• Monitor for unusual bleeding and bruising, thromboembolic events (DVT, PE, stroke, MI) and signs of hepatotoxicity during therapy. If thromboembolism occurs, discontinue eltrombopag and continue horse antithymocyte globulin (h-ATG) and cyclosporine.
• Monitor for signs and symptoms of cataracts. Perform baseline ocular examination prior to administration and periodically during therapy.

Lab Test Considerations:

• May cause laboratory discoloration and interference with accurate results. Many tests may be impacted including bilirubin, serum creatinine, total protein, albumin, and others. Communicate to the lab that the patient is taking eltrombopag and consider retesting using other methods to determine validity of results.
• For Chronic Immune Thrombocytopenia (Promacta): Monitor CBC with differential weekly until platelets stable at ≥50 × 10⁹/L. Modify dose based on platelet count. If platelets <50 × 10⁹/L following ≥2 wk of therapy, ↑ daily dose by 25 mg (max = 75 mg/day). For dose of 12.5 mg once daily, ↑ to 25 mg once daily before ↑ daily dose by 25 mg. If platelets 200 × 10⁹/L–400 × 10⁹/L,↓ daily dose by 25 mg. For dose of 25 mg once daily, ↓ to 12.5 once daily. Wait 2 wk to assess effects of dose adjustment. If platelets >400 × 10⁹/L, stop Promacta and ↑ monitoring of platelets to twice weekly. Once platelets <150 × 10⁹/L, reinitiate therapy by ↓ dose by 25 mg/day. For dose of 25 mg once daily, reinitiate at 12.5 mg once daily. If platelets >400 × 10⁹/L after 2 wk of therapy at lowest dose, permanently discontinue Promacta. Discontinue Promacta if platelets do not ↑ to a level sufficient to avoid clinically important bleeding after 4 wk of therapy at max dose of 75 mg/day.
  • For Chronic Immune Thrombocytopenia (Alvaiz)Monitor CBC with differential weekly until platelets stable at ≥50 × 10⁹/L. Modify dose based on platelet count. If platelets <50 × 10⁹/L following ≥2 wk of therapy, ↑ daily dose by 18 mg (max = 54 mg/day). For dose of 9 mg once daily, ↑ to 18 mg once daily before ↑ daily dose by 18 mg. If platelets 200 × 10⁹/L–400 × 10⁹/L,↓ daily dose by 18 mg. For dose of 18 mg once daily, ↓ to 9 mg once daily. Wait 2 wk to assess effects of dose adjustment. If platelets >400 × 10⁹/L, stop Alvaiz and ↑ monitoring of platelets to twice weekly. Once platelets <150 × 10⁹/L, reinitiate therapy by ↓ dose by 18 mg/day. For dose of 18 mg once daily, reinitiate at 9 mg once daily. If platelets >400 × 10⁹/L after 2 wk of therapy at lowest dose, permanently discontinue Alvaiz. Discontinue Alvaiz if platelets do not ↑ to a level sufficient to avoid clinically important bleeding after 4 wk of therapy at max dose of 54 mg/day.
  • Chronic Hepatitis C-Associated Thrombocytopenia (Promacta)Monitor platelet counts every week prior to starting antiviral therapy. Goal is to achieve and maintain platelet count necessary to initiate and maintain antiviral therapy with pegylated interferon and ribavirin. Modify dose based on platelet count. Adjust dose in 25-mg increments every 2 wk as necessary for target platelet count required to initiate antiviral therapy. During antiviral therapy, adjust dose to avoid dose ↓ of peginterferon. Monitor CBC with differential weekly during antiviral therapy until stable platelet count achieved. Monitor platelet counts monthly thereafter. If platelets <50 × 10⁹/L following ≥2 wk of therapy, ↑ daily dose by 25 mg (max = 100 mg/day). If platelets 200 × 10⁹/L–400 × 10⁹/L,↓ daily dose by 25 mg. Wait 2 wk to assess effects of dose adjustment. If platelets >400 × 10⁹/L, stop Promacta; ↑ monitoring of platelets to twice weekly. Once platelets <150 × 10⁹/L, reinitiate therapy by ↓ dose by 25 mg/day. For dose of 25 mg once daily, reinitiate at 12.5 mg once daily. If platelets >400 × 10⁹/L after 2 wk of therapy at lowest dose, permanently discontinue Promacta. Discontinue Promacta when antiviral therapy is discontinued.
  • Chronic Hepatitis C-Associated Thrombocytopenia (Alvaiz)Monitor platelet counts every week prior to starting antiviral therapy. Goal is to achieve and maintain platelet count necessary to initiate and maintain antiviral therapy with pegylated interferon and ribavirin. Modify dose based on platelet count. Adjust dose in 18-mg increments every 2 wk as necessary for target platelet count required to initiate antiviral therapy. During antiviral therapy, adjust dose to avoid dose ↓ of peginterferon. Monitor CBC with differentials weekly during antiviral therapy until stable platelet count achieved. Monitor platelet counts monthly thereafter. If platelets <50 × 10⁹/L following ≥2 wk of therapy, ↑ daily dose by 18 mg (max = 72 mg/day). If platelets 200 × 10⁹/L–400 × 10⁹/L,↓ daily dose by 18 mg. Wait 2 wk to assess effects of dose adjustment. If platelets >400 × 10⁹/L, stop Alvaiz; ↑ monitoring of platelets to twice weekly. Once platelets <150 × 10⁹/L, reinitiate therapy by ↓ dose by 18 mg/day. For dose of 18 mg once daily, reinitiate at 9 mg once daily. If platelets >400 × 10⁹/L after 2 wk of therapy at lowest dose, permanently discontinue Alvaiz. Discontinue Alvaiz when antiviral therapy is discontinued.
  • Aplastic Anemia (Promacta)Goal is platelet count >50 × 10⁹/L. Modify dose based on platelet count. If platelets <50 × 10⁹/L following ≥2 wk of therapy, ↑ daily dose by 50 mg. For dose of 25 mg once daily, ↑ to 50 mg once daily before ↑ daily dose by 50 mg (max = 150 mg/day). If platelets 200 × 10⁹/L–400 × 10⁹/L,↓ daily dose by 50 mg. Wait 2 wk to assess effects of dose adjustment. If platelets >400 × 10⁹/L, stop Promacta for 1 wk. Once platelets <150 × 10⁹/L, reinitiate therapy by ↓ dose by 50 mg/day. If platelets >400 × 10⁹/L after 2 wk of therapy at lowest dose, permanently discontinue Promacta. If no hematologic response after 16 wk of therapy, discontinue Promacta.
  • Aplastic Anemia (Alvaiz)Goal is platelet count >50 × 10⁹/L. Modify dose based on platelet count. If platelets <50 × 10⁹/L following ≥2 wk of therapy, ↑ daily dose by 36 mg. For dose of 18 mg once daily, ↑ to 36 mg once daily before ↑ daily dose by 50 mg (max = 150 mg/day). If platelets 200 × 10⁹/L–400 × 10⁹/L,↓ daily dose by 50 mg. Wait 2 wk to assess effects of dose adjustment. If platelets >400 × 10⁹/L, stop Alvaiz for 1 wk. Once platelets <150 × 10⁹/L, reinitiate therapy by ↓ dose by 50 mg/day. If platelets >400 × 10⁹/L after 2 wk of therapy at lowest dose, permanently discontinue Alvaiz. If no hematologic response after 16 wk of therapy, discontinue Alvaiz.
  • When switching between Promacta oral suspension and tablet, assess platelet count weekly for 2 wk; then follow standard monthly monitoring.

