WHAT IS THIS MEDICINE AND WHAT IS IT USED FOR?
R-PAG contains eltrombopag, a medicine that works by stimulating a
receptor (the thrombopoietin receptor, or c-Mpl) on the surface of
platelet-producing cells in the bone marrow called megakaryocytes.
This stimulation drives the bone marrow to produce more platelets — the
tiny blood cells essential for clotting and stopping bleeding.
Eltrombopag is used for:
· chronic immune thrombocytopenia (ITP)
in adults and children — a condition where the immune system mistakenly
destroys platelets, leading to dangerously low platelet counts, bruising, and
bleeding risk;
· aplastic anaemia (AA) in adults — a
rare, serious condition where the bone marrow stops producing blood cells, used
alongside immunosuppressive therapy;
· Thrombocytopenia (low platelets)
associated with chronic hepatitis C infection — to enable interferon-based
therapy to continue (though this indication has largely been superseded by
newer hepatitis C treatments).
The 25mg tablet is used for patients who need a lower starting dose or a
dose adjustment from the standard 50mg.
3. HOW TO TAKE THIS MEDICINE
For ITP: the starting dose is usually 50mg once daily, but patients of
East Asian heritage (Japanese, Chinese, Korean, Taiwanese) and those with liver
disease should start at 25mg once daily, as these populations have higher drug
exposure.
The dose is adjusted based on platelet count response — upwards to 75mg
or downwards to 25mg. Take tablets on an empty stomach — at least 2 hours
before or 4 hours after food (see admin note). For aplastic anaemia: 150mg once
daily (or 75mg for East Asian patients) — typically higher doses are needed.
Eltrombopag must always be taken on an empty stomach — at least 2 hours
before any food and at least 4 hours after any food, antacids, dairy products,
or mineral supplements. Food — especially calcium-rich foods like dairy — forms
complexes with eltrombopag and dramatically reduces its absorption. Do not take
it with milk, dairy products, calcium supplements, iron supplements, magnesium
supplements, or antacids containing aluminium or magnesium. The timing rules
are strict and affect how much of the medicine your body actually absorbs.
⚠ PATIENT TIP: Many patients find it easiest to
take eltrombopag first thing in the morning — at least 30 minutes before
breakfast and well before any morning vitamins or supplements. Set a phone
alarm to remind you of the timing. Sticking to consistent timing every day
gives the most predictable platelet response.
4. POSSIBLE SIDE EFFECTS
|
How Common? |
Side Effects |
|
Common |
Nausea, diarrhoea,
headache, upper respiratory infections (colds), fatigue, raised liver enzyme
levels on blood tests |
|
Less Common |
Hair loss, cataracts
(clouding of the eye lens — eye checks are recommended with long-term use),
abnormal changes in bone marrow structure (reticulin fibrosis — monitored
with bone marrow tests in long-term users) |
|
Serious — Tell Your
Doctor |
Liver toxicity
(hepatotoxicity): jaundice, dark urine, severe nausea, right upper tummy pain
— liver function tests are monitored before and during treatment. Blood clots
(thromboembolism) — eltrombopag increases platelet count, and if platelets
rise too high, clot risk increases (DVT, PE, portal vein thrombosis).
Worsening of pre-existing bone marrow fibrosis. Signs of haematological
malignancy progression in MDS patients (where eltrombopag is not indicated as
it may accelerate disease). |
5. WHO SHOULD NOT TAKE THIS MEDICINE
Eltrombopag must not be used in patients with myelodysplastic syndrome
(MDS) or other blood cancers — there is evidence it can stimulate cancer cell
growth and accelerate disease progression. It must be used with extreme caution
in patients with a history of portal vein thrombosis or other thromboembolic
events.
Not recommended during pregnancy — effective contraception required. Use
with significant liver impairment requires careful dose reduction and
monitoring.
⚠ LIVER FUNCTION MONITORING: Liver function
tests (ALT, AST, bilirubin) must be performed before starting, every 2 weeks
during dose adjustment, then monthly once stable. Significant liver enzyme
elevations require dose reduction or discontinuation.
⚠ THROMBOTIC RISK AT HIGH PLATELET COUNTS: If
platelet counts rise too high (above 400 x 10⁹/L), clot risk increases
significantly. Platelet counts are monitored regularly — doses are adjusted
downward if counts exceed the target range. Report leg swelling,
breathlessness, or chest pain promptly.
