Thrombopoietin receptor agonists for the treatment of primary immune thrombocytopenia: a meta-analysis and systematic review

Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice

“…57 In a large systematic review, treatment failure was seen in 21% of TPO-RA treated patients compared with 47% of control patients, with a lower risk of significant bleeding and all-cause mortality. 58 There are currently three TPO-RAs approved for treatment of ITP: romiplostim, eltrombopag, avatrombopag, described below and summarized in Table 1. 59 Thrombosis is the major potential adverse event of concern with TPO-RA use and though clinical trials have not found an increased thrombotic risk of TPO-RA agents compared with placebo, uncontrolled observational data suggest an increase in thrombotic risk on the order of 2-3-fold.…”

“…89 In a meta-analysis, the incidence of remission after TPO-RA discontinuation ranged from 5-36%. 58 Tapering of TPO-RAs is dependent on multiple factors, including platelet count at or above the lower limit of normal, lack of a major bleeding history, low trauma risk, and taking into account antiplatelet or anticoagulant agents the patient is taking. 90 In an expert consensus panel, the duration of ITP, duration on TPO-RA, and timing of platelet response did not affect the panel's recommendations regarding discontinuation.…”

Off-Label Use of Thrombopoietin Receptor Agonists: Case Series and Review of the Literature

“…Indications for their use are similar in the United States and Europe. Eltrombopag (Revolade ® , Promacta ® ) is approved for second-line therapy of ITP patients older than 1 year of age with a disease lasting at least 6 months ( 2 ), for second-line therapy of severe aplastic anemia after failure of immune suppressive therapy ( 3 ), and for the treatment of thrombocytopenia in adults with chronic hepatitis C treated with interferon-based regimens ( 4 ). Romiplostim (Nplate ® ) is only approved as second-line treatment for chronic ITP patients (i.e., after 12 months from diagnosis).…”

A case of newly diagnosed immune thrombocytopenia in the COVID-19 era

“…Both are safe and effective, although they imply some known side effects, namely liver toxicity and increase in thrombotic risk for TPO-RAs, and immunosuppression for Rituximab. In this patient, the benefits of a rapid increase in platelet count must be weighed against the risk of deterioration of the ongoing viral infection, of superimposed hospital-acquired infections, of liver impairment, and of venous thromboembolic events, which might be favored by ITP itself [6,7], the treatment with a TPO-RA [8], the suspected presence of a neoplasm, the length of hospitalization and SARS-CoV-2 infection [9,10]. The impact of the anti-CD20 activity of Rituximab on the course of SARS-CoV-2 infection in a patient on steroid treatment was unknown and particularly worrisome given the crucial role of humoral immunity in infection contrast [11,12].…”

“…The choice of second-line treatment in the COVID-19 era may, however, be simplified. The use of Rituximab requires caution, whereas the use of TPO-Rasis quite effective and supported by the latest evidence [7,8], thus it appears as the second-line treatment of choice for ITP [14]. A potential side effect is the thrombotic risk, which would add to that induced by COVID-19 itself, and venous thrombo-embolism prophylaxis cannot be prescribed in patients with severe thrombocytopenia and ongoing bleeding.…”