Avatrombopag in Chronic ITP and Post-HSCT Thrombocytopenia
Dr. Chokri Ben Lamine, Adult Hematology and Stem Cell Transplantation Assistant Consultant at Oncology Center of Excellence at King Faisal Specialist Hospital and Research Center, shared a post on X:
“Avatrombopag – Hema-Fellows Review
(Adult focus
• Chronic ITP/Post-HSCT thrombocytopenia – ASH/NCCN 2024-25)
Overview
•Oral, non-peptide TPO-Receptor Agonist
•Stimulates megakaryocyte proliferation and platelet production
•FDA-approved for:
• Chronic ITP after ≥1 prior therapy
• Thrombocytopenia in chronic liver disease pre-procedure (not hematology use)
•Off-label: persistent thrombocytopenia post-HSCT / chemotherapy-induced
Adult Dosing (Chronic ITP)
•Start: 20 mg PO once daily with food
•Adjust q2 wk to keep Plt ≥50×10⁹/L (avoid >200–250)
• If Plt <50×10⁹/L → ↑ by 20 mg/d (max 40 mg/d)
• If Plt >200–250×10⁹/L → ↓ by 20 mg/d
• If Plt >400×10⁹/L → hold → restart at ↓ dose when <150×10⁹/L
•Do NOT exceed 40 mg/d for ITP
Administration Advantage vs Eltrombopag
•Take with food (↑ absorption)
•No restriction with dairy, calcium, iron, antacids → easier for patients
Monitoring
•CBC weekly ×4 wk → then monthly
•Monitor LFTs periodically (less hepatotoxic than eltrombopag)
•Check for thrombosis risk if Plt >200–250×10⁹/L
Safety
•Common: headache, fatigue, contusion
•Rare: thromboembolic events, hepatotoxicity (lower risk vs eltrombopag)
•Long-term data still maturing → monitor for clonal cytogenetic evolution in AA/post-HSCT settings
Clinical Pearls
•Faster platelet rise than eltrombopag in some ITP studies
•Preferred when GI absorption is concern or patient cannot follow fasting rules
•Used in post-HSCT persistent thrombocytopenia at 20–40 mg/d
•Not a rescue for acute bleeding → needs several days for platelet rise
•Not studied for front-line ITP → used after failure of steroids ± IVIG․”
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