunoglobulin, do not seem to have a significant impact on the natural history of the disease. The majority of children with ITP do not need therapy and have a spontaneous resolution of the disease. Some children can develop chronic ITP that is not commonly life-threatening but can lead to impaired quality of life. Traditional therapies such as rituximab and splenectomy for chronic ITP are not without significant adverse effects. Thrombopoietin receptor agonists are newer agents for the treatment of chronic ITP and hold promise, however, their cost currently precludes use in most of the patients in low-middle-income countries. This review compares and contrasts the specific treatments available for the treatment of ITP to help the reader make a balanced choice. This review, based on a series of case examples, will help physicians in making decisions about choosing a practical management strategy for patients with newly diagnosed as well as chronic ITP.
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Affiliation(s)
- Gurpreet Singh
- Division of Hematology/Immunology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 28 Oki Dr Nw, Calgary, T3B 6A8, Canada
| | - Deepak Bansal
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Advanced Pediatrics Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nicola A M Wright
- Division of Hematology/Immunology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, 28 Oki Dr Nw, Calgary, T3B 6A8, Canada.
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23
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Cooper N, Cines DB. The child with immune thrombocytopenia: to treat or not to treat, is that still the question? Haematologica 2019; 104:2132-2134. [PMID: 31666343 DOI: 10.3324/haematol.2019.229179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Nichola Cooper
- Centre for Haematology, Department of Medicine, Imperial College, Hammersmith Hospital, London, UK
| | - Douglas B Cines
- Departments of Pathology and Laboratory Medicine and Medicine, University of Pennsylvania-Perelman School of Medicine, Philadelphia, PA, USA
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24
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Bussel J, Kulasekararaj A, Cooper N, Verma A, Steidl U, Semple JW, Will B. Mechanisms and therapeutic prospects of thrombopoietin receptor agonists. Semin Hematol 2019; 56:262-278. [PMID: 31836033 DOI: 10.1053/j.seminhematol.2019.09.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 07/30/2019] [Accepted: 09/30/2019] [Indexed: 12/13/2022]
Abstract
The second-generation thrombopoietin (TPO) receptor agonists eltrombopag and romiplostim are potent activators of megakaryopoiesis and represent a growing treatment option for patients with thrombocytopenic hematological disorders. Both TPO receptor agonists have been approved worldwide for the treatment of children and adults with chronic immune thrombocytopenia. In the EU and USA, eltrombopag is approved for the treatment of patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy and in the USA for the first-line treatment of severe aplastic anemia in combination with immunosuppressive therapy. Eltrombopag has also shown efficacy in several other disease settings, for example, chemotherapy-induced thrombocytopenia, selected inherited thrombocytopenias, and myelodysplastic syndromes. While both TPO receptor agonists stimulate TPO receptor signaling and enhance megakaryopoiesis, their vastly different biochemical structures bestow upon them markedly different molecular and functional properties. Here, we review and discuss results from preclinical and clinical studies on the functional and molecular mechanisms of action of this new class of drug.
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Affiliation(s)
- James Bussel
- Pediatric Hematology/Oncology, Weill Cornell Medicine, New York, NY.
| | | | | | - Amit Verma
- Albert Einstein College of Medicine, New York, NY
| | | | - John W Semple
- Division of Hematology and Transfusion Medicine, Lund University, Lund, Sweden
| | - Britta Will
- Albert Einstein College of Medicine, New York, NY.
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25
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Schifferli A, Nimmerjahn F, Kühne T. Immunomodulation in Primary Immune Thrombocytopenia: A Possible Role of the Fc Fragment of Romiplostim? Front Immunol 2019; 10:1196. [PMID: 31214173 PMCID: PMC6557984 DOI: 10.3389/fimmu.2019.01196] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/13/2019] [Indexed: 12/14/2022] Open
Abstract
Fc fusion proteins and Fc fusion peptides or peptibodies are chimeric molecules composed of an active pharmacological protein or peptide and the Fc fragment of an immunoglobulin. The primary aim of this drug construct is to prolong the half-life of the active component. This molecular architecture is seen in drugs, such as etanercept, romiplostim, and the recombinant factor VIII (efmoroctocog alfa). A considerable number of Fc fusion proteins and peptibodies are currently in pre-clinical and clinical development. The isolated effect of the Fc fragment has been studied intensively during last years, but is still poorly understood in the clinical setting and in relation with the active drug and underlying disease. In this short review, we will propose new hypotheses of possible immunomodulatory functions of the Fc fragment of romiplostim in patients with primary immune thrombocytopenia.
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Affiliation(s)
- Alexandra Schifferli
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
| | - Falk Nimmerjahn
- Department of Biology, Institute of Genetics, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Kühne
- Department of Hematology/Oncology, University Children's Hospital Basel, Basel, Switzerland
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