Efficacy and Safety of Eltrombopag for Refractory Thrombocytopenia Associated With Connective Tissue Disease

Efficacy and Safety of Eltrombopag for the Treatment of Refractory Thrombocytopenia Associated With Connective Tissue Disease

Immune thrombocytopenia (ITP) is a haemorrhagic disorder often associated with CTD. Corticosteroids are the first-line treatment for CTD-associated thrombocytopenia, but not all patients respond well. Eltrombopag is an oral, small molecule thrombopoietin receptor agonist. It interacts with the transmembrane domain of the thrombopoietin receptor and stimulates platelet production. This study is designed to evaluate the efficacy and safety of eltrombopag in patients with refractory CTD-ITP. It is a single-centre, retrospective, observational study involving a cohort of 52 patients diagnosed with CTD-RITP who received eltrombopag between 2013 and 2023. Follow-up data will be systematically collected and analysed to evaluate the therapeutic efficacy and safety of the drug. The study will provide valuable insight into the benefit of eltrombopag in CTD-RITP by reviewing baseline characteristics and performing subsequent clinical assessments to determine drug response and adverse events.

Study Overview

• Status: Completed
• Conditions: Connective Tissue Diseases; Refractory Thrombocytopenia
• Intervention / Treatment: Drug: Eltrombopag

Detailed Description

Immune thrombocytopenia (ITP) is a hemorrhagic disorder typically attributed to the formation of autoantibodies against platelet antigens. Patients experience decreased platelet count, clinically presenting as purpura, petechiae, mucosal bleeding, and increased menstrual bleeding. ITP is often associated with connective tissue diseases (CTD), with reports indicating a concurrent presence of ITP in 10%-15% of systemic lupus erythematosus (SLE) patients and 7.8% of primary Sjögren's syndrome (SS) patients.

Currently, corticosteroids are the first-line therapy for CTD-associated thrombocytopenia, with second-line options including immunosuppressive agents, intravenous immunoglobulin (IVIG), splenectomy, and rituximab. However, not all patients respond favorably to these treatments. Patients with CTD who are unresponsive or have a low response to conventional first- and second-line therapies, with platelet counts below 30×10^9/L, are considered to have CTD-related refractory ITP (RITP). There are currently no internationally unified diagnostic criteria for RITP. For adult RITP diagnosis, criteria proposed by George et al. include: being diagnosed with ITP under the premise that treatment with glucocorticoids and/or splenectomy is ineffective; age ≥18 years; ③ duration of illness >6 months; ④ absence of other conditions causing thrombocytopenia; ⑤ platelet count ≤30×10^9/L.

Eltrombopag is an oral, small-molecule, non-peptide thrombopoietin receptor agonist that interacts with the transmembrane domain of the thrombopoietin receptor, stimulating platelet production and increasing platelet counts. To evaluate the efficacy and safety of eltrombopag in CTD-RITP, this study will conduct a single-center retrospective observational analysis of 52 patients with CTD-RITP who received eltrombopag treatment between 2013 and 2023, recording their follow-up information. Patient characteristics at baseline will be analyzed, and drug efficacy and safety will be assessed through follow-up examinations at different time points.

During treatment, patients may receive other ITP medications for maintenance therapy (such as glucocorticoids, azathioprine, danazol, cyclosporine A, and mycophenolate mofetil), excluding those concurrently using other TPO receptor agonists. Patient follow-up examinations will be continuously recorded (for at least six months, with monthly records, and patients followed until the last follow-up time if less than six months). Univariate analysis (descriptive analysis or non-parametric tests), single and multiple logistic regression analysis, and multiple correspondence analysis (MCA) will be used to analyze early clinical predictive factors for drug response. Patient drug responsiveness will be judged based on laboratory test results and clinical symptoms: ① Complete remission (CR): PLT ≥100×10^9/L with no bleeding tendency; ② Partial remission (PR): PLT ≥50×10^9/L but <100×10^9/L with no bleeding tendency, or platelet count at least twice that of pre-treatment; ③ No remission (NR): Does not meet criteria ① or ②. Mann-Kendall test will be used to analyze trends in PLT changes among patients during treatment, and the rates of CR, PR, and NR at different time points (4, 8, 12, 24 weeks) will be calculated to determine drug onset time and remission degree. The incidence of major adverse reactions to eltrombopag (hepatotoxicity, thrombosis) will be statistically analyzed at 24 weeks to assess drug safety.

