Treatment of immune thrombocytopenia during pregnancy with thrombopoietin receptor agonists

Abstract

SummaryThe introduction of thrombopoietin receptor agonists (TPO‐RAs) led to a paradigm shift in the management of immune thrombocytopenia (ITP). However, TPO‐RAs are not approved for use during pregnancy due to the absence of evidence and concerns for possible effects on the fetus due to their expected transplacental transfer. This comprehensive review examines the safety and efficacy of TPO‐RA in 45 pregnancies of women with ITP (romiplostim n = 22; eltrombopag n = 21; both in the same pregnancy n = 2). Mothers experienced failure of the median of three treatment lines during pregnancy prior to TPO‐RA administration. A platelet response (>30 × 109/L) was seen in 86.7% of cases (including a complete response >100 × 109/L in 66.7%) and was similar between eltrombopag and romiplostim (87.0% and 83.3%, p = 0.99). The maternal safety profile was favourable, with no thromboembolic events encountered. Neonatal thrombocytopenia was noted in one third of cases, with one case of ICH grade 3, and neonatal thrombocytosis was observed in three cases. No other neonatal adverse events attributable to TPO‐RAs were seen. This review suggests that the use of TPO‐RA during pregnancy is associated with a high response rate and appears safe. Nevertheless, TPO‐RA should not be routinely used in pregnancy and should be avoided in the first trimester until further evidence is accumulated.

Immune thrombocytopenia (ITP) in pregnancy

“…7 In a pregnant woman with ITP in the third trimester receiving steroids and/or IVIG with diminishing effect, TPO agents have a high rate of success, seem safe and can be continued without evident toxicity. 8 More than 70 women conceived on romiplostim and did not have an "abnormal" child but use of TPO-RA (or any second line treatment) in the first trimester is considered higher risk than later use. Rituximab, azthioprin, dapsone, and ciclosporin may be used intrapartum with varying delays of platelet increase in responders.…”