Eltrombopag: More Than Just a Thrombopoietin Receptor Agonist (TPO-RA) in Immune Thrombocytopenia (ITP)
Authors: Sayed Anwar A. , Malik Amna , Ayoola Grace , Lucchini Elisa , Candrianita Sasfia , Tan Michelle H , Vladescu Camelia , Paul Deena , Hart Alice C J , Khoder Ahmad , Imami Nesrina , Cooper Nichola 
Published: November 2019

Immune thrombocytopenia (ITP) is an autoimmune disorder characterized by a skewed proinflammatory T cell profile. Thrombopoietin-receptor agonists (TPO-RA) have largely replaced immunosuppressants in the management of this disorder, with some patients achieving remission after a period of treatment with TPO-RA. The potential immune modulatory role of TPO-RA has not been fully investigated.
The two current TPO-RA licensed for use in ITP; Eltrombopag (Elt) and Romiplostim (Romi) act on different parts of the TPO-R and have similar response rates. However, patients can respond to one agent but not the other. Elt has been described to have a strong iron chelating effect, and hence we propose that it may have an additive immunomodulatory effect on the T cells, absent in Romi. We determined the immunomodulatory effect of Elt by assessing the proliferation and functionality of T-cell lines and primary T-cells.
T cell proliferation was assessed using both CFSE proliferation assay and MTT cell viability assay. T cell phenotype and functionality were assessed by multicolor surface and intracellular flow cytometric staining. Cells were co-cultured with Elt and Romi in vitro and ex vivo with both Jurkat and DG75 cells lines as well as primary cells, respectively. Deferoxamine (DFX) was used as a positive control for iron-chelation, and human TPO was used as a positive control for TPO-RA. All treatment doses were based on their calculated therapeutic serum levels. Mann Whitney U and Kruskal-Wallis H statistical tests were applied where applicable, and a P value of less than 0.05 were considered significant.
Elt significantly decreased Jurkat T cells proliferation in a dose-dependent manner compared to no treatment and Romi. DFX, an iron chelator, also decreased Jurkat T cell proliferation to comparable levels of Elt. Interestingly, this anti-proliferative effect of Elt was only observed on Jurkat T cells, but not DG75 B cell line.
Ex vivo CFSE proliferation assay was performed on primary CD4 and CD8 T cells assessing the antiproliferative effect of Elt. Elt significantly reduced proliferation compared to no treatment. DFX exhibited a similar antiproliferative effect on primary T cells, however, less potent compared to Elt. Neither Romi nor TPO affected the proliferation of Jurkat cells, DG75 cells or primary T cells.
The functionality of CD4 and CD8 T cells was assessed based on the capacity of T cells to produce intracellular TNFα, IFNγ and Granzyme B. Elt significantly reduced the percentages of TNFα+/IFNγ+ CD4+ and CD8+ T cells in a dose-dependent manner. This reduction was also observed, albeit to a lesser extent, when T cells were treated with DFX. Furthermore, Granzyme B expression in CD8+ T cells was significantly reduced when cells were treated Elt, compared to no treatment. Romi did not affect the frequency of CD8+ TNFα+/IFNγ+ populations nor the expression of Granzyme B in CD8+ T cells. CD4+ and CD8+ T cells did not express TPO-R on their surface.
To confirm the immunomodulatory role of Elt in vivo, the terminally-differentiated effector (CD45RA+CD62L-) CD8+ T cells were assessed in 13 Elt-treated patients and 11 Romi-treated patients. Patients on Elt had significantly reduced frequency of effector CD8 T cells compared to Romi-treated patients (44% vs 76.8%; p<0.01).
Taken together, these novel findings suggest an off target immunomodulatory nature of Elt besides its thrombopoietic effect. This dose-dependent immunomodulatory effect is not TPO-R dependent and targets T cells primarily. This study is the first to display such property of Elt and could explain why there is a differential response to Elt and Romi. We hypothesise that Elt may be more effective in patients with T cell mediated disease, whilst patients with predominantly antibody mediated disease are more likely respond to Romi. These findings can also offer an explanation for Elt effectiveness in other T cell-mediated autoimmune conditions such as Aplastic Anemia.

Disclosures
Cooper: Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Rigel: Consultancy, Membership on an entity's Board of Directors or advisory committees; Principia: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.