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Initiating Therapy in ITP

Panelists: Ivy Altomare, MD, Duke University Medical Center; Terry Gernsheimer, MD, Fred Hutchingson Cancer Research Center; Keith R McCrae, MD, The Cleveland Clinic
Published: Wednesday, Jan 24, 2018



Transcript: 

Ivy Altomare, MD: Obviously, if a patient is an inpatient, they’re sick enough to be in the hospital. That’s an indication for treatment. But in the outpatient setting, what would be the scenarios to pull the trigger on treating? Dr. Gernsheimer mentioned trying to make the diagnosis. The patient might not be symptomatic, but we may use treatment to diagnose. What are some other triggers?

Keith R. McCrae, MD: That’s a hard question to answer. That’s one of the questions that I’m asked often, and I never give a straight answer. I always say that it depends. It really depends on the patient. For someone who works in an office and sits in a chair all day, who really doesn’t do much physical work or doesn’t get involved in any high-risk activities, I think a platelet count of 20,000 to 25,000 is often quite fine, particularly if they’re not bleeding.

Ivy Altomare, MD: Really?

Keith R. McCrae, MD: I don’t know what your experience is, but there’s clearly some people who have platelet counts of 40,000 who are real bleeders. I’ve had patients who are refractory to all therapies and live for years and years and years with a platelet count of 8000. They never have a bruise. So I think this probably depends on the antibody and where on the platelet it’s binding. And, which receptor it’s hitting and inactivating, or not. That’s kind of off topic, a little bit.

Ivy Altomare, MD: No, not at all.

Keith R. McCrae, MD: If I have a younger person who plays on an intramural hockey league, or a college student who plays lacrosse, they’re probably going to want to have a platelet count of about 100,000, if there’s a lacrosse ball winging by their head at 60 miles per hour. So, again, it’s totally dependent on the patient, their wishes, their needs, and their lifestyle.

Ivy Altomare, MD: We talk about bleeding as a reason to initiate therapy. We think about bleeding as symptomatic bleeding. But what about bruises or petechiae? I know that it is individualized, but how much ecchymoses do you generally allow? When do you start therapy?

Keith R. McCrae, MD: I do believe that oral bleeding is a high-risk concern for ITP patients. After all, the mouth is part of the gastrointestinal tract. One of the major types of bleeding you can experience in ITP, among others, is gastrointestinal bleeding. I tolerate some ecchymosis here and there, but not all over. Again, in any case, with ITP, you have to sit down with the patient. Some patients really don’t like to have these bruises. It changes their quality of life and how they feel in public. That is not an unreasonable reason for treating the patient, if that’s something that’s important to them.

Ivy Altomare, MD: Yes. It’s true that ITP patients are so individual. So are their goals, and comorbidities, and their lifestyle features. It’s hard to compare what you do for one patient versus another patient. What has your experience been?

Terry Gernsheimer, MD: One of my favorite patients to talk about was a roofer who was doing the roof on our stadium. Obviously, he was someone for whom I want to keep at a higher level. I think this true for a lot of people who are contractors, who are getting a lot of daily trauma. The other thing is, I often have to get to know a patient to truly understand what their symptoms are, what their own comfort level is, and where they bleed. I think platelet mass may be as important as platelet count. In other words, very large platelets may have more function. Younger platelets may have more function. But it looks like platelet mass may be more important than bleeding symptoms. In a patient who requires chronic therapy, I’m very willing to dial it down as we go along and to get to lower and lower numbers if they’re asymptomatic, if I know I can trust them to call me.
I
vy Altomare, MD:
They probably get more comfortable?

Terry Gernsheimer, MD: They do.

Ivy Altomare, MD: That nothing bad has happened.

Terry Gernsheimer, MD: And they’re more willing to see that although the count isn’t normal, it’s OK.

Ivy Altomare, MD: Yes.

Transcript Edited for Clarity 

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Transcript: 

Ivy Altomare, MD: Obviously, if a patient is an inpatient, they’re sick enough to be in the hospital. That’s an indication for treatment. But in the outpatient setting, what would be the scenarios to pull the trigger on treating? Dr. Gernsheimer mentioned trying to make the diagnosis. The patient might not be symptomatic, but we may use treatment to diagnose. What are some other triggers?

Keith R. McCrae, MD: That’s a hard question to answer. That’s one of the questions that I’m asked often, and I never give a straight answer. I always say that it depends. It really depends on the patient. For someone who works in an office and sits in a chair all day, who really doesn’t do much physical work or doesn’t get involved in any high-risk activities, I think a platelet count of 20,000 to 25,000 is often quite fine, particularly if they’re not bleeding.

Ivy Altomare, MD: Really?

Keith R. McCrae, MD: I don’t know what your experience is, but there’s clearly some people who have platelet counts of 40,000 who are real bleeders. I’ve had patients who are refractory to all therapies and live for years and years and years with a platelet count of 8000. They never have a bruise. So I think this probably depends on the antibody and where on the platelet it’s binding. And, which receptor it’s hitting and inactivating, or not. That’s kind of off topic, a little bit.

Ivy Altomare, MD: No, not at all.

Keith R. McCrae, MD: If I have a younger person who plays on an intramural hockey league, or a college student who plays lacrosse, they’re probably going to want to have a platelet count of about 100,000, if there’s a lacrosse ball winging by their head at 60 miles per hour. So, again, it’s totally dependent on the patient, their wishes, their needs, and their lifestyle.

Ivy Altomare, MD: We talk about bleeding as a reason to initiate therapy. We think about bleeding as symptomatic bleeding. But what about bruises or petechiae? I know that it is individualized, but how much ecchymoses do you generally allow? When do you start therapy?

Keith R. McCrae, MD: I do believe that oral bleeding is a high-risk concern for ITP patients. After all, the mouth is part of the gastrointestinal tract. One of the major types of bleeding you can experience in ITP, among others, is gastrointestinal bleeding. I tolerate some ecchymosis here and there, but not all over. Again, in any case, with ITP, you have to sit down with the patient. Some patients really don’t like to have these bruises. It changes their quality of life and how they feel in public. That is not an unreasonable reason for treating the patient, if that’s something that’s important to them.

Ivy Altomare, MD: Yes. It’s true that ITP patients are so individual. So are their goals, and comorbidities, and their lifestyle features. It’s hard to compare what you do for one patient versus another patient. What has your experience been?

Terry Gernsheimer, MD: One of my favorite patients to talk about was a roofer who was doing the roof on our stadium. Obviously, he was someone for whom I want to keep at a higher level. I think this true for a lot of people who are contractors, who are getting a lot of daily trauma. The other thing is, I often have to get to know a patient to truly understand what their symptoms are, what their own comfort level is, and where they bleed. I think platelet mass may be as important as platelet count. In other words, very large platelets may have more function. Younger platelets may have more function. But it looks like platelet mass may be more important than bleeding symptoms. In a patient who requires chronic therapy, I’m very willing to dial it down as we go along and to get to lower and lower numbers if they’re asymptomatic, if I know I can trust them to call me.
I
vy Altomare, MD:
They probably get more comfortable?

Terry Gernsheimer, MD: They do.

Ivy Altomare, MD: That nothing bad has happened.

Terry Gernsheimer, MD: And they’re more willing to see that although the count isn’t normal, it’s OK.

Ivy Altomare, MD: Yes.

Transcript Edited for Clarity 
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