Portal vein thrombosis during eltrombopag treatment for immune thrombocytopenic purpura in a patient with liver cirrhosis due to hepatitis C viral infection

Treatment of Acute Ischaemic Stroke and Concomitant Multiple Arterial Splanchnic Thromboses in a Patient with Immune Thrombocytopenia on Thrombopoietin Agonist: A Case Report

Immune thrombocytopenia (ITP) is an autoimmune blood disorder characterised by isolated severe thrombocytopenia. Arterial thrombotic events, such as acute ischaemic stroke (AIS), are rare complications. A 56-year-old woman with chronic ITP on eltrombopag and dexamethasone therapy presented to the emergency department due to AIS in the vertebrobasilar territory, and lower abdominal pain. The computed tomography (CT) scan of the head was unremarkable, whereas CT angiography revealed left vertebral artery occlusion. As the platelet count was sufficient, intravenous thrombolysis (IVT) was initiated. However, after 15 min, an anaphylactic reaction occurred, which was appropriately solved. Although the IVT was prematurely stopped, the NIHSS score improved from 7 to 2, and the follow-up head CT scan remained unremarkable. CT angiography of the thoracoabdominal aorta revealed multiple thrombi in the infrarenal aorta, inferior mesenteric artery (IMA), and left renal artery. The abdominal pain subsided after IVT, but recurred within 24 h. Repeated CT angiography showed ischaemia of the descending colon, with persistent IMA occlusion. After the hemicolectomy condition stabilised. Discrete left-sided ataxia and impaired sensation were the only neurological sequelae. We found two articles reporting only three patients with ITP who suffered AIS and were treated with IVT. A favourable outcome was observed in two cases, while one patient suffered an intracranial haemorrhage (ICH) and died. A review of AIS cases with undefined thrombocytopenia treated with IVT reported ICH in up to 6.8% of patients. Our case suggests that IVT for AIS may be effective in patients with ITP. Further data are needed to better clarify this issue.

Severe Portal Vein Thrombosis During Eltrombopag Treatment Concomitant Splenectomy for Immune Thrombocytopenia

The treatment of immune thrombocytopenia (ITP) has recently changed; however, each treatment has not only advantages, but also disadvantages, and may have unexpected complications. We describe an instructive case of ITP that was complicated by severe portal vein thrombosis during treatment with eltrombopag, an oral thrombopoietin-receptor agonist (TPO-RA) drug, plus prednisolone (PSL) concomitant splenectomy. A male ITP patient who had been receiving eltrombopag treatment for more than four years at our department underwent a splenectomy at the age of 51. Soon after splenectomy, splenic vein and portal vein thrombosis developed, while splenectomy was ineffective. The patient resumed eltrombopag treatment after thrombosis disappeared. Although fluctuations in PLT were observed, eltrombopag and PSL were used together for a while. Subsequently, lower-limb deep vein thrombosis recurred, and edoxaban tosylate was administered for a total of 8.4 months. More than three years after splenectomy, at the age of 54, abdominal computed tomography (CT) revealed a continuous thrombus extending from the intrahepatic portal vein to the superior mesenteric vein. In patients with ITP in whom splenectomy fails and treatment with a TPO-RA ± PSL needs to be continued, clinicians should be aware of the possibility of abdominal thrombotic adverse events, such as severe portal vein thrombosis, by following-up on CT imaging, not only in the short term but also in the medium-long term.

Eltrombopag-related renal vein thromboembolism in a patient with immune thrombocytopenia: A case report

BACKGROUND

Eltrombopag is an orally administered thrombopoietin receptor agonist linked to a heightened risk of treatment-related thromboembolism. Both venous and arterial thromboses have been documented in the medical literature.

CASE SUMMARY

In the absence of nephropathy, a 48-year-old patient receiving eltrombopag for immune thrombocytopenia (ITP) developed renal vein thrombosis and pulmonary embolism. The renal vein thrombus spontaneously resolved during subsequent anticoagulant treatment, restoring venous circulation.

CONCLUSION

A rapid upsurge in platelets, rather than their absolute number, may trigger thrombotic events in this setting. For patients at high thrombotic risk, individualized eltrombopag dosing and vigilance in platelet monitoring are perhaps needed during treatment of ITP.

Use of Chinese Herbal Medicine Improves Chemotherapy-Induced Thrombocytopenia among Gynecological Cancer Patients: An Observational Study

Background

Chemotherapy-induced thrombocytopenia (CIT) is a serious complication among patients with gynecological malignancies, yet management options are limited. This study aimed at reporting the potential of the Chang Gung platelet elevating formula (CGPEF), a prescription with a fixed proportion of Chinese herbs, for improving CIT among gynecologic cancer patients.

Materials

From 1/1/2007 to 31/12/2009, a total of 23 patients with two consecutive CIT episodes (≤ 100×10³ /μL) (last cycle: C0; index cycle: C1) received the CGPEF from the nadir of platelet count of C1 and through the subsequent chemotherapy cycles (C2 and beyond). The CGPEF was taken orally four times a day. The evolution of platelet counts of 18 patients after administration of CGPEF was analyzed (2 patients had different chemotherapy regimens after CGPEF, two patients discontinued CGPEF due to the flavor and the amount of CGPEF, and one patient had no further chemotherapy).

