Orlando, Florida—Eltrombopag may be superior to intravenous immune globulin (IVIG) for the achievement of platelet count targets in patients with immune thrombocytopenia (ITP) undergoing major and minor surgery, according to results from a multi-center, randomized trial presented at the 2019 ASH Annual Meeting.

“Patients with ITP may require treatment to raise the platelet count before surgery. IVIG is commonly used for this purpose, but eltrombopag, an oral thrombopoietin receptor agonist, may be a good alternative,” explained Donald M. Arnold, MD, Department of Medicine, McMaster University, Hamilton, Ontario, Canada, and colleagues.

Thus, Dr Arnold and co-investigators conducted a noninferiority trial comparing perioperative eltrombopag with IVIG for achieving targeted platelet counts for major or minor surgery.

The trial enrolled patients with ITP and a platelet count of <100x109/L before major surgery or <50x109/L before minor surgery. Patients were randomized to receive daily eltrombopag starting 3 weeks before surgery or IVIG 1 week before surgery. Eltrombopag was discontinued 1 week after surgical hemostasis, and a repeat dose of IVIG was permitted up to 1 week after surgical hemostasis.

The primary end point of the study was the achievement of platelet counts (90 x109/L for major surgery and 45 x109/L for minor surgery) before and after surgery. Intention-to-treat (ITT) and per-protocol analyses were completed using a 1-sided test for the difference in rates of achieving perioperative platelet count targets with a non-inferiority margin of 10% at a significance level of 0.05.

A total of 74 patients were enrolled on the study. Of these patients, 38 received eltrombopag and 36 received IVIG before undergoing major (n = 31) or minor (n = 43) surgery.

Ultimately, 30 (78.9%) patients who received eltrombopag achieved perioperative platelet count targets compared with 22 (61.1%) who received IVIG. Eltrombopag was superior to IVIG in the ITT analysis (P = .047) but not in the per-protocol analysis (P = .074).

Dr Arnold and colleagues noted that 1 patient developed a pulmonary embolism 14 days after minor surgery and 7 days after stopping eltrombopag when their platelet count was 135 x109/L.

In addition, 2 (11.1%) of 18 patients who underwent splenectomy and received eltrombopag had post-splenectomy thrombocytosis.

“Eltrombopag is noninferior and may be superior to IVIG for achieving target platelet counts perioperatively for patients with ITP,” Dr Arnold concluded.—Janelle Bradley

Arnold DM, Heddle N, Cook R, et al. Perioperative Eltrombopag or Intravenous Immune Globulin for Patients with Immune Thrombocytopenia: A Multicenter Randomized Trial. Presented at: the 2019 ASH Annual Meeting & Exposition; December 7-10, 2019; Orlando, FL. Abstract 896