Clinical Topics & News

Concurrent Romiplostim With FOLFIRINOX for Secondary Prevention of Thrombocytopenia in a Patient With Myelodysplastic Syndrome and Pancreatic Adenocarcinoma



Romiplostim is an agonist of the thrombopoietin receptor that stimulates platelet production. Several studies have evaluated the role of romiplostim in the prevention of chemotherapy-induced thrombocytopenia (CIT). Romiplostim may reduce dose reductions, treatment delays, bleeding events, and transfusions.

Less is known about treatment of CIT in patients with pre-existing thrombocytopenia (TCP), such as those with myelodysplastic syndrome (MDS). Here we present a case of a patient with TCP secondary to MDS who was given romiplostim during the treatment of pancreatic adenocarcinoma with FOLFIRINOX.

Case Report

The patient is a 76-year-old male with history of chronic TCP (baseline platelets 50-90 K/μL) presumed secondary to myelodysplastic syndrome, although a bone marrow biopsy was inconclusive. He had not had any major bleeding events or transfusions, aside from one unit of platelets given after a cervical spine fusion.

He was later diagnosed with borderline-resectable pancreatic adenocarcinoma, Stage IbT2N0. Plan made to administer neoadjuvant FOLFIRNOX chemotherapy, followed by Whipple.

The patient was started on romiplostim with a dose range of 1-10 mcg/kg weekly to maintain platelets between 60-200. We initially planned to give all 12 cycles neoadjuvantly but found that we could not maintain a platelet count over 50 K/μL despite maximal uptitration of romiplostim so the Whipple was performed after Cycle 9. Three additional cycles were given post-operatively. There were no dose-reductions, although oxaliplatin was held after cycle 9 due to neuropathy. He developed a jejunal bleed post-Whipple that required embolization but did not require transfusion.


This was a case in which romiplostim was successfully used during FOLFIRINOX to support platelets in a patient with baseline TCP from MDS. Despite a jejunal bleed after Whipple, the patient tolerated the treatment well and was able to complete all 12 cycles of peri-operative FOLFIRINOX. This approach may be beneficial in other patients with pre-existing TCP receiving chemotherapy.

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