Romiplostim: A Bridge To Splenectomy In Three Patients With Refractory Immune Thrombocytopenia (ITP)

Background Ten to thirty percent of patients with immune thrombocytopenia (ITP) do not respond to initial therapy. Options for such patients include Rituximab, TPO-mimetic agents and splenectomy. We report on three patients with refractory ITP and significant thrombocytopenia who received romiplostim as a bridge to splenectomy. Methods Three patients with isolated ITP or Evans syndrome did not respond to steroids, intravenous immune-globulin (IVIG) or Rituximab. Romiplostim was given to increase the platelet count prior to laparoscopic splenectomy. Before surgery the bone marrow was evaluated and patients were vaccinated. We reviewed their baseline clinical characteristics, and clinical course. Results Patient 1: 51 y/o M presented with fatigue and melena. Laboratory data showed hemoglobin (Hgb) of 7.9 g/dl, platelet (plt) count of Download : Download high-res image (86KB) Download : Download full-size image Figure 1 . Clinical course of Pt 1. Patient 2: 28 y/o F presented with bruising and plt count of 12,000/uL. She was treated with 5 days of dexamethasone with transient improvement in plt count to 50,000/uL which rapidly dropped to Patient 3: 66 y/o M with coronary artery disease and long standing ITP was on prednisone 10-20 mg/day with plt count of 10-20,000/uL. Because of side effects of steroids, he was treated with danazol and rituximab (6 weeks) with no response in plt count. Cardiac catheterization prior to splenectomy could not be done because of thrombocytopenia. Romiplostim was then started at dose of 1 mcg/kg and advanced weekly to 3 mcg/kg with improvement in counts to 60,000/uL with peak of 200,000/uL. Cardiac catheterization was normal and he underwent successful laparoscopic splenectomy. Plt count before splenectomy was 73,000/uL and increased to 513,000/uL post-op. The plt count decreased to 120,000/uL and has remained stable for more than two years without further treatment. Conclusions Rituximab and TPO-mimetic agents are increasingly used for treatment of relapsed, refractory ITP as an alternative to splenectomy. Rituximab has a significant relapse rate. TPO-mimetic agents are expensive, require lifelong use, and are associated with rebound thrombocytopenia in those who stop treatment. Long-term use has also been associated with reversible bone marrow fibrosis and thromboembolism. Laparoscopic splenectomy is a safe procedure that is ideally done after a platelet response to high dose steroids and/or IVIG to reduce bleeding risk. Two of our patients were refractory to Rituximab. One received Rituximab concurrently with Romiplostim. All 3 patients did not want long term treatment with a TPO agent and had low platelet counts that were an impediment to surgery. We found that a short course of Romiplostim increased the platelet counts enough to enable surgery. All 3 patients achieved sustained remissions requiring no further treatment. No rebound thrombocytopenia was observed after stopping Romiplostim and none of the patients had bleeding or thrombotic complications. This case series suggests that a short course of Romiplostim can be used safely and effectively as a bridge to splenectomy for patients with refractory ITP. Disclosures: No relevant conflicts of interest to declare.