Consensus on the Administration of TPO-RA as Second-Line Therapy in ITP
What is the role of thrombopoietin receptor agonists (TPO-RA) in the second line treatment of patients with immune thrombocytopenia (ITP)? Italian authors conducted a survey using the Delphi method among selected experts to gather answers to this question and recommendations for clinical practice. Here, we briefly summarize the key points of their consensus published last year.
Position of TPO-RA in the Management of ITP Treatment
Primary immune thrombocytopenia is an acquired autoimmune disease characterized by a decrease in blood platelets due to their increased peripheral destruction and disrupted production. The first line of treatment usually includes corticosteroids, or possibly intravenous immunoglobulins (IVIG). However, in many adults, ITP becomes persistent or chronic, necessitating consideration of second-line treatment. Options include rituximab, immunosuppression, splenectomy, or administration of thrombopoietin receptor agonists. The role of TPO-RA has been evolving in recent years, but clinical recommendations regarding their initiation and discontinuation remain unclear.
Agreed Recommendations Among Experts
The authors conducted a survey using the Delphi method among 11 specialists. They received answers to 5 factual questions regarding the position of TPO-RA as second-line treatment for ITP. Consensus (> 75% agreement) was reached on 3 out of 5 statements:
- Early switching from corticosteroids to TPO-RA offers a double benefit – reduced corticosteroid exposure and improved long-term clinical outcomes (100% agreement).
- Reducing the dose of TPO-RA can be considered in patients with a stable complete response (CR) and platelet count > 100 × 109/L, maintained for at least 6 months without the need for additional medication (100% agreement). However, when the same question was asked with a platelet count threshold of > 50 × 109/L, indicating partial remission, only a slight majority responded positively (54.5% agreement).
- Optimizing tapering or discontinuation of TPO-RA in select patients can improve quality of life (90.1% agreement).
Discussion and Conclusion
This method of survey is important and typically helps lay the foundation for creating national guidelines. The results showed that early initiation of TPO-RA benefits patients according to expert opinions, as well as the possibility of gradual discontinuation in select stable responders. Of course, questions remain regarding the approach to long-term stable partial responses, which will likely need to be addressed by clinical studies.
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Source: Carpenedo M., Baldacci E., Barate C. et al. Second-line administration of thrombopoietin receptor agonists in immune thrombocytopenia: Italian Delphi-based consensus recommendations. Ther Adv Hematol 2021 Oct 9; 12: 20406207211048361, doi: 10.1177/20406207211048361.
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