Advances in Treatment and Management of Immune Thrombocytopenia - Episode 9

Selecting an Oral TPO-RA for Chronic Immune Thrombocytopenia

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A brief discussion of factors that influence selection of oral versus injectable TPO-RA therapy for ITP.


Morey Blinder, MD: We obviously have 3 drugs available in this class: eltrombopag and avatrombopag—the 2 oral agents—and the injectable romiplostim. I think there are a couple of ways to look at this. One would be how to decide between the 2 oral agents, if you were going that route. Then would be how to decide between an oral agent and an injectable agent. I'd like to hear each of your perspectives. Let's start with the second one first. Danny, what are your thoughts about deciding between an oral agent and injectable agents? What goes into that decision-making?

Daniel Landau, MD: A lot of that is going to be based on patient preference, and frankly, when I'm offering an injectable versus an oral, it's rare that the injectable is preferred. It actually has come up, but for the most part, my patients are favoring the oral agent. I've had the conversation with some of my fellows about some patients where there may be compliance concerns and follow-up concerns where we at least know when they're coming in that they're being dosed and that they are receiving the drug. Sometimes starting an injectable on an inpatient is a little bit easier than starting an oral on an inpatient, so those are the general times that I've used the romiplostim in place of the oral agents. But if I had to just sort of estimate, I'd say it's probably beyond 90% of my patients who are on a TPO receptor agonist who are on 1 of the oral agents.

Morey Blinder, MD: Between the oral agents, do you want to comment on if there is a decision point? I think that's not an easy question to answer.

Daniel Landau, MD: Certainly. We've had eltrombopag available to us for a longer period of time, and our institution did participate in some of the early clinical studies. So, just based on the longer-term data and the longest time I've had in clinical practice to use it, I've developed a certain comfort level with eltrombopag. I have used a fair amount of avatrombopag in the folks who need surgery and have a liver dysfunction and sort of need it as a bridge to get through the surgery. I do have a conversation about both agents with the patient. Generally speaking, I don't think the patient has a strong priority one way or the other, but the longer-term data—the 7 years follow-up with 1 drug compared with another—offers at least some comfort.

Transcript edited for clarity.