⚠ FOOD AND SUPPLEMENT INTERACTIONS: Eltrombopag
has strict food and supplement timing requirements. Taking it within 2 hours of
food, dairy, or mineral supplements dramatically reduces absorption and makes
the treatment less effective.
6. MEDICINES THAT INTERACT WITH THIS TREATMENT
Antacids containing polyvalent cations (aluminium, magnesium, calcium
hydroxide) must not be taken within 4 hours of eltrombopag — they bind the
medicine in the gut.
Calcium, iron, magnesium, and zinc supplements have the same interaction.
Dairy products and calcium-rich foods have the same binding effect — separate
by at least 4 hours.
Statins: eltrombopag inhibits OATP1B1, a transport protein — it can
increase rosuvastatin levels by up to 55% and simvastatin levels significantly.
Dose reduction of these statins may be needed. Ciclosporin reduces eltrombopag
absorption. CYP1A2 inhibitors (fluvoxamine, ciprofloxacin) increase eltrombopag
levels.
7. HOW TO STORE THIS MEDICINE
Store below 30°C. Keep in original packaging. Protect from moisture. Keep
out of reach of children.
8. PRESCRIPTION REQUIREMENT
|
Field |
Details |
|
Status |
Prescription Only
Medicine (POM) — Specialist (haematology) prescription required |
9. GUIDANCE FOR PATIENTS & CAREGIVERS
Take your tablet on a completely empty stomach — at least 2 hours before
eating and at least 4 hours after your last meal or snack. Do not take it with
milk, dairy, calcium supplements, iron, or antacids.
Morning dosing — at least 30 minutes before breakfast and before any
supplements — works well for most people. Attend all blood test appointments
for platelet counts and liver function. If your platelets rise too high, you
might feel unusual symptoms — report any leg pain or swelling, breathlessness,
or chest pain to your haematologist. Do not take any supplements (iron,
calcium, magnesium) within 4 hours of your tablet without checking with your
pharmacist.
10. PHARMACIST & PRESCRIBER NOTES
|
Field |
Details |
|
Clinical Dispensing
Notes |
Strict fasting
administration — 2 hours pre-meal AND 4 hours post-meal (or post-polyvalent
cation supplement/antacid/dairy). Non-compliance with this is the most common
cause of inadequate platelet response. Reinforce at every dispensing. East
Asian patients and those with liver impairment: start at 25mg OD. Liver
monitoring: LFTs pre-treatment, every 2 weeks during titration, monthly when
stable. Platelet monitoring: weekly during initiation and dose adjustment;
monthly once stable. Thrombosis risk: if platelets >400 x 10⁹/L — reduce
dose; if >400 after 2 weeks at lowest dose — discontinue. Cataract
monitoring: periodic eye examinations recommended for long-term users.
Reticulin fibrosis: periodic bone marrow assessment for long-term users per
haematologist protocol. Statin interaction: rosuvastatin and simvastatin dose
review required. Ciclosporin reduces absorption. Pregnancy: contraindicated —
effective contraception required. Not for MDS — confirm diagnosis before
dispensing. |
11. FREQUENTLY ASKED QUESTIONS
Q: Why do I have to take it on an empty stomach?
Eltrombopag chemically binds to minerals like calcium, magnesium, iron,
and aluminium — forming complexes that cannot be absorbed from the gut. Food
(especially dairy), mineral supplements, and antacids all interfere
significantly with absorption. Taking it on a completely empty stomach, well
away from food and supplements, ensures the full dose reaches your bloodstream.
Q: What if I forget and have breakfast first?
Wait at least 4 hours from your last food or supplement before taking the
tablet. If it is very close to your next scheduled dose, skip the missed dose
and take the next one as normal. Do not take a double dose.
Q: Why do I need liver blood tests?
Eltrombopag can cause elevated liver enzymes in some patients, and rarely
more significant liver toxicity. Regular blood tests — every 2 weeks during
dose adjustment and monthly thereafter — detect any liver changes early so the
dose can be adjusted if needed.
Q: Are there any supplements I can't take with this medicine?
Yes — calcium, iron, magnesium, and zinc supplements all bind to
eltrombopag and prevent it from being absorbed. They must be taken at least 4
hours after your eltrombopag tablet. Antacids containing aluminium or magnesium
(like Gaviscon or Maalox) have the same effect. Dairy products and calcium-rich
foods also interact — keep at least 2 hours between any food and your tablet.