Eltrombopag for Low-Risk Myelodysplastic Syndromes With Thrombocytopenia: Interim Results of a Phase II, Randomized, Placebo-Controlled Clinical Trial (EQOL-MDS)

Author(s): Esther Natalie Oliva, MD¹; Marta Riva, MD²; Pasquale Niscola, MD³; Valeria Santini, MD⁴; Massimo Breccia, MD⁵; Valentina Giai, MD⁶; Antonella Poloni, MD⁷; Andrea Patriarca, MD⁸; Elena Crisà, MD⁹; Isabella Capodanno, MD¹⁰; Prassede Salutari, MD¹¹; Gianluigi Reda, MD¹²; Nicola Cascavilla, MD¹³; Dario Ferrero, MD¹⁴; Attilio Guarini, MD¹⁵; Giovanni Tripepi, PhD¹⁶; Giuseppe Iannì, BSc¹⁷; Emilio Russo, PhD¹⁸; Andrea Castelli, MD¹⁹; Bruno Fattizzo, MD^12,20; Germana Beltrami, MD²¹; Monica Bocchia, MD²²; Alfredo Molteni, MD²³; Pierre Fenaux, MD²⁴; Ulrich Germing, MD²⁵; Alessandra Ricco, MD²⁶; Giuseppe A. Palumbo, MD, PhD²⁷; Stefana Impera, MD²⁸; Nicola Di Renzo, MD²⁹; Flavia Rivellini, MD³⁰; Francesco Buccisano, MD³¹; Aspasia Stamatoullas-Bastard, MD³²; Anna Marina Liberati, MD³³; Anna Candoni, MD³⁴; Ilaria Maria Delfino, BSc¹; Maria Teresa Arcadi, BSc³⁵; Patrizia Cufari, BSc¹; Lorenzo Rizzo, MD³⁶; Irene Bova, BSc³⁷; Maria Grazia D’Errigo, BSc³⁷; Gina Zini, MD^38,39; and Roberto Latagliata, MD⁴⁰

Source: DOI: 10.1200/JCO.22.02699 Journal of Clinical Oncology 41, no. 28 (October 01, 2023) 4486-4496

Dr. Maen Hussein's Thoughts

Eltrombopag improved platelet count and decreased bleeding , was safe, but did not affect progression to AML or survival. May consider in severe thrombocytopenia to help improve quality of life.

PURPOSE

In myelodysplastic syndromes (MDS), severe thrombocytopenia is associated with poor prognosis. This multicenter trial presents the second-part long-term efficacy and safety results of eltrombopag in patients with low-risk MDS and severe thrombocytopenia.

METHODS

In this single-blind, randomized, placebo-controlled, phase-II trial of adult patients with International Prognostic Scoring System low- or intermediate-1-risk MDS, patients with a stable platelet (PLT) count (<30 × 103/mm3) received eltrombopag or placebo until disease progression. Primary end points were duration of PLT response (PLT-R; calculated from the time of PLT-R to date of loss of PLT-R, defined as bleeding/PLT count <30 × 103/mm3 or last date in observation) and long-term safety and tolerability. Secondary end points included incidence and severity of bleeding, PLT transfusions, quality of life, leukemia-free survival, progression-free survival, overall survival and pharmacokinetics.

RESULTS

From 2011 to 2021, of 325 patients screened, 169 patients were randomly assigned oral eltrombopag (N = 112) or placebo (N = 57) at a starting dose of 50 mg once daily to maximum of 300 mg. PLT-R, with 25-week follow-up (IQR, 14-68) occurred in 47/111 (42.3%) eltrombopag patients versus 6/54 (11.1%) in placebo (odds ratio, 5.9; 95% CI, 2.3 to 14.9; P < .001). In eltrombopag patients, 12/47 (25.5%) lost the PLT-R, with cumulative thrombocytopenia relapse-free survival at 60 months of 63.6% (95% CI, 46.0 to 81.2). Clinically significant bleeding (WHO bleeding score ≥ 2) occurred less frequently in the eltrombopag arm than in the placebo group (incidence rate ratio, 0.54; 95% CI, 0.38 to 0.75; P = .0002). Although no difference in the frequency of grade 1-2 adverse events (AEs) was observed, a higher proportion of eltrombopag patients experienced grade 3-4 AEs (χ2 = 9.5, P = .002). AML evolution and/or disease progression occurred in 17% (for both) of eltrombopag and placebo patients with no difference in survival times.

CONCLUSION

Eltrombopag was effective and relatively safe in low-risk MDS with severe thrombocytopenia. This trial is registered with ClinicalTrials.gov identifier: NCT02912208 and EU Clinical Trials Register: EudraCT No. 2010-022890-33.

