Treatment efficacy for adult persistent immune thrombocytopenia: a systematic review and network meta-analysis

Persistent immune thrombocytopenia (ITP) patients require second-linetreatments, for which information on clinical outcomes are lacking. A sys-tematic review and network meta-analysis (NMA) were conducted. Onlyrandomised controlled trials (RCT) of second-line drugs in adult persistentITP patients with platelet response, platelet count, any bleeding or seriousadverse events (SAE) outcome were eligible. Twelve RCTs (n=1313) wereincluded in NMA. For platelet response outcome, eltrombopag and romi-plostin were the best relative to placebo; the former had a non-significantadvantage [risk ratio (RR)=1 10 (95% confidence interval: 0 46, 2 67)].Both treatments were superior to rituximab and recombinant humanthrombopoietin (rhTPO)+rituximab, with corresponding RRs of 4 56 (1 89,10 96) and 4 18 (1 21, 14 49) for eltrombopag; 4 13 (1 56, 10 94) and 3 79(1 02, 14 09) for romiplostim. For platelet count, romiplostim ranked high-est, followed by eltrombopag, rhTPO+rituximab, and rituximab. For bleed-ing, rituximab had lowest risk, followed by eltrombopag and romiplostim.For SAEs, rhTPO+rituximab had highest risk, followed by rituximab,eltrombopag and romiplostim. From clustered ranking, romiplostim hadthe best balance between short-term efficacy and SAEs, followed by eltrom-bopag. In conclusion, romiplostim and eltrombopag may yield high efficacyand safety. Rituximab may not be beneficial due to lower efficacy andhigher complications compared with the thrombopoietin receptor agonists.RCTs with long-term clinical outcomes are required.