Immune Thrombocytopenia: SYK Inhibitors and COVID-19
During a discussion on the adoption of SYK inhibitors into clinical practice as treatment for immune thrombocytopenia, expert panelists remark on the benefits of using the newer oral class of drugs, especially during the coronavirus disease 2019 (COVID-19) pandemic.
Bhavesh Shah, RPh, BCOP: Going back to COVID-19 [coronavirus disease 2019], we touched upon how ITP [immune thrombocytopenia] treatments may have been changed because of COVID-19, and I wanted to see how you both have changed practice in managing ITP because of COVID-19.
Ali McBride, PharmD, MS, BCOP, FASHP, FAzPA: With COVID-19 back in March, really since the introduction, when everyone thought it wasn't as bad and I was still hanging out in Florida and New York in these cases, it wasn't an issue. But what made this an easier change for us was the IVIg [intravenous immunoglobulin] shortage. We've almost forgotten that starting last year and early this year, we couldn't get IVIg products. We were all fighting for IVIg products. In some cases, we had to switch patients off of IVIg and supplement them with oral therapies. Moving forward, it wasn't that much of a difficulty. But looking at infusion centers, looking at locations where people will have increased density, is an important discussion for COVID-19.
Furthermore, we’ve utilized oral therapies where patients can have laboratory tests followed up and don't need to come in all the time. The advent, as we've talked about many times, of telemedicine has allowed for remote monitoring of patients while they're on therapy, especially oral therapies. That's really reduced the risk for these patients. There are only a few of these therapies out there, and again, we're talking about TPO [thrombopoietin] receptor agonists and SYK [spleen tyrosine kinase] inhibitors as well. In these cases, we have oral therapies for both. Therefore, the utilization under COVID-19 has allowed us to restrict those infusions or potentially give home infusion if that's an option for IVIg, but also increase utilization for oral therapies in the same market.
We've seen an increase in oral therapies, whether it's chemotherapy or, in this case, SYK inhibition or TPO receptor agonists. That transition has been rather seamless and comes on the heels of the IVIg shortage just a few months ago.
Bhavesh Shah, RPh, BCOP: David, have you seen similar types of switches in your practice, where patients are coming off of IV [intravenous] TPO agonist to an oral agent or switching from one IV to another oral agent?
David Hughes, PharmD, BCOP: Yes, as Ali mentioned, there’s been a large uptake, not only in ITP, but in the oral oncology and hematology spaces. There has been a preference to utilize more of an oral-based option. We have seen some patients use a home administration of romiplostim, which is a subcutaneous TPO receptor agonist. We are utilizing these options with specific guidelines and measures in place to ensure that patients who have been on stable doses are still able to get remote platelet monitoring done and also safely administer them in their homes. Even if patients can't get access or can't switch necessarily to oral agents, they have another fallback to administer this at home.
I also think it's important to recognize the SYK inhibitor here, because that definitely brought a whole new treatment option for patients who may not necessarily need that frequent platelet visit and platelet monitoring in the initial stages. Simultaneously, there was a large uptick of COVID-19 cases in the hematology space, and what are the underlying comorbidities that may predispose the patient. Ultimately, fostamatinib now, the SYK inhibitor, is being evaluated with a large trial sponsored by the NIH [National Institutes of Health] for the treatment of severe COVID-19. It's an interesting concept to understand. As we go forward, we'll start to see this more and more in practice.
Bhavesh Shah, RPh, BCOP: Yes, I'm curious to know, Ali, were any providers reluctant to use one agent over the other because of concerns of exacerbating COVID-19–related mortality?
Ali McBride, PharmD, MS, BCOP, FASHP, FAzPA: Not right now. I think there hasn't been that much of a discussion of exacerbation at the University of Arizona Cancer Center. Our facility has done well in terms of developing a plan for review, making sure we promote access to patients who don't need to be congregated in certain areas. At that point, it hasn't been an issue. We have moved toward oral therapy. If there is a compatible or comparable therapy—either the same type of formulation or a different type of drug therapy—we've moved patients to oral therapies. But for all cases in point, we have not transitioned or had any issues with that, which has made our workflow rather seamless. But, it's also become essential for us to continue these patients for treatment, monitoring, and also address some urgent care needs; so not much of a change there. I wish I could add more to that, but really, it's been status quo for many of my patients.
Bhavesh Shah, RPh, BCOP: It may be hard to identify any type of signal because this is not a large volume of patients that you have. It really speaks to the fact that we still need to continue to have these registries so we can have more data and understand the implications of the mechanisms of action on COVID-19. And great point, Dave, it's reassuring to see the NIH is doing a clinical trial in severe COVID-19 with fostamatinib, so there's definitely a mechanistic rationale. Of course, we don't know what the evidence will show until the results come out. Maybe COVID-19 will be gone by that time.