The Annals of Pharmacotherapy □. 2012 November ... DISCUSSION: The primary clinical concern in this elderly patient with multiple co- morbidities was to ...
CASE REPORTS
Use of Romiplostim in a Hemodialysis Patient with Primary Immune Thrombocytopenia Hassan Al-Jafar, Aristoteles Giagounidis, Kamel El-Rashaid, Masouma Al-Ali, and Abbas A Hakim
irst-line treatment for primary immune thrombocytopenia (ITP) generally comprises corticosteroids, intravenous immunoglobulin (IVIG), anti-D immunoglobulin, or a combination of these agents.1,2 Treatment nonresponse is common, however, and most adults require second-line treatment that may include cytotoxic agents, the anti-CD -20 monoclonal antibody rituximab, or splenectomy to remove the primary site of platelet destruction. Recently, thrombopoietin receptor agonists such as eltrombopag and romiplostim have emerged as alternative second-line therapeutic options that stimulate platelet production.3-6 To date, clinical studies with romiplostim have not evaluated efficacy and safety in patients with ITP and renal impairment, and it is unclear whether the peptibody is eliminated during hemodialysis or whether the frequency of hemodialysis impacts its efficacy.7 We report the successful management of a patient with primary ITP, stage V renal failure, and chronic hepatitis C virus (HCV) infection with romiplostim after treatment failure with corticosteroids, IVIG, eltrombopag, and rituximab.
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OBJECTIVE:
To present the case of a patient with primary immune thrombocytopenia (ITP), renal impairment, and chronic hepatitis C virus (HCV) infection who was treated with platelet transfusions, intravenous immunoglobulin (IVIG), corticosteroids, eltrombopag, rituximab, and romiplostim in an attempt to raise platelet counts to a clinically acceptable level.
CASE SUMMARY: A 71-year-old man with end-stage renal disease (ESRD) was on maintenance hemodialysis and had long-term diabetes mellitus, chronic obstructive pulmonary disease, and other comorbidities. He was admitted with epistaxis, severe thrombocytopenia, and a platelet count of 4 × 109/L. Platelet transfusions, treatment with IVIG, corticosteroids, eltrombopag, and rituximab resulted in transient and inadequate increases in platelet counts. Further bleeding manifestations, including epistaxis, melena, hematomas, and ecchymotic patches prompted treatment with blood product concentrates and a higher dose of eltrombopag, resulting in a further lack of clinical response. After 6 weeks of failed treatment attempts, initiation of weekly treatment with romiplostim 5 µg/kg resulted in rapid stabilization (within a week) of platelet counts in the range of 200 × 109/L. The patient was discharged, with subsequent dose adjustment of weekly romiplostim treatment to 2.5 µg/kg, continued hemodialysis, and a return to normal daily activities. DISCUSSION:
The primary clinical concern in this elderly patient with multiple comorbidities was to lower the bleeding risk associated with consistent thrombocytopenia. Despite the lack of clinical data to support the efficacy and safety of romiplostim in patients with ITP and renal impairment, stimulation of platelet production with romiplostim was a reasonable approach in view of the bleeding risk and following nonresponse to treatment with corticosteroids, IVIG, eltrombopag, and rituximab. To our knowledge, this case represents the first successful use of romiplostim to manage primary ITP in the presence of ESRD and concurrent chronic HCV infection in a patient on hemodialysis.
CONCLUSIONS:
Romiplostim appears to be a viable option for treatment of ITP in a patient with ESRD and chronic HCV infection following nonresponse to treatment with corticosteroids, IVIG, eltrombopag, and rituximab.
KEY WORDS:
primary immune thrombocytopenia, renal dialysis, romiplostim, treatment resistance.
Ann Pharmacother 2012;46:e31. Published Online, 31 Oct 2012, theannals.com, doi: 10.1345/aph.1R134 Author information provided at end of text.
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Case Report A 71-year-old Kuwaiti man with end-stage renal disease (ESRD) on 3 times weekly maintenance hemodialysis via a right central venous catheter also had long-term diabetes mellitus with associated nephropathy, retinopathy, neuropathy, dyslipidemia, and hypertension; chronic obstructive pulmonary disease; prostate hypertrophy; Parkinson syndrome; and chronic HCV infection with a high viral load (650,192 IU/mL, reference
