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Background and Importance Thrombopoietin receptor agonists represent a therapeutic tool in patients with chronic primary immune thrombocytopenia (ITP) who are refractory to conventional treatments. Among them, eltrombopag and avatrombopag have demonstrated significant efficacy in increasing platelet counts, including favourable outcomes in patients with previous eltrombopag failure. However, they present differences in pharmacological profile, safety and cost, which may influence therapeutic selection.Aim and Objectives To compare the effectiveness, safety, and economic impact of avatrombopag versus eltrombopag in adult patients with chronic ITP treated at a tertiary hospital, as well as to estimate the potential savings derived from a sequential use strategy.Material and Methods A retrospective observational study that included all adult patients receiving active treatment with avatrombopag between January and September 2025.Data were obtained from electronic medical records and the pharmacy dispensing system, recording the following:Number of active patients.Previous exposure to eltrombopag.Reason for switching to avatrombopag.Platelet response.Adverse events.Cost.A cost simulation was performed assuming that patients initially treated with avatrombopag had instead received eltrombopag.Results In 2025, 39 active patients treated with avatrombopag, with two lost to follow-up due to death. Only 33% had previously received eltrombopag. The switch to avatrombopag occurred in 50% of cases due to loss of platelet response and in the remaining 50% for other reasons: 40% due to dietary restrictions and 10% due to adverse reactions (elevated liver enzymes or thrombocytosis). The platelet response rate (≥50×10 9/L) was 64%, with an interval from treatment initiation to the next blood test of 23.8 days (range: 7–60), consistent with data reported in pivotal trials (65.6% at 8 days). The economic simulation, considering a monthly cost of €44.7 for eltrombopag and €547.54 for avatrombopag, showed that if 67% of patients had started treatment with eltrombopag, the estimated annual savings would amount to €120.672.Conclusion and Relevance Avatrombopag and eltrombopag show comparable efficacy and safety profiles. Therapeutic choice should be based on tolerability and individual patient characteristics, reserving avatrombopag for cases of intolerance, adverse reactions or loss of response to eltrombopag. The implementation of a sequential strategy could optimise resource utilisation in the hospital setting, maintaining therapeutic efficiency and reducing costs.Conflict of Interest No conflict of interest