SAFE BUT FLUCTUATING RESPONSE TO TREATMENT WITH TPO MIMETICS IN PREGNANT PATIENT WITH REFRACTORY ITP
(Abstract release date: 05/19/16)
EHA Library. Omenetto E. 06/09/16; 134981; PB2081
Dr. Elisabetta Omenetto
Contributions
Contributions
Abstract
Abstract: PB2081
Type: Publication Only
Background
Maternal platelet count less than 20x10^9/L has been associated with risk of spontaneous bleeding, postpartum haemorrhage, and placental abruption. 5% of newborns will be born with platelets less than 20x10^9/L and less than 1% will have bleeding complications. Primary treatment options for maternal ITP are similar to those of non pregnant adult patients: corticosteroids and IV-Ig are the first-line treatments.
Aims
Describe a case of use of TPO-mimetic during pregnancy in refractory ITP.
Methods
We report a case of a 25 years old Moldovan woman with refractory chronic primary immune thrombocytopenia (ITP), diagnosed on 2002. On 2006 the patient underwent splenectomy with a partial response and low dose of prednisone (2.5 mg/die) obtaining a stable remission (platelets 150 x10^9/L). During the follow-up the patient underwent abdominal CT scan, which was negative for an accessory spleen. In November 2013, the ITP recurred with petechiae and platelets were 6 x10^9/L; platelet associated autoantibodies against GpIIb/IIIa (HPA 1a/3a) and GpIb (HPA 5b/5a) were positives. Since the patient was refractory to full doses of prednisone (1 mg/kg) and IV-Ig (1g/kg for 2 days), she was treated with increasing doses of romiplostim, (NPLATE®) (1 mcg/kg up to 3,5 mcg/kg) once a week for 26 weeks. The response to TPO-mimetic was fluctuating with both severe thrombocytosis and symptomatic thrombocytopenia needing platelet transfusions. The patient was then treated on April 2014 with Rituximab (375 mg/m x 4 doses) with complete response.
Results
The ITP remission continued until April 2015, when at 21st week of gestation, relapsed (Figure 1). She was treated again with prednisone and two IV-Ig courses with transitory response. After an unsuccessful course with dexamethasone (40mg/kg) we obtained the patient informed consent for the use of romiplostim (1 mcg/kg up to 10 mcg/kg) once a week for 3 weeks before delivery, without response. The elective caesarean delivery was performed on 26 week of pregnancy with the infusion of platelet concentrates due to a severe thrombocytopenia (platelets 3x10^9/L. Major bleeding complications did not occur, and baby's platelets were normal. After delivery, romiplostin was administered for other 10 weeks with fluctuating positive response (Figure 1). Because of the discontinuous response to romiplostim, we shifted to oral eltrombopag (Revolade® 50 mg/day) waiting for a new course with rituximab. Due to a severe thrombocytosis (platelet 1985 x10^9/L) the TPO mimetic has been withdrawal after only one week. The response to rituximab was complete and stable, steroid was gradually tapered until suspension and the ITP remitted without any therapy so far.
Conclusion
There are few case report on ITP treated with romiplostim during pregnancy, and no one showing fetal complications. Although TPO mimetics have not been indicated in pregnant ITP, it may represent an important alternative treatment choice for refractory cases because its speed of activity and an high rate of success. In our patient, we obtained a positive response to romiplostim during the first recurrence of ITP and after delivery but both responses were discontinuous without finding the lowest effective dose. Therefore we tried a switch to eltrombopag after delivery, but the response to the standard initial dose was characterized by an extreme thrombocytosis. We can speculate that TPO mimetic are safe during pregnancy in ITP but they may require more customized dosages mostly after delivery. Instead, using rituximab we obtained a complete and longstanding response showing the effectiveness of the combination of drugs that act by different but complementary mechanisms.
Session topic: E-poster
Keyword(s): Idiopathic thombocytopenic purpura (ITP), Pregnancy, Therapy
Type: Publication Only
Background
Maternal platelet count less than 20x10^9/L has been associated with risk of spontaneous bleeding, postpartum haemorrhage, and placental abruption. 5% of newborns will be born with platelets less than 20x10^9/L and less than 1% will have bleeding complications. Primary treatment options for maternal ITP are similar to those of non pregnant adult patients: corticosteroids and IV-Ig are the first-line treatments.
Aims
Describe a case of use of TPO-mimetic during pregnancy in refractory ITP.
