Romiplostim for Immune Thrombocytopenia (ITP) Treatment

Introduction to Romiplostim

• The American Society of Hematology recommends TPO-receptor agonists, including romiplostim, over rituximab for second-line treatment of adults with ITP lasting ≥3 months who have failed or are dependent on corticosteroids/immunoglobulins, with either TPO-RAs or splenectomy as appropriate choices 1, 2

Patient Selection and Timing

• The 2024 ASH guideline review confirms that TPO-RAs, including romiplostim, remain appropriate for adults with persistent and chronic ITP lasting ≥3 months who are corticosteroid-dependent or non-responsive 4

Positioning in Treatment Algorithm

• TPO-receptor agonists like romiplostim are preferred over rituximab for second-line therapy, while the choice between TPO-RAs and splenectomy should be based on patient-specific factors 1, 2, 5
• ASH guidelines suggest TPO-RAs rather than rituximab (conditional recommendation) for second-line treatment 1, 2, 5
• Either TPO-RAs or splenectomy is acceptable, with the choice depending on individual circumstances 1, 2, 5

Expected Efficacy

• Approximately 30% of patients achieve long-term (≥6 months) treatment-free remission after discontinuation of romiplostim, compared to only 9% spontaneous remission in untreated adults 3

Safety Considerations and Monitoring

• Bone marrow reticulin formation is a concern, with increased reticulin found in 10 or more patients in romiplostim trials 6

Romiplostim vs Eltrombopag

• Either romiplostim or eltrombopag is acceptable, with choice primarily driven by patient preference for route of administration (weekly subcutaneous injection vs daily oral medication) 1, 2
• No substantial differences in efficacy or safety between the two TPO-RAs 4, 5