Current evidence and the emerging role of eltrombopag in severe aplastic anemia

Abstract

Acquired aplastic anemia (AA) is characterized by a reduced stem cell reserve. Several preclinical studies have confirmed the beneficial effect of thrombopoietin (TPO) on the expansion and maintenance of hematopoietic stem cells (HSCs). Thus, TPO receptor agonists seem to be an ideal therapeutic agent for AA to augment marrow function. First studies with eltrombopag as a single agent at 150 mg/day showed an overall response rate of 40-50% in patients with refractory severe AA (rSAA). Subsequent studies examined the first-line use of eltrombopag together with horse antithymocyte globulin and cyclosporine, reaching response rates up to 94%. Although used at high doses, known adverse events in the form of skin, gastrointestinal, or hepatic impairment are feasible in AA, however first data show a relatively high rate of clonal evolution in the form of karyotypic aberrations in patients with rAA. Nonetheless, there is a strong rationale that eltrombopag can contribute to restoring hematopoiesis in SAA by stimulating HSCs. Further studies are needed to decide if eltrombopag is clearly superior to current established treatments and to determine optimal treatment duration, dosage, and long-term effects.

Keywords: aplastic anemia; eltrombopag.

Figure 1.

Proposed mechanism of action of eltrombopag in aplastic anemia. (Adapted from Scheinberg, P. Activity of eltrombopag in severe aplastic anemia. Blood Adv 2018; 2: 3054–3062.) HSC, human stem cell; IFNɣ, interferon gamma; TGFβ, transforming growth factor beta; TNFɑ, tumor necrosis factor alpha.

Figure 2.

Proposed treatment algorithm for first-line treatment of acquired SAA/vSAA. HLA, human leukocyte antigen; HSCT, hematopoietic stem cell transplantation; IST, immunosuppression therapy; SAA, severe aplastic anemia; vSAA, very severe aplastic anemia.