Methods
We report a case of a 25 years old Moldovan woman with refractory chronic primary immune thrombocytopenia (ITP), diagnosed on 2002. On 2006 the patient underwent splenectomy with a partial response and low dose of prednisone (2.5 mg/die) obtaining a stable remission (platelets 150 x10^9/L). During the follow-up the patient underwent abdominal CT scan, which was negative for an accessory spleen. In November 2013, the ITP recurred with petechiae and platelets were 6 x10^9/L; platelet associated autoantibodies against GpIIb/IIIa (HPA 1a/3a) and GpIb (HPA 5b/5a) were positives. Since the patient was refractory to full doses of prednisone (1 mg/kg) and IV-Ig (1g/kg for 2 days), she was treated with increasing doses of romiplostim, (NPLATE®) (1 mcg/kg up to 3,5 mcg/kg) once a week for 26 weeks. The response to TPO-mimetic was fluctuating with both severe thrombocytosis and symptomatic thrombocytopenia needing platelet transfusions. The patient was then treated on April 2014 with Rituximab (375 mg/m x 4 doses) with complete response.
Results
The ITP remission continued until April 2015, when at 21st week of gestation, relapsed (Figure 1). She was treated again with prednisone and two IV-Ig courses with transitory response. After an unsuccessful course with dexamethasone (40mg/kg) we obtained the patient informed consent for the use of romiplostim (1 mcg/kg up to 10 mcg/kg) once a week for 3 weeks before delivery, without response. The elective caesarean delivery was performed on 26 week of pregnancy with the infusion of platelet concentrates due to a severe thrombocytopenia (platelets 3x10^9/L. Major bleeding complications did not occur, and baby's platelets were normal. After delivery, romiplostin was administered for other 10 weeks with fluctuating positive response (Figure 1). Because of the discontinuous response to romiplostim, we shifted to oral eltrombopag (Revolade® 50 mg/day) waiting for a new course with rituximab. Due to a severe thrombocytosis (platelet 1985 x10^9/L) the TPO mimetic has been withdrawal after only one week. The response to rituximab was complete and stable, steroid was gradually tapered until suspension and the ITP remitted without any therapy so far.
Conclusion
There are few case report on ITP treated with romiplostim during pregnancy, and no one showing fetal complications. Although TPO mimetics have not been indicated in pregnant ITP, it may represent an important alternative treatment choice for refractory cases because its speed of activity and an high rate of success. In our patient, we obtained a positive response to romiplostim during the first recurrence of ITP and after delivery but both responses were discontinuous without finding the lowest effective dose. Therefore we tried a switch to eltrombopag after delivery, but the response to the standard initial dose was characterized by an extreme thrombocytosis. We can speculate that TPO mimetic are safe during pregnancy in ITP but they may require more customized dosages mostly after delivery. Instead, using rituximab we obtained a complete and longstanding response showing the effectiveness of the combination of drugs that act by different but complementary mechanisms.
Session topic: E-poster
Keyword(s): Idiopathic thombocytopenic purpura (ITP), Pregnancy, Therapy
Abstract: PB2081
Type: Publication Only
Background
Maternal platelet count less than 20x10^9/L has been associated with risk of spontaneous bleeding, postpartum haemorrhage, and placental abruption. 5% of newborns will be born with platelets less than 20x10^9/L and less than 1% will have bleeding complications. Primary treatment options for maternal ITP are similar to those of non pregnant adult patients: corticosteroids and IV-Ig are the first-line treatments.
Aims
Describe a case of use of TPO-mimetic during pregnancy in refractory ITP.
Methods
We report a case of a 25 years old Moldovan woman with refractory chronic primary immune thrombocytopenia (ITP), diagnosed on 2002. On 2006 the patient underwent splenectomy with a partial response and low dose of prednisone (2.5 mg/die) obtaining a stable remission (platelets 150 x10^9/L). During the follow-up the patient underwent abdominal CT scan, which was negative for an accessory spleen. In November 2013, the ITP recurred with petechiae and platelets were 6 x10^9/L; platelet associated autoantibodies against GpIIb/IIIa (HPA 1a/3a) and GpIb (HPA 5b/5a) were positives. Since the patient was refractory to full doses of prednisone (1 mg/kg) and IV-Ig (1g/kg for 2 days), she was treated with increasing doses of romiplostim, (NPLATE®) (1 mcg/kg up to 3,5 mcg/kg) once a week for 26 weeks. The response to TPO-mimetic was fluctuating with both severe thrombocytosis and symptomatic thrombocytopenia needing platelet transfusions. The patient was then treated on April 2014 with Rituximab (375 mg/m x 4 doses) with complete response.
Results
The ITP remission continued until April 2015, when at 21st week of gestation, relapsed (Figure 1). She was treated again with prednisone and two IV-Ig courses with transitory response. After an unsuccessful course with dexamethasone (40mg/kg) we obtained the patient informed consent for the use of romiplostim (1 mcg/kg up to 10 mcg/kg) once a week for 3 weeks before delivery, without response. The elective caesarean delivery was performed on 26 week of pregnancy with the infusion of platelet concentrates due to a severe thrombocytopenia (platelets 3x10^9/L. Major bleeding complications did not occur, and baby's platelets were normal. After delivery, romiplostin was administered for other 10 weeks with fluctuating positive response (Figure 1). Because of the discontinuous response to romiplostim, we shifted to oral eltrombopag (Revolade® 50 mg/day) waiting for a new course with rituximab. Due to a severe thrombocytosis (platelet 1985 x10^9/L) the TPO mimetic has been withdrawal after only one week. The response to rituximab was complete and stable, steroid was gradually tapered until suspension and the ITP remitted without any therapy so far.