  • Monitor AST, ALT, and serum bilirubin before starting therapy, every 2 wk during dose adjustment, and monthly following stable dose. If bilirubin ↑, perform fractionation. If transaminases abnormal, repeat test in 3–5 days. If abnormalities confirmed, monitor serum transaminases weekly until resolved, stabilized, or returned to baseline. Discontinue eltrombopag if ALT levels ≥3 times upper limit of normal (ULN) in patients with normal liver function or ≥3 times baseline or >5 times ULN and progressively ↑, or persistent for ≥4 wk, or accompanied by ↑ direct bilirubin or symptoms of liver injury or hepatic decompensation.

  • First-line treatment of aplastic anemia (Promacta)Measure ALT, AST, and bilirubin before starting therapy, every other day while hospitalized for h-ATG therapy, and then every 2 wk during therapy. Do not start Promacta if AST or ALT ≥6 times ULN. Once AST or ALT <5 times ULN, restart Promactaat same dose. If AST or ALT >6 times ULN after restarting therapy, discontinue therapy and monitor ALT or AST at least every 3–4 days. Once ALT or AST <5 times ULN, restart Promacta at dose ↓ from previous dose by 25 mg/day. If AST or ALT >6 times ULN with ↓ dose,↓ daily dose by 25 mg until AST or ALT <5 times ULN. In pediatric patient <12 yr,↓ daily dose by ≥15% to nearest dose that can be administered.