One of my ITP patients is developing hemolytic anemia and I suspect Evans syndrome. Would romiplostim or eltrombopag be appropriate?
Romiplostim and eltrombopag were recently approved by the FDA for use in chronic ITP. The randomized trials leading to approval for both drugs enrolled adult patients with primary chronic ITP who had failed at least one first-line therapy. Patients with moderate (or greater) anemia were excluded from these trials. There is no mention in the published literature whether patients with Evans’ syndrome were treated. A brief review of ASH abstracts from 2008 and 2009 did not identify any reports of use of these agents in Evans’ syndrome. The blood smear should be reviewed in this case and TTP ruled out. A direct Coombs’ test should be ordered and if positive and if other laboratory data suggest hemolysis (reticulocyte count, indirect bilirubin, LDH, etc) then Evans’ syndrome becomes a more likely diagnosis. If there is uncertainty, a bone marrow aspirate and biopsy can be done to rule out a primary bone marrow or lymphoproliferative disorder. Romiplostim and eltrombopag as thrombopoietin re
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