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Severe romiplostim-induced rebound thrombocytopenia after splenectomy for refractory ITP.
Ann Pharmacother. 2015 Jan; 49(1):140-4.AP

Abstract

OBJECTIVE

To report a case of severe rebound thrombocytopenia after temporary discontinuation of romiplostim during splenectomy in the context of refractory immune (idiopathic) thrombocytopenic purpura (ITP).

CASE SUMMARY

A 65-year-old man with a history of severe refractory ITP failing multiple treatments was considered for romiplostim therapy. He was initiated on 1 µg/kg and titrated upward to 4 µg/kg to elevate and stabilize his platelet levels prior to splenectomy. On day 74 of his clinical course, his platelets increased to 434 × 10(9)/L, and his scheduled dose of romiplostim was withheld on day 75 for fear of romiplostim-induced postsplenectomy rebound thrombocytosis. On day 78, his platelets dropped precipitously to 9 × 10(9)/L, and he experienced multiple episodes of epistaxis. He was reinitiated at 5 µg/kg and soon recovered. He later missed a scheduled dose of romiplostim, and his platelets fell to 23 × 10(9)/L. After resuming romiplostim at 8 µg/kg, his platelets continued to recover.

DISCUSSION

Romiplostim, a thrombopoietin mimetic is directly regulated by megakaryocytes and existing circulating platelets via a negative feedback mechanism. This explains the theoretical risk of rapid clearance of romiplostim caused by an increased platelet pool. Clinically, alternative causes of his severe postoperative thrombocytopenia were considered and deemed unlikely. The rebound effect was observed after romiplostim was withdrawn on 2 occasions, and platelet counts improved after restarting romiplostim. The Naranjo Adverse Drug Reaction Probability Score of 7 suggests a probable adverse drug reaction.

CONCLUSION

Physicians using romiplostim as a bridge to splenectomy should be cautious about withholding a scheduled dose around the time of surgery.

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Publisher Full Text (DOI)

Authors+Show Affiliations

Choe MJ
Case Western Reserve School of Medicine, Cleveland Heights, OH, USA mjc206@case.du.
Packer CD
Case Western Reserve School of Medicine, Cleveland Heights, OH, USA Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.

MeSH

HumansMalePlatelet CountPurpura, Thrombocytopenic, IdiopathicReceptors, FcRecombinant Fusion ProteinsSplenectomyThrombocytopeniaThrombopoietin

Pub Type(s)

Journal Article

Language

eng

PubMed ID

25325908

Citation

Choe, Michael J., and Clifford D. Packer. "Severe Romiplostim-induced Rebound Thrombocytopenia After Splenectomy for Refractory ITP." The Annals of Pharmacotherapy, vol. 49, no. 1, 2015, pp. 140-4.
Choe MJ, Packer CD. Severe romiplostim-induced rebound thrombocytopenia after splenectomy for refractory ITP. Ann Pharmacother. 2015;49(1):140-4.
Choe, M. J., & Packer, C. D. (2015). Severe romiplostim-induced rebound thrombocytopenia after splenectomy for refractory ITP. The Annals of Pharmacotherapy, 49(1), 140-4. https://doi.org/10.1177/1060028014555540
Choe MJ, Packer CD. Severe Romiplostim-induced Rebound Thrombocytopenia After Splenectomy for Refractory ITP. Ann Pharmacother. 2015;49(1):140-4. PubMed PMID: 25325908.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Severe romiplostim-induced rebound thrombocytopenia after splenectomy for refractory ITP. AU - Choe,Michael J, AU - Packer,Clifford D, Y1 - 2014/10/16/ PY - 2014/10/18/entrez PY - 2014/10/18/pubmed PY - 2015/8/22/medline KW - TPO KW - adverse KW - drug KW - eltrombopag KW - events KW - idiopathic thromobocytic purpura KW - megakaryocyte KW - mimetic KW - platelets KW - reaction KW - rebound KW - refractory KW - romiplostim KW - splenectomy KW - thrombocytosis SP - 140 EP - 4 JF - The Annals of pharmacotherapy JO - Ann Pharmacother VL - 49 IS - 1 N2 - OBJECTIVE: To report a case of severe rebound thrombocytopenia after temporary discontinuation of romiplostim during splenectomy in the context of refractory immune (idiopathic) thrombocytopenic purpura (ITP). CASE SUMMARY: A 65-year-old man with a history of severe refractory ITP failing multiple treatments was considered for romiplostim therapy. He was initiated on 1 µg/kg and titrated upward to 4 µg/kg to elevate and stabilize his platelet levels prior to splenectomy. On day 74 of his clinical course, his platelets increased to 434 × 10(9)/L, and his scheduled dose of romiplostim was withheld on day 75 for fear of romiplostim-induced postsplenectomy rebound thrombocytosis. On day 78, his platelets dropped precipitously to 9 × 10(9)/L, and he experienced multiple episodes of epistaxis. He was reinitiated at 5 µg/kg and soon recovered. He later missed a scheduled dose of romiplostim, and his platelets fell to 23 × 10(9)/L. After resuming romiplostim at 8 µg/kg, his platelets continued to recover. DISCUSSION: Romiplostim, a thrombopoietin mimetic is directly regulated by megakaryocytes and existing circulating platelets via a negative feedback mechanism. This explains the theoretical risk of rapid clearance of romiplostim caused by an increased platelet pool. Clinically, alternative causes of his severe postoperative thrombocytopenia were considered and deemed unlikely. The rebound effect was observed after romiplostim was withdrawn on 2 occasions, and platelet counts improved after restarting romiplostim. The Naranjo Adverse Drug Reaction Probability Score of 7 suggests a probable adverse drug reaction. CONCLUSION: Physicians using romiplostim as a bridge to splenectomy should be cautious about withholding a scheduled dose around the time of surgery. SN - 1542-6270 UR - https://www.unboundmedicine.com/medline/citation/25325908/Severe_romiplostim_induced_rebound_thrombocytopenia_after_splenectomy_for_refractory_ITP_ DB - PRIME DP - Unbound Medicine ER -