The aim of this study is to improve treatment of Moderate Aplastic Anemia (MAA) by evaluating the safety and efficiency of Eltrombopag as a new treatment option in patients with therapy requiring MAA.
After enrollment (see detailed inclusion and exclusion criteria below) the patients are randomized either to the Placebo or Eltrombopag arm. The randomization is double blinded. Randomization will take in account patient's age and disease severity by stratifying into 4 block combinations to ensure homogeneity between treatment arms. All patients receive background therapy with CSA, regardless of randomisation group, to treat MAA according to current standard of care. Eltrombopag (or Placebo) is given at a daily starting dose of 150 mg orally as 75 mg tablets once daily (2 tablets Eltrombopag or placebo per day), (Olnes et al NEJM 2012). In Asian patients Eltrombopag (or Placebo) is given at a daily starting dose of 75 mg orally (1 tablet Eltrombopag or placebo per day). In Asian-Caucasian patients no dose reduction of the starting dose is carried out, but cautious observation of the liver function due to the possibility of altered Eltrombopag metabolism is recommended. Dose reduction: In patients without history of thromboembolism or known risk factors for thrombembolism dose reduction (the possibility of an alternating dose schedule is given) is recommended if the platelet count is increasing \> 150 G/L. * Dosage should be decreased to achieve a platelet count between 100 and 150 G/L after reaching a sufficient erythrocyte and granulocyte response (see 10.1). * If the platelet count decreases below 100 G/L the Eltrombopag dose should be escalated again. * Eltrombopag should be discontinued if the platelet count exceeds 450 G/L and could be restarted with a lower dose after decrease of the platelet count below 150 G/L. In patients with history of thromboembolism or known risk factors for thromboembolism (e. g. Factor V Leiden, ATIII deficiency, antiphospholipid syndrome, PNH with GPI-deficient granulocyte population \> 50 %, prolonged periods of immobilization, contraceptives and hormone replacement therapy or surgery) dose reduction is recommended if the platelet count is increasing \> 100 G/L * The target platelet count will be 70-120 G/L after reaching a sufficient erythrocyte and granulocyte response (see 10.1). * If the platelet count decreases below 70 G/L the Eltrombopag dose should be escalated again. * Eltrombopag should be discontinued in patients with history of and risk factors for thromboembolism if the platelet count exceeds 150 G/L. Duration of follow up: Last Follow up 24 months after end of study treatment. Patients will receive Eltrombopag or placebo within the study for a minimum of 6 months. Exceptions are patients with disease progression in Severe or Very Severe AA or patients with inacceptable adverse events within the first 6 months. Eltrombopag will be administered for a maximum period of 12 months within the protocol. Recent data show that the response of hematopoiesis in refractory severe aplastic anemia can be sustained on discontinuation of Eltrombopag25. As long-term effects of investigational treatments are an objective of the study, the follow-up of patients will cover 24 months after the end of the study treatment according to the protocol
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
QUADRUPLE
Enrollment
93
* CSA + Eltrombopag, evaluation after three month therapy start regarding dose escalation * 6 month after therapy start --\> evaluation and report of remission status of the study office --\> unblinding by study office --\> partial or complete remission Eltrombopag and slow tapering of CSA * 12 month after therapy start --\> evaluation and report of remission status --\> complete and partial remission --\> tapering/end of study treatment
* CSA + Placebo, evaluation after three month therapy start regarding dose escalation * 6 month after therapy start --\> evaluation and report of remission status of the study office --\> unblinding by study office --\> no complete remission: CSA + Eltrombopag and evaluation 3 months after therapy start --\> dose escalation * 12 month after start of eltrombopag --\> evaluation and report of remission status --\> complete and partial remission --\> tapering/end of study treatment
University Hospital Ulm
Ulm, Germany
Trilineage hematologic response rate (CR + PR)
The primary objective of this trial is to investigate whether Eltrombopag added to standard immunosuppressive treatment increases the rate of hematologic responses (complete and partial response) in untreated AA patient at six months after treatment start. A complete response (according to Marsh et al Blood 1992): A peripheral blood count with an ANC \> 2.0 G/L and a platelet count \> 100 G/L and transfusion independence. A partial response (according to Marsh et al Blood 1992): A peripheral blood count with an ANC \>1.0 G/L and a platelet count \>30 G/L and transfusion independence Transfusion independence is defined as No need for platelet transfusions in the last 4 weeks prior to evaluation and no need for packed red blood cell concentrates (PRBC) in the last 6 weeks prior to evaluation. Patients who remain transfusion-dependent will be classified as non-responders regardless of the ANC and platelet count.
Time frame: 6 months after treatment start
Trilineage hematological response rate (CR and PR, detailed definition => primary endpoint) at 3, 12 and 18
Increase of the platelet count by 20 G/L or hemoglobin by \> 1.5 g/dL above baseline in patients without prior transfusion dependence or an absolute increase in ANC of \> 0.5 G/L respectively at least a 100 percent increase over the baseline ANC in those with pre-treatment absolute ANC of ≤ 0.5 G/L or transfusion independence for a minimum of 8 weeks or a reduction of transfused units during the last 8 weeks compared with the 8 weeks previous to study entry in patients with prior transfusion dependency
Time frame: 3, 12 and 18 months
single hematological response rate (CR and PR, detailed definition => primary endpoint) at 3, 12 and 18
Increase of the platelet count by 20 G/L or hemoglobin by \> 1.5 g/dL above baseline in patients without prior transfusion dependence or an absolute increase in ANC of \> 0.5 G/L respectively at least a 100 percent increase over the baseline ANC in those with pre-treatment absolute ANC of ≤ 0.5 G/L
Time frame: 3, 12 and 18 months
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cumulative incidence of response
proportion of patients with need for transfusions and number of units transfused (PRBC and platelet concentrates) since start of treatment cumulative incidence of progress to SAA/VSAA or intensive immunosuppressive treatment with ATG
Time frame: 3, 6, 12 and 18 months
Comparison of number of SAEs between the two arms (CSA + Placebo versus CSA + Eltrombopag
using the CTCAE criteria and the study specific criteria (developing of a ALT \> 3.0 × ULN combined with an elevation of bilirubine \> 2.0 × ULN, thrombotic/thromboembolic complications, clonal evolution)
Time frame: 2 years