A Non-Inferiority Trial of Perioperative Eltrombopag or Intravenous Immune Globulin for Immune Thrombocytopenia

Abstract

Background: Patients with immune thrombocytopenia (ITP) are at risk of bleeding during surgery. Intravenous immune globulin (IVIG) is a blood product that is commonly used to increase platelet counts before surgery or invasive procedures for patients with ITP; however, eltrombopag, an oral thrombopoietin receptor agonist, may be an effective alternative.

Methods: We conducted a multicenter randomised trial to determine whether eltrombopag was non-inferior to IVIG for the achievement of perioperative platelet count targets without the use of rescue treatment. We did an intention to treat and per-protocol analysis using an absolute non-inferiority margin of -10%. Secondary endpoints were thrombosis, bleeding, adverse events and treatment satisfaction. We enrolled 74 patients with ITP who had a planned major or minor surgery and with a platelet count below 100 x10⁹/L or 50 x10⁹/L respectively. Patients were randomised to receive oral daily eltrombopag from 21 days preoperatively, or IVIG (1 or 2g per kg) seven days preoperatively.

Findings: By intention to treat, perioperative platelet targets were achieved by 30 of 38 patients (78·9%) assigned to eltrombopag and 22 of 36 patients (61·1%) assigned to IVIG (absolute difference, 17·8%; one-sided lower limit of the 95% confidence interval, 0·4%; p=0·005 for non-inferiority). Results were similar for patients who completed the protocol. One patient in the eltrombopag group developed a pulmonary embolism 14 days after minor surgery, and one patient in the IVIG group developed a distal deep vein thrombosis 30 days after major surgery. There was no difference in bleeding or adverse events. Patients reported higher treatment satisfaction with eltrombopag.

Interpretation: Eltrombopag was no worse than IVIG for the achievement of platelet count targets around the time of surgery for patients with ITP. This population may be at increased risk of thrombosis.

Trial Registration: www.clinicaltrials.gov number as NCT01621204.

Funding Statement: This trial was funded by GlaxoSmithKline and Novartis.

Declaration of Interests: N.M.H., R.J.C., M.B., J.K., A.T., M.S., M.W., P.V., J.C., N.L., S.L., and J.G.K. report no competing financial interests. D.M.A. reports grants from GlaxoSmithKline and Novartis during the conduct of the study; grants and/or personal fees from Novartis, Amgen, Bristol Myers Squibb, UCB, Principia, and Rigel outside the submitted work. C.H. reports personal fees from Novartis, Amgen, and GSK, outside the submitted work. E.J. reports personal fees from Novartis, outside the submitted work. M.S. reports personal fees from Novartis, outside the submitted work. Y.L. reports grants from Novartis during the conduct of the study, and other fees from Pfizer, outside the submitted work. L.L. reports personal fees from Novartis during the conduct of the study. S.A. reports grants from Novartis NL during the conduct of the study; grants from Amgen, outside the submitted work. W.L. reports personal fees from Novartis, outside the submitted work.

Ethics Approval Statement: The trial was approved by the research ethics boards at each participating center. The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines.

Keywords: immune thrombocytopenia; eltrombopag; IVIG; peri-operative; Surgery