Conclusion
There are few case report on ITP treated with romiplostim during pregnancy, and no one showing fetal complications. Although TPO mimetics have not been indicated in pregnant ITP, it may represent an important alternative treatment choice for refractory cases because its speed of activity and an high rate of success. In our patient, we obtained a positive response to romiplostim during the first recurrence of ITP and after delivery but both responses were discontinuous without finding the lowest effective dose. Therefore we tried a switch to eltrombopag after delivery, but the response to the standard initial dose was characterized by an extreme thrombocytosis. We can speculate that TPO mimetic are safe during pregnancy in ITP but they may require more customized dosages mostly after delivery. Instead, using rituximab we obtained a complete and longstanding response showing the effectiveness of the combination of drugs that act by different but complementary mechanisms.
Session topic: E-poster
Keyword(s): Idiopathic thombocytopenic purpura (ITP), Pregnancy, Therapy
Type: Publication Only
Background
Maternal platelet count less than 20x10^9/L has been associated with risk of spontaneous bleeding, postpartum haemorrhage, and placental abruption. 5% of newborns will be born with platelets less than 20x10^9/L and less than 1% will have bleeding complications. Primary treatment options for maternal ITP are similar to those of non pregnant adult patients: corticosteroids and IV-Ig are the first-line treatments.
Aims
Describe a case of use of TPO-mimetic during pregnancy in refractory ITP.
Methods
We report a case of a 25 years old Moldovan woman with refractory chronic primary immune thrombocytopenia (ITP), diagnosed on 2002. On 2006 the patient underwent splenectomy with a partial response and low dose of prednisone (2.5 mg/die) obtaining a stable remission (platelets 150 x10^9/L). During the follow-up the patient underwent abdominal CT scan, which was negative for an accessory spleen. In November 2013, the ITP recurred with petechiae and platelets were 6 x10^9/L; platelet associated autoantibodies against GpIIb/IIIa (HPA 1a/3a) and GpIb (HPA 5b/5a) were positives. Since the patient was refractory to full doses of prednisone (1 mg/kg) and IV-Ig (1g/kg for 2 days), she was treated with increasing doses of romiplostim, (NPLATE®) (1 mcg/kg up to 3,5 mcg/kg) once a week for 26 weeks. The response to TPO-mimetic was fluctuating with both severe thrombocytosis and symptomatic thrombocytopenia needing platelet transfusions. The patient was then treated on April 2014 with Rituximab (375 mg/m x 4 doses) with complete response.
Results
The ITP remission continued until April 2015, when at 21st week of gestation, relapsed (Figure 1). She was treated again with prednisone and two IV-Ig courses with transitory response. After an unsuccessful course with dexamethasone (40mg/kg) we obtained the patient informed consent for the use of romiplostim (1 mcg/kg up to 10 mcg/kg) once a week for 3 weeks before delivery, without response. The elective caesarean delivery was performed on 26 week of pregnancy with the infusion of platelet concentrates due to a severe thrombocytopenia (platelets 3x10^9/L. Major bleeding complications did not occur, and baby's platelets were normal. After delivery, romiplostin was administered for other 10 weeks with fluctuating positive response (Figure 1). Because of the discontinuous response to romiplostim, we shifted to oral eltrombopag (Revolade® 50 mg/day) waiting for a new course with rituximab. Due to a severe thrombocytosis (platelet 1985 x10^9/L) the TPO mimetic has been withdrawal after only one week. The response to rituximab was complete and stable, steroid was gradually tapered until suspension and the ITP remitted without any therapy so far.
Conclusion
There are few case report on ITP treated with romiplostim during pregnancy, and no one showing fetal complications. Although TPO mimetics have not been indicated in pregnant ITP, it may represent an important alternative treatment choice for refractory cases because its speed of activity and an high rate of success. In our patient, we obtained a positive response to romiplostim during the first recurrence of ITP and after delivery but both responses were discontinuous without finding the lowest effective dose. Therefore we tried a switch to eltrombopag after delivery, but the response to the standard initial dose was characterized by an extreme thrombocytosis. We can speculate that TPO mimetic are safe during pregnancy in ITP but they may require more customized dosages mostly after delivery. Instead, using rituximab we obtained a complete and longstanding response showing the effectiveness of the combination of drugs that act by different but complementary mechanisms.
Session topic: E-poster
Keyword(s): Idiopathic thombocytopenic purpura (ITP), Pregnancy, Therapy
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