Case Report/Case Presentation
Our patient is a sixty years old Female who was diagnosed with ITP in
October 2018. At that time, an incidental finding of platelets count of
61,000/mm³ was identified. Work up was done and the diagnosis of ITP was
made by exclusion followed by starting the patient on steroid. One week
later, there was no significant improvement in platelets count as it
decreased from 61,000/mm³ to 33,000/mm³.
The decision to start Eltrombopag as second line was discussed with the
patient, he agreed and consent was taken. Eltrombopag started on
22/11/2018 with a dose of 25 mg daily. On next check up on 6/12/2018,
platelets count improved to 137,000/mm³.
Follow up appointment on 15/1/2019, the platelets count was found to be
40,000/mm³. Eltrombopag was increased to 50 mg daily which showed good
response on next follow up appointments by increasing platelets count to
121,00/mm² and 203,000/mm³ consequently in two weeks apart.
The patient maintained adequate platelets count throughout 2019 on
Eltrombopag 50 mg daily. In 22/04/2020, the patient developed left foot
pain, redness and swelling, he came to hospital and found to have
evidence of infection and high inflammatory markers. A diagnosis of
cellulitis was made and the patient started on oral antibiotic
(amoxicillin with clavulanate) and pain killers. At this time the
platelets count jumbled to be 536,000/mm³ as secondary reactive
thrombocytosis. Eltrombopag stopped on 30/4/2020 with close observation
of platelets count and patient clinical condition.
As patient was receiving treatment for cellulitis, platelets count was
maintained over the following two weeks after stopping Eltrombopag
between 150,000/mm³ and 200,000/mm³ without significant drop or bleeding
symptoms.
Two weeks later, the patient finished antibiotic and his clinical
condition improved. His platelets count was checked and found to be
100.000/mm³. Eltrombopag was restarted again on 19/05/2020 and platelets
count maintained without dropping. Last platelets count check was found
to be 143,000/mm³ on 20/8/2020 while the patient on Eltrombopag 50 mg
daily.
Discussion/Conclusion
Eltrombopag is an oral medication,
relatively new drug that stimulate the bone marrow to produce platelets.
It’s taken as once daily tablet on an empty stomach. Eltrombopag used to
correct thrombocytopenia that result from various condition such as ITP,
Aplastic anemia and chronic Hepatitis C infection associated
thrombocytopenia [4,5]. It is also important to note that
Eltrombopag is used to note that Eltrombopag may help to control the
condition but will not cure it.
Eltrombopag is usually started with low (12.5 mg or 25 mg daily). Then
the dose is gradually built up to maintain minimum platelets count
> 50,000/mm³ to prevent bleeding. Eltrombopag dose is
adjusted as following [6]:
- Platelets count < 50,000/mm³, the dose should be increased
gradually to reach minimum count of 50,000/mm³. maximum dose is 75 mg
daily.
- Platelets count between 50,000/mm² and 200,000/mm³, the dose should be
maintained with no change.
- Platelets count between 200.000/mm³ and 400,000/mm³, the dose should
be reduced by 25 mg daily. If taking 25 mg then to be reduced to 12.5
mg daily.
- Platelets count > 400,000/mm³, withhold dose; assess
platelet count twice weekly; when platelet count
<150,000/mm3, resume with the daily dose reduced by 25 mg
(if taking 25 mg once daily, resume with 12.5 mg once daily).
All of the above-mentioned dose modification is based on platelets count
increment that results from Eltrombopag use. With nothing mentioned
clearly about secondary reactive thrombocytosis.
In our case, we followed the guidelines by starting the patient on
initial dose of 25 mg daily, then and we built up to 50 mg daily to
reach stable platelets count above 50,000/mm³. The patient management
went smoothly and he was doing very well with stable platelets count and
no symptoms of bleeding for more than one year. When he developed
cellulitis, platelets count jumped to 536,000/mm³ representing
challenging situation to treating team. Literature was reviewed looking
for similar situation on how to adjust the dose of Eltrombopag in
reactive thrombocytosis but no clear recommendation found.
To avoid exposing the patient to risk of thrombus formation, we decided
to take the risk of stopping Eltrombopag taking in consideration that
platelets count could drop rapidly and bleeding may occur due to
underlying ITP. Fortunately, the challenging situation went safely and
the patient maintained platelets count above 50,000/mm³ throughout
cellulitis treatment period. No acute drop in platelets count occur, no
bleeding occurs and reactive thrombocytosis was enough to prevent
bleeding during Eltrombopag free period.
Conclusion;
Eltrombopag can be safely stopped during reactive secondary
thrombocytosis due to infection without fear of acute drop in platelets
count or bleeding. However, more studies are needed to reproduce the
same finding.