Immune thrombocytopenia (ITP) is an acquired autoimmune disorder characterized by increased platelet destruction and impaired platelet production. While thrombopoietin receptor agonists (TPO‐RAs), including romiplostim and eltrombopag, have significantly improved ITP management, some patients remain relapsed to multiple lines of therapy, necessitating alternative approaches. Avatrombopag, a second‐generation TPO‐RA, has shown promising efficacy and a favorable safety profile, yet its role in cases unresponsive to prior TPO‐RAs remains underexplored. We report the case of a 37‐year‐old woman with relapsed severe ITP, unresponsive to corticosteroids, IVIG, rituximab, romiplostim, eltrombopag, vincristine, cyclosporine, and splenectomy. Despite multiple treatments, her platelet count remained critically low, with persistent bleeding symptoms. Given the failure of standard therapies, avatrombopag was initiated at 20 mg daily, resulting in a rapid platelet response, increasing from 14 × 10 9 /L to 72 × 10 9 /L within 9 days. The platelet count peaked at 848 × 10 9 /L, necessitating dose adjustments, after which it stabilized within the target range (100–300 × 10 9 /L). The patient tolerated avatrombopag well, with no thromboembolic events or significant adverse effects reported. This case demonstrates the efficacy of avatrombopag in a patient unresponsive to multiple prior therapies, including other TPO‐RAs and splenectomy. Further studies are warranted to determine optimal treatment sequencing and long‐term outcomes for patients in this challenging subgroup.
Almutairi et al. (2026) studied this question.