When switching between TPO-RAs in patients with ITP, are there any guidelines for dosing? For example, I am switching a patient who is on max dose avatrombopag to romiplostim, should I start romiplostim at the max dose or start lower and titrate up like in a treatment naïve patient?
There are no guidelines for how to switch TPO-RAs that I am aware of. I usually start at either the lowest dose or an intermediate dose, depending on how low the platelet count is and titrate up. I typically continue the original TPO-RA for at least two weeks while beginning the new TPO-RA if possible. If the platelet count is <30 or there is bleed, I would start romiplostim at a higher dose of 4-6 mcg/kg. If not, then would start at the 1 mcg/kg.