This project aims to evaluate the efficacy and safety of eltrombopag in treating CTD-RITP patients, providing evidence for formulating treatment plans for CTD-RITP patients. It aims to guide physicians in considering the use of eltrombopag when selecting treatment methods, understanding individual differences in patient response to eltrombopag efficacy, and helping physicians develop more personalized treatment plans based on early clinical predictive factors to improve treatment targeting and effectiveness. Furthermore, it aims to observe the long-term effects of eltrombopag treatment and explore the optimal dosage, course of treatment, and best combination therapy with other drugs.

• Study Type: Observational
• Enrollment (Actual): 52

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Non-Probability Sample

Study Population

In this study, a total of 52 CTD patients fulfilling refractory ITP criteria were enrolled, and all received oral eltrombopag at 25 to 75 mg once daily after failing to respond to conventional treatment of corticosteroids for more than one year. The time of follow-up ranged from 1 month to 15 months.

1. Age at diagnosis, median (IQR) 45(34-60)
2. Female, n (%) 43(82.7)
3. SLE, n (%) 28(53.9)
4. SS, n (%) 15(28.9)

Description

Inclusion Criteria:

1. The patient is diagnosed with CTD, SLE, SS, APS, MCTD, ANCA or RA according to international diagnostic criteria;
2. The patient meets the diagnostic criteria of RITP: (i) glucocorticoid therapy and/or splenectomy is ineffective; (ii) age ≥18 years; (iii) duration of the disease >6 months; (iv) no other diseases leading to thrombocytopenia; (v) platelet count ≤30×109/L;
3. At the time of enrolment, patients have received ineffective conventional first-line treatment for one year or more;
4. Enrolled patients need to be aware of the clinical information they are being given.

Exclusion Criteria:

1. The patient has a history of lymphoproliferative disease or malignancy of any organ system within the last 5 years;
2. The patient has a combination of other autoimmune diseases or malignant haematological diseases;
3. Patient's intermittent use of medication and failure to take medication as prescribed;
4. Patient refuses to participate in this study.

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
El-treatment; patients receive oral eltrombopag at 25 to 75 mg once daily during the course.	Drug: Eltrombopag; patients receive oral eltrombopag at 25 to 75 mg once daily according to disease severity，with the treatment of DMARDs at minimal or routine dosages.; Other Names: Promacta

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
platelet counts of 52 patients from baseline after taking eltrombopag (Therapeutic effects-for refractory CTD-related ITP)	Platelet counts are measured to determine remission status (CTD-RITP). Partial remission is defined as platelet counts ≥ 50 × 10^9/L, and complete remission is defined as platelet counts ≥ 100 × 10^9/L.	Baseline, post-intervention week 4, post-intervention week 8, post-intervention week 12, post-intervention week 24

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
changes in disease activity index (Systemic Lupus Erythematosus Disease Activity Index 2000 for SLE patients and EULAR Sjögren's Syndrome Disease Activity Index 2000 for pSS patients) from baseline after taking Eltrombopag	Disease activities are measured in SLE patients by the SLEDAI (systemic lupus erythematosus disease activity index 2000) and in SS patients by the ESSDAI (EULAR Sjögren's syndrome disease activity index 2000), which indicate patients' remission from treatment. For Systemic Lupus Erythematosus Disease Activity Index 2000, the minimum score is 0 and the maximum score is 105. With a score of 5 or more, the disease is considered active. For EULAR Sjögren's Syndrome Disease Activity Index 2000, the minimum score is 0 and the maximum score is 51. With a score of 5 or more, the disease is considered active. The lower the disease activity, the more effective Eltrombopag is.	Baseline, post-intervention week 4, post-intervention week 8, post-intervention week 12, post-intervention week 24

Collaborators and Investigators

• Sponsor: Tongji Hospital
• Investigators: Principal Investigator: Lingli Dong, MD, Tongji Hospital

Study record dates

Study Major Dates

• Study Start (Actual): May 6, 2013
• Primary Completion (Actual): May 11, 2023
• Study Completion (Actual): November 19, 2023

Study Registration Dates

• First Submitted: June 4, 2024
• First Submitted That Met QC Criteria: June 12, 2024
• First Posted (Actual): June 14, 2024

Study Record Updates

• Last Update Posted (Estimated): June 17, 2024
• Last Update Submitted That Met QC Criteria: June 13, 2024
• Last Verified: June 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Hematologic Diseases; Blood Platelet Disorders; Cytopenia; Connective Tissue Diseases; Thrombocytopenia
• Other Study ID Numbers: TJ-IRB202404119

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No