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Efficacy of Oral Thrombopoietin Receptor Agonist Lusutrombopag in Chronic Liver Disease by Underlying Disease Aetiology

| Hepatology
Authors:
*Naim Alkhouri,1 Michio Imawari,2 Namiki Izumi,3 Yukio Osaki,4 Toshimitsu Ochiai,5 Roy Bentley,6 Takeshi Kano7
Disclosure:

Dr Alkhouri has been an advisor and part of a speakers’ bureau for Dova Pharma and Shionogi. Dr Imawari has been a consultant for Shionogi & Co., Ltd. and for Japan Bio Products Co., Ltd. Dr Izumi has been part of a speakers’ bureau for AbbVie, Shionogi, Bayer, Gilead Science, Otsuka, and Eisai. Dr Osaki has been a speaker and teacher for Gilead Sciences Inc., Bayer Yakuhin, Ltd, MSD Co., Inc., Shionogi & Co., Ltd., AbbVie GK, and Eisai Co., Ltd. Dr Ochiai, Dr Bentley, and Dr Kano are employed by Shionogi.

Acknowledgements:

These studies were funded by Shionogi & Co., Ltd. (Osaka, Japan). Medical writing assistance was provided by Rebecca D. Miles, MedVal Scientific Information Services (Princeton, New Jersey, USA) and funded by Shionogi Inc. (Florham Park, New Jersey, USA).

Citation
EMJ Hepatol. ;7[1]:40-42.

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.

BACKGROUND AND AIMS

Among patients with chronic liver disease (CLD), thrombocytopenia (TCP) is a frequent complication.1,2 Before invasive procedures and surgery in CLD patients with TCP, platelet transfusions (PT) have been used to increase platelet counts, but their use is limited by several factors, including the short lifespan of transfused platelets, alloimmunisation, and various haemolytic, allergic, and other secondary reactions, which can lead to hospitalisations.3

Lusutrombopag is an oral thrombopoietin receptor agonist that has been approved in Japan (2015) and the USA (2018) for treatment of TCP, and in Europe for severe TCP (2019),  and is associated with CLD in patients undergoing a planned invasive procedure.4-6 In L-PLUS 1 (Japan) and L-PLUS 2 (global), two similarly designed, Phase III, multicentre, randomised, double-blind, placebo-controlled studies, patients with CLD and platelet count <50×109/L scheduled for an invasive procedure were randomised 1:1 to lusutrombopag 3 mg or placebo and dosed orally once daily for up to 7 days. Results showed that a higher proportion of lusutrombopag-treated than placebo-treated patients did not require a PT.3,7

Certain CLD aetiologies, such as alcohol abuse and hepatitis C virus, may cause bone marrow suppression and low thrombopoietin production.8 Accordingly, the authors undertook the pooled analysis described herein to evaluate the efficacy of lusutrombopag in patients with CLD by underlying disease aetiology.

METHODS

For the current analysis, data from the L-PLUS 1 and L-PLUS 2 per-protocol (PP) patient populations (defined as all randomised patients with no major protocol violations) were pooled and assessed by various underlying CLD disease aetiologies. The primary efficacy endpoint was the proportion of patients who required no PT prior to the invasive procedure and no rescue therapy for bleeding from randomisation throughout 7 days after the procedure. Treatment-emergent adverse events (TEAE) were also assessed by disease aetiology subgroup.

RESULTS

Of the 312 patients randomised, 270 were in the PP population (lusutrombopag: n=137; placebo: n=133). Underlying CLD aetiologies were present in the PP population in the following proportions: chronic hepatitis B: 10.7% (29/270); chronic hepatitis C: 47.8% (129/270); alcoholic hepatitis: 11.5% (31/270); nonalcoholic steatohepatitis: 8.5% (23/270); autoimmune hepatitis: 3.0% (8/270); and other (including multiple aetiology): 18.5% (50/270). The underlying aetiologies for CLD were generally similar between the two  treatment arms. Overall, 73.7% (101/137) of lusutrombopag patients met the primary endpoint versus 17.3% (23/133) placebo  patients (difference of proportion: 55.8 [95% confidence interval: 46.6–65.0]; p<0.0001). Similarly, in each disease aetiology subgroup, more patients met the primary endpoint in the lusutrombopag versus placebo arm (Figure 1).

Figure 1: Proportion of patients who met primary endpoint by underlying aetiology for chronic liver disease.

Proportion of patients experiencing ≥1 TEAE  were 61.9% for lusutrombopag and 64.5% for placebo; 6.5% and 9.0% of events, respectively, were deemed to be treatment-related. TEAE  were generally similar between the two treatment arms across the underlying  aetiologies. Thrombosis and thromboembolism-related TEAE occurred in 1.9% (3/155) of patients in the lusutrombopag arm (all deemed serious adverse events) and in 1.9% (3/155) of patients in the placebo arm (all deemed non-serious).

CONCLUSION

Regardless of underlying disease aetiology, lusutrombopag was found to be efficacious compared to placebo in avoiding the need for PT in patients with CLD-TCP scheduled to undergo invasive procedures. Furthermore, TEAE were generally similar between the treatment arms across disease aetiologies.

References
Giannini EG, Peck-Radosavljevic M. Platelet dysfunction: Status of thrombopoietin in thrombocytopenia associated with chronic liver failure. Semin Thromb Hemost. 2015;41(5):455-61. Giannini EG et al. Incidence of bleeding following invasive procedures in patients with thrombocytopenia and advanced liver disease. Clin Gastroenterol Hepatol. 2010;8(10):899-902;quiz e109. Hidaka H et al. Lusutrombopag reduces need for platelet transfusion in patients with thrombocytopenia undergoing invasive procedures. Clin Gastroenterol Hepatol. 2019;17(6):1192-200. Pharmaceuticals and Medical Devices Agency. Mulpleta® (lusutrombopag) tablets. Report on the Deliberation Results. 2015. Available at: http://www.pmda.go.jp/files/000215708.pdf. Last accessed: 23 April 2019. U.S. Food and Drug Administration. MULPLETA® (lusutrombopag tablets) for oral use. Prescribing information. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/210923s000lbl.pdf. Last accessed: 23 April 2019. European Commission. Union Register of medicinal products for human use: Lusutrombopag Shionogi. 2019. Available at: http://ec.europa.eu/health/documents/community-register/html/h1348.htm. Last accessed: 23 April 2019. Peck-Radosavljevic M et al. Lusutrombopag for the treatment of thrombocytopenia in patients with chronic liver disease undergoing invasive procedures (L-PLUS 2). Hepatology. 2019.[Epub ahead of print]. Peck-Radosavljevic M. Thrombocytopenia in chronic liver disease. Liver Int. 2017;37(6):778-93.