Portal Vein Thrombosis during Eltrombopag Treatment for Immune Thrombocytopenic Purpura in a Patient with Liver Cirrhosis due to Hepatitis C Viral Infection

Abstract

Portal vein thrombosis is a rare, aggressive and life-threatening complication of liver cirrhosis (LC). Eltrombopag is effective for the treatment of chronic hepatitis with thrombocytopenia, and portal vein thrombosis at this time has rarely been reported. We describe the case of a 78-year-old woman who suffered from LC due to hepatitis C viral infection. The patient developed immune thrombocytopenic purpura (ITP) that was diagnosed on the basis of nasal bleeding, progressive severe thrombocytopenia, elevation of platelet-associated IgG (PAIgG), no response to the transfusion of platelets and no abnormal findings on bone marrow biopsy. Although we first administered prednisolone (0.5 mg/kg/day), there was no recovery of platelet function and the nasal bleeding persisted. Subsequently, we administered eltrombopag for refractory ITP at a dose of 12.5 mg/day, and the thrombocytopenia gradually improved. Fifty-four days after the start of eltrombopag therapy, she developed portal vein thrombosis. Eltrombopag was stopped immediately, and antithrombin III was administered for prophylaxis against further portal vein thrombosis. Despite these treatments, there were subsequent deep vein and pulmonary artery thromboses. We then administered heparin for recanalization of the thrombi. One month after the initiation of heparin, there was recanalization as well as improvements of the portal vein, deep vein and pulmonary artery thromboses. There was no further thrombosis progression after switching from heparin to warfarin therapy. Our case suggests that eltrombopag may increase the risk of portal vein thrombosis ; therefore, this drug must be used carefully in the treatment of ITP in patients with LC due to hepatitis C viral infection. 〔J Clin Exp Hematop 53(2) : 151-155, 2013〕

Platelet transfusions in platelet consumptive disorders are associated with arterial thrombosis and in-hospital mortality

“…23,[41][42][43][44][45] The occasional case reports of thrombotic events with ITP have been concurrent with administration of thrombopoietic agonists and not with platelet transfusions. 46 Our current study also reports no adverse thrombotic events, AMI, or stroke with platelet administration in ITP admissions. Also, platelets were not associated with higher odds of mortality in ITP patients after adjustment for age and gender.…”

Portal Vein Thrombosis in a Chirrotic Patient with Immune Thrombocytopenic Purpura During Eltrombopag Treatment

“…Heparin and antithrombin III were used and recanalization was seen. [8]. In our case, thrombosis occured in portal and splenic veins at the first month of the treatment.…”

“…Mechanism of thrombosis development with eltrombopag is not clear. Increase in platelet count and activity can be causes [8]. In non cirrhotic patients, standart treatment of PVT is anticoagulation with drugs such as antithrombin III and heparin for 14-15 months.…”

“…But in cirrhotic patients, anticoagulant therapy increased bleeding [7]. In a cirrhosis case with PVT after eltrombopag, there was no bleeding [8]. In these kinds of patients, treatment must be set for each patient individually.…”

Thrombopoietin receptor agonists for preparing adult patients with immune thrombocytopenia to splenectomy: results of a retrospective, observational GIMEMA study

“…The development of portal vein portal thrombosis during eltrombopag treatment was previously highlighted. Kawano et al described the case of a 78-year-old woman with HCVrelated liver chirrosis and corticosteroid refractory ITP that, 54 days after the start of eltrombopag therapy, developed portal vein thrombosis [15]. Notably, an increased incidence of portal-vein thrombosis was also registered in the ELEVATE study, which was designed to evaluate the efficacy of eltrombopag to increase platelet count and reduce the platelet transfusions requirement in patients with thrombocytopenia and chronic liver disease undergoing an elective invasive procedure [16].…”