From the Guidelines
Abrupt interruptions of TPO-RAs or excessive dose adjustments should be avoided to prevent platelet fluctuations. Fluctuations in platelets can be a concern in patients with immune thrombocytopenia, particularly those on second-line therapy with thrombopoietin receptor agonists (TPO-RAs) such as eltrombopag or romiplostim 1. The optimal use of TPO-RAs involves using the minimum dose necessary to maintain a target platelet count and prevent bleeding. If a patient achieves a stable platelet count at the lowest recommended dose, it is recommended to hold the TPO-RA and monitor the platelet count closely to assess for potential remissions 1.
Key Considerations
- Platelet fluctuations are more common with romiplostim and may be resolved by switching to eltrombopag 1.
- Splenectomized patients may experience more frequent platelet fluctuations due to the absence of normal splenic functions, including platelet sequestration 1.
- Patients who do not respond to or do not tolerate a TPO-RA may switch to the alternate TPO-RA, with the majority responding to the alternate treatment 1.
Monitoring and Treatment
- Regular blood tests may be recommended to monitor platelet levels and adjust treatment as needed.
- Treatment depends on the underlying cause of the platelet fluctuations and may involve medication adjustments, treating infections, or specific therapies for blood disorders.
- Severe thrombocytopenia increases the risk of bleeding and may require immediate treatment.
From the FDA Drug Label
Your healthcare provider will check your platelet count during your treatment with ALVAIZ and change your dose of ALVAIZ as needed. The FDA drug label for eltrombopag (ALVAIZ) mentions that the healthcare provider will check the platelet count during treatment and adjust the dose as needed, which implies that fluctuations in platelets can occur and will be monitored.
- The label does not provide specific information on the management of fluctuations in platelets, but it emphasizes the importance of regular monitoring of platelet counts.
- It is essential to follow the healthcare provider's instructions and attend scheduled check-ups to ensure that any fluctuations in platelet counts are promptly addressed 2.
From the Research
Fluctuations in Platelets
- Fluctuations in platelet count levels over time may help distinguish immune thrombocytopenia (ITP) from other causes of thrombocytopenia, as seen in a study published in 2021 3
- A high platelet variability index (PVI) score correlated with the diagnosis of definite ITP, even when calculated at the patient's initial assessment, before any treatment had been administered 3
- Platelet count fluctuations alone contributed to the specificity of the overall PVI score, which may help clinicians diagnose ITP among patients who present with thrombocytopenia for evaluation 3
Causes and Treatment of Thrombocytopenia
- Thrombocytopenia can occur from decreased platelet production, increased destruction, splenic sequestration, or dilution or clumping, and patients with a platelet count greater than 50 × 10^3 per μL are generally asymptomatic 4
- Common causes of thrombocytopenia include drug-induced thrombocytopenia, immune thrombocytopenia, and hepatic disease, and treatment may involve transfusion of platelets, especially when patients have active hemorrhage or when platelet counts are less than 10 × 10^3 per μL 4
- The use of thrombopoietin receptor agonists (TRAs) such as romiplostim and eltrombopag has been shown to be effective and safe in the treatment of ITP, and switching between these medications can be a successful way to overcome adverse effects and inadequacy 5, 6
Comparison of Thrombopoietin Receptor Agonists
- Romiplostim and eltrombopag have been compared in terms of clinical effectiveness, cost-effectiveness, adverse effects, and the possibility of switching between them in case of ineffectiveness, with both medications appearing to be largely effective and safe 6
- A real-world evidence study found that patients receiving eltrombopag experienced significantly reduced bleeding-related episodes, severe bleeding-related episodes, rescue medication use, and platelet transfusions, compared to those receiving romiplostim 7
- Diarrhea and headache were significantly less frequent in patients receiving eltrombopag, while other adverse events occurred equally in both groups 7