Author Affiliations

¹U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy; ²Dipartimento di Ematologia, Ospedale Niguarda Ca’ Granda, Milano, Italy; ³U.O. di Ematologia, Ospedale Sant’Eugenio, Roma, Italy; ⁴U.O. di Ematologia, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy; ⁵Dipartimento di Ematologia Policlinico Umberto I, Università La Sapienza, Roma, Italy; ⁶S.C. a Direzione Universitaria di Ematologia A.O., SS. Antonio e Biagio e Cesare Arrigo Alessandria, Alessandria, Italy; ⁷Clinica di Ematologia Azienda Ospedaliera Universitaria—Ospedali Riuniti di Ancona, Ancona, Italy; ⁸AOU Maggiore della Carità, Novara, Italy; ⁹Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy; ¹⁰U.O. di Ematologia, A.U.S.L.-IRCCS di Reggio Emilia, Reggio Emilia, Italy; ¹¹Dipartimento Oncologico-Ematologico, Ospedale Civile Spirito Santo, Pescara, Italy; ¹²Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; ¹³U.O. Ematologia Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy; ¹⁴Dipartimento Biotecnologie Molecolari, Ematologia Universitaria A.O.U. Citta’ della Salute e della Scienza di Torino, Turin, Italy; ¹⁵U.O. Ematologia I.R.C.C.S. Istituto Tumori “Giovanni Paolo II”, Bari, Italy; ¹⁶IFC-CNR Institute of Clinical Physiology, Reggio Calabria, Italy; ¹⁷Dielnet SRL—CRO Reggio Calabria, Reggio Calabria, Italy; ¹⁸Department of Pharmacology, University of Germaneto Catanzaro, Catanzaro, Italy; ¹⁹SSD Ematologia Ospedale degli Infermi, Biella, Italy; ²⁰Dipartimento di Oncologia ed Emato-Oncologia, Università degli Studi di Milano, Milan, Italy; ²¹U.O. Ematologia e terapie cellulari, IRCCS Azienda Ospedaliera Universitaria San Martino, Genova, Italy; ²²UOC Ematologia, Università di Siena, Azienda Ospedaliera Universitaria Senese, Siena, Italy; ²³Divisione di Ematologia, ASST di Cremona, Cremona, Italy; ²⁴Groupe Francais desmyélodysplasies (GFM), Paris, France; ²⁵Department of Hematology, Oncology, and Clinical Immunology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany; ²⁶U.O. Ematologia con Trapianto, Azienda Ospedale Policlinicodi Bari, Bari, Italy; ²⁷Dipartimento di Scienze Mediche Chirurgiche e Tecnologie Avanzate “G.F. Ingrassia”, University of Catania, Catania, Italy; ²⁸U.O. C. Ematologia, A. O.ad Alta Specializzazione Ospedale Garibaldi Nesima, Catania, Italy; ²⁹U.O. di Ematologia, Ospedale Vito Fazzi, Lecce, Italy; ³⁰Divisione Ematologia, P.O. A. Tortora di Pagani-ASL Salerno, Pagani, Italy; ³¹Divisione di Biopatologia e Diagnostica per Immagini, Policlinico Universitario Tor Vergata, Rome, Italy; ³²Centre Henri Becquerel, Rue d’Amiens, Rouen, France; ³³S.C. Oncoematologia, Università degli Studi di Perugia A.O. Santa Maria, Terni, Italy; ³⁴Divisione Ematologia, P.O. Santa Maria della Misericordia, A.S.U.F.C di Udine, Udine, Italy; ³⁵U.O. Farmacia Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy; ³⁶Dipartimento di Ematologia, Ospedale Niguarda Ca’ Granda, Milan, Italy; ³⁷U.O.S. di Genetica Medica Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio di Calabria, Italy; ³⁸Fondazione Policlinico, Universitario A. Gemelli IRCCS, Rome, Italy; ³⁹Università Cattolica del Sacro Cuore, Rome, Italy; ⁴⁰Divisione di Ematologia, Ospedale Belcolle, Viterbo, Italy

Ianalumab plus Eltrombopag in Immune Thrombocytopenia

Ianalumab, a monoclonal antibody targeting B cells was assessed in adults with primary Immune Thrombocytopenia (ITP) and an insufficient response or a relapse after first-line glucocorticoid therapy at a dose of 9 mg or 3 mg per kilogram of body weight or placebo once monthly for 4 months with eltrombopag which was tapered to discontinuation by week 24. The time to treatment failure was significantly longer with ianalumab plus eltrombopag than with placebo plus eltrombopag with HR of 0.55 in the 9-mg group and 0.58 in the 3-mg group. The percentage of patients with a stable response at 6 months was significantly higher in the 9-mg group than in the placebo group (62% vs. 39%; P=0.045)

Immune thrombocytopenia in patients treated with immune checkpoint inhibitors Available to Purchase

This is a nice reminder that immune checkpoint inhibitors (ICI)-associated immune thrombocytopenia (ITP) is uncommon but definitely not benign~1 in 400 incidence with a meaningful subset recurring on rechallenge of 30%, and while most patients recover, severity clearly tracks with worse outcomes including higher mortality. It reinforces that even “rare” hematologic irAEs can carry real clinical weight, so early recognition and thoughtful decisions around rechallenge are key.

Romiplostim versus Placebo for Chemotherapy-Induced Thrombocytopenia

This is the first phase 3 data we’ve had for chemotherapy-induced thrombocytopenia, and romiplostim really moved the needle, 84% of patients were able to avoid CIT-driven dose reductions or delays versus just 36% with placebo, with a risk ratio of 2.8. Platelet nadirs were higher, responses were faster (median ≈1 week), and relative dose intensity was meaningfully better maintained across cycles. Bleeding wasn’t significantly different, but events were numerically lower, and this study wasn’t powered for that. Toxicity was largely chemo-related, with a small signal for thromboembolism (2%), so overall this feels like a practical tool to help maintain dose intensity in gastrointestinal tract (GI) cancers getting oxaliplatin-based regimens.

Monoclonal Antibodies in the Pathogenesis of Heparin-Induced Thrombocytopenia

This NEJM study challenges the long-held view that heparin-induced thrombocytopenia (HIT) is a polyclonal antibody disorder. Using mass spectrometry and immunofixation, the investigators found that all 9 patients with HIT had monoclonal, platelet-activating anti–PF4–heparin antibodies, with 67% showing a detectable M-protein by immunofixation. Functional assays confirmed that only the monoclonal fraction was pathogenic. It looks like HIT is driven by a single rogue antibody clone, which could have big implications for diagnostics and targeted therapy—this would be a paradigm shift for how we think about this disease.