Results

Most of the patients had recurrent ovarian cancer (11/18, 61%) with a median of 2.5 previous chemotherapy regimens, and carboplatin-based regimens were the most commonly used for these patients (13/18, 72%). The trend of successive CIT could be reversed after taking CGPEF. Also, the platelet nadir was higher after CGPEF treatment (16.5×10³/μL versus 32×10³/μL, before and after CGPEF treatment, resp., p = 0.002). Moreover, the chemotherapy interval decreased from 30.5 days to 24 days. No thrombocytosis, clinical bleeding, thromboembolism, or other adverse events were found among these patients.

Conclusions

The CGPEF is worthy of further large-scale, well-designed clinical trials for CIT among gynecological cancer patients.

Thrombopoietin receptor agonists for preparing adult patients with immune thrombocytopenia to splenectomy: results of a retrospective, observational GIMEMA study

In patients with immune thrombocytopenia (ITP) refractory to corticosteroids and intravenous immunoglobulins (IVIG), splenectomy may result at higher risk of peri-operative complications and, for this reason, potentially contraindicated. The thrombopoietin receptor agonists (TPO-RAs) romiplostim and eltrombopag have shown high therapeutic activity in primary ITP, but data of efficacy and safety regarding their use in preparation for splenectomy are missing. Thirty-one adult patients, median age 50 years, with corticosteroids and/or IVIG refractory persistent and chronic ITP who were treated with TPO-RAs (romiplostim= 24; eltrombopag= 7) with the aim to increase platelet count and allow a safer execution of splenectomy were retrospectively evaluated. Twenty-four patients (77%) responded to the use of TPO-RAs with a median platelet count that increased from 11 × 10(9) /L before starting TPO-RAs to 114 × 10(9) /L pre-splenectomy, but a concomitant treatment with corticosteroids and/or IVIG was required in 19 patients. Twenty-nine patients underwent splenectomy while two patients who responded to TPO-RAs subsequently refused surgery. Post-splenectomy complications were characterized by two Grade 3 thrombotic events (1 portal vein thrombosis in the patient with previous history of HCV hepatitis and 1 pulmonary embolism), with a platelet count at the time of thrombosis of 260 and 167 × 10(9) /L, respectively and one Grade 3 infectious event. TPO-RAs may represent a therapeutic option to improve platelet count and reduce the risk of peri-operative complications in ITP candidates to splenectomy. An increased risk of post-splenectomy thromboembolic events cannot be ruled out and thromboprophylaxis with low-molecular weight heparin is generally recommended.

Platelet transfusions in platelet consumptive disorders are associated with arterial thrombosis and in-hospital mortality

While platelets are primary mediators of hemostasis, there is emerging evidence to show that they may also mediate pathologic thrombogenesis. Little data are available on risks and benefits associated with platelet transfusions in thrombotic thrombocytopenic purpura (TTP), heparin-induced thrombocytopenia (HIT) and immune thrombocytopenic purpura (ITP). This study utilized the Nationwide Inpatient Sample to evaluate the current in-hospital platelet transfusion practices and their association with arterial/venous thrombosis, acute myocardial infarction (AMI), stroke, and in-hospital mortality over 5 years (2007-2011). Age and gender-adjusted odds ratios (adjOR) associated with platelet transfusions were calculated. There were 10 624 hospitalizations with TTP; 6332 with HIT and 79 980 with ITP. Platelet transfusions were reported in 10.1% TTP, 7.1% HIT, and 25.8% ITP admissions. Platelet transfusions in TTP were associated with higher odds of arterial thrombosis (adjOR = 5.8, 95%CI = 1.3-26.6), AMI (adjOR = 2.0, 95%CI = 1.2-3.3) and mortality (adjOR = 2.0,95%CI = 1.3-3.0), but not venous thrombosis. Platelet transfusions in HIT were associated with higher odds of arterial thrombosis (adjOR = 3.4, 95%CI = 1.2-9.5) and mortality (adjOR = 5.2, 95%CI = 2.6-10.5) but not venous thrombosis. Except for AMI, all relationships remained significant after adjusting for clinical severity and acuity. No associations were significant for ITP. Platelet transfusions are associated with higher odds of arterial thrombosis and mortality among TTP and HIT patients.

Use of eltrombopag in thrombocytopenia of liver disease

Second generation thrombopoietin agonists including eltrombopag and romiplostim act on the thrombopoietin receptor to increase the megakaryocyte production. These agents were needed as use of first generation recombinant products was associated with formation of autoantibodies. Eltrombopag is an oral thrombopoietin agonist found effective in raising platelet counts in patients with immune thrombocytopenia. The drug has now been found to be useful in raising platelet counts in thrombocytopenia related to liver disease including cirrhosis and chronic viral hepatitis. Although the drug may help enable adequate interferon therapy in patients with HCV infection and help carry out invasive procedures in patients with cirrhosis, concerns have been raised of possible thrombotic complications including portal vein thrombosis. Randomized trials have shown that use of eltrombopag concomitant with pegylated interferon and ribavirin increased the chances of sustained virologic response while decreasing the dose reductions of interferon. The data on use of romiplostim in these clinical indications is also emerging. However, in the future, availability of interferon free regimens is likely to decrease the use of eltrombopag for enabling antiviral therapy. The review discusses the role of eltrombopag in management of liver disease related thrombocytopenia in wake of recent data as also the dosage, precautions and adverse effects associated with its use.