The document discusses thrombocytopenia (low platelet count) and the use of eltrombopag to treat chronic immune thrombocytopenia. Eltrombopag is an oral thrombopoietin receptor agonist that stimulates platelet production. A 6-month study of 135 patients treated with eltrombopag found that 79% responded well with platelet counts between 50,000-400,000, with few serious bleeding events or thromboembolic risks compared to placebo. Transient increases in liver enzymes were reported in some patients treated with eltrombopag. The conclusions are that eltrombopag seems beneficial for patients who do not respond to other treatments for chronic immune thrombocytopenia, but further studies

1. Dr. V. Venkat Narayana Goutham.
1st year PG in INTERNAL MEDICINE.

2.  Thrombocytes or platelets are small, regularly
shaped clear cell fragments, 2–3 µm in
diameter, which are derived from fragmentation of
precursor megakaryocytes. The average lifespan of
a platelet is normally just 5 to 9 days. Platelets are a
natural source of growth factors. They circulate in the
blood of mammals and are involved in
hemostasis, leading to the formation of blood
clots.other functions include Clot retraction ,Pro-
coagulation, Inflammation ,Cytokine
signalling, Phagocytosis.

3.  In human beings a normal platelet count ranges from
1,50,000 to 4,50,000 platelets per microliter of blood
 Decreased platelet count than normal is known as
Thrombocytopenia.
 General clinical manifestations include
(skin)purpura,petechiae,ecchymoses-(mucous
membranes)epistaxis,haemorrhagic bullae in oral
mucosa,GI bleeding,genitourinary bleeding-fundal
haemorrhage and intracranial bleeding occur in
severe cases.

4. Causes
 DECREASED PRODUCTION-Vitamin B12 or folic acid
deficiency, Leukemia or myelodysplastic syndrome
,Decreased production of thrombopoietin by the liver in
liver failure, Sepsis, systemic viral or bacterial infection
Dengue fever , Hereditary syndromes(Congenital
amegakaryocytic thrombocytopenia (CAMT),
Thrombocytopenia absent radius syndrome, Fanconi
anemia, Grey platelet syndrome etc.
 INCREASED DESTRUCTION—NON
IMMUNOLOGIC(vasculitis,DIC,TTP,HUS)–
IMMUNOLOGIC(ITP,HIV,drugs like
heparin,quinine,methyldopa,valproic
acid,methotrexate,h2blockers and PPI etc)
 Other causes include Hypersplenism,dilutional(massive
blood transfusion).

5. CHRONIC IMMUME
THROMBOCYTOPENIA
 It was previously known as Idiopathic
Thrombocytopenic Purpura.
 Antiplatelet antibodies accelerate platelet destruction
and simultaneously prevent the release of platelets
from megakaryocytes resulting in mild to serious
bleeding.
 It is more frequent between 20 to 40 years,common
in females.
 Treatment includes platelet
transfusions, corticosteroids (prednisalone 1-2 mg
/kg for 2 to 4 weeks and reduced slowly) to induce
remission and splenectomy is indicated in adults
who did not respond to corticosteroids.

6. For the patients who did not
respond to corticosteroids or
splenectomy.
 Immunosuppressive therapy with
vincristine,vinblastin,azithioprine,cyclophosphamide
etc.
 Intravenous immunoglobulin(igG) and anti –RHD
globulin(Rh positive) provides temporary effect.

7. Eltrombopag
 It is an oral thrombopoetin receptor agonist which is
the physiological target of the hormone
thrombopoietin which stimulate platelet production.
 In preclinical studies, the compound was shown to
interact selectively with the thrombopoeitin receptor,
leading to activation of the JAK-STAT signaling
pathway and increased proliferation and
differentiation of megakaryocytes. Animal studies
confirmed that administration could increase platelet
counts. In healthy volunteers, higher doses of
eltrombopag caused larger increases in the number
of circulating platelets without tolerability problems.

8. EFFICACY OF
ELTROMBOPAG IN 6 MONTH
STUDY
 EFFICACY OF ELTROMOPAG WAS TESTED IN
ELIGIBLE PATIENTS who are suffering from past 6
months and has baseline counts less than 30,000
per microlitre.
 The dose includes 50mg once daily.Dose
modification was done from 25mg to 75mg based on
patient response. Assesed weekly for efficacy.

9.  Dose can be decreased to 25mg once daily if the
platelet counts increased higher than 2,00,000 per
microlitre.
 Post treatment assessment occurred at 1,2 and 4
weeks,3 and 6 months.
 Adverse events associated with the use may
include, but are not limited to, the
following:nausea,vomiting,myalgia etc.

10.  Findings between nov22,2006 and july 31,2007 ,197
patients----135 patients were treated with
eltrombopag ,62 were treated with placebo.79%
responded well,2%of the patients had
thromboembolic events compared to placebo.7% of
patients had increased alanine aminotransaminase
concentration,5% had increased bilirubin levels.only
1% of the patients had serious bleedingevents
compared to placebo group.

11. WHO Bleeding Scale
 Grade 0-no bleeding
 Grade 1-petechiae
 Grade 2-mild blood loss
 Grade 3-gross blood loss
 Grade 4-debilitating blood loss
 The rate of on-treatment bleeding events were
significantly lower in patients receiving
ELTROMBOPAG. Post treatment bleeding were also
reported to be lower.

12. DISCUSSION
 Our results showed that Eltrombopag maintained
platelet counts between 50,000 to 4,00,000 per
microlitre.
 Although eltrombopag was generally well tolerated
during treatment ,transient increases of alanine
aminotransaminase and indirect bilirubin
concentrations were reported.
 All aminotransferase and bilirubin should be
monitored before initiation of and during eltrombopag
treatment and stopped if necessary.

13.  Eltrombopag treatment should proceed with caution
in patient with known predispostion to thrombosis
and patients at risk of thrombosis should be closely
monitored.
 There was no evidence of worsened
thrombocytopenia and serious bleeding after
discontinuation of eltrombopag.
 Close monitoring of platelet count should be done for
atleast two weeks after stoppage of treatment.

14. CONCLUSION
 On the basis of these findings,eltrombopag seems to
be beneficial for patients who have not responded to
splenectomy or who have had temporary or
negligible responses to treatment such as
corticosteroids,immunoglobulins or continued to
have bleeding symptoms.
 Additionally eltrombopag might be considered for
some patients with chronic immune
thrombocytopenia who have not undergone
spleenectomy.

15.  FURTHER STUDIES WILL HELP TO ESTABLISH
HOW ELTROMBOPAG SHOULD BEST BE USED
IN THE MANAGEMENT OF PATIENTS WITH
CHRONIC IMMUNE THROMBOCYTOPENIA.

16.  THANK YOU