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Counseling Patients on Goals of 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: Monday, Jan 22, 2018



Transcript: 

Ivy Altomare, MD: We have a patient. We’ve made the diagnosis and we’re thinking about treatment. What are your long-term goals for the patient? We know that this is a chronic disease. What are you trying to achieve for the patient, knowing that they’re going to probably live with this disease throughout their lifetime, Dr. Gernsheimer?

Terry Gernsheimer, MD: Obviously, all patients want to be cured. That’s what everybody wants. They want something that is going to allow them to walk away and never see me again. My patients say, “I really like you, Dr. Gernsheimer, but I’d really rather not see you as often as I have to.” I think that the idea of cure is probably not realistic for the majority of patients, unless we can find some underlying reason for it. I think the long-term goals are to minimize steroids. I think that’s incredibly important. And it’s to get people back to living their lives normally. Also, it is to ensure that their treatments affect their lives as little as possible. I’m looking for a safe platelet count, not a normal platelet count. Sometimes, patients have trouble with that idea. I’ll tell them, “Oh well, you’re up to 80,000. I’m so pleased.” And they’ll say, “But it’s still in the red.”

Ivy Altomare, MD: Right, it’s not normal.

Terry Gernsheimer, MD: They don’t like that.

Ivy Altomare, MD: Yes.

Terry Gernsheimer, MD: But I think that over time, people begin to understand that the goal is to keep them safe.

Ivy Altomare, MD: How about you, Dr. McCrae?

Keith R. McCrae, MD: I agree with that. I tell patients, “You’re probably going to have this disease for a long time.” I suppose I’m a little more idealistic. I still have this hope that I can make their ITP go away. I don’t know what the correct approach is. There’s conflicting data and emerging data on early treatment, but I am a proponent, I think, of aggressive treatment early in the course of the disease with more than just the standard of care. Some of that is out of my hands. It’s in the hands of the insurers because these approaches are not inexpensive. But in general, I do agree with what Dr. Gernsheimer said. You tell patients that this is probably a long-term disease. I tell them there may, with the right patient, be some things we could do, upfront, if the conditions are right and they are willing to take a little more medication and allow for discomfort.

Ivy Altomare, MD: I’m glad you mentioned more aggressive up-front therapy. We will get to that because I’m very interested to hear what you have to say. In your experience, how do patients present with this disease? Is it that patients present with symptomatic bleeding? Or is it just detected through the laboratory value on a complete blood count?

Keith R. McCrae, MD: I think it depends on your practice, to some extent. We certainly get a lot of asymptomatic thrombocytopenias that are discovered incidentally on the annual physical exam and annual blood count. On the other hand, in my practice, probably the most common source I see is people who have been hospitalized for an initial course of ITP, or have failed early treatment. The patients who are initially hospitalized are often symptomatic, at the time. Maybe the symptoms don’t include life-threatening bleeding, but certainly bruising. And perhaps, epistaxis, or things like that. We all have different thresholds for admissions. When you come to an emergency room with a certain level of platelet count, you’re probably going to get admitted. Hematologists might not admit for that. I probably get about 50/50, of those different types of patients.

Transcript Edited for Clarity 

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Transcript: 

Ivy Altomare, MD: We have a patient. We’ve made the diagnosis and we’re thinking about treatment. What are your long-term goals for the patient? We know that this is a chronic disease. What are you trying to achieve for the patient, knowing that they’re going to probably live with this disease throughout their lifetime, Dr. Gernsheimer?

Terry Gernsheimer, MD: Obviously, all patients want to be cured. That’s what everybody wants. They want something that is going to allow them to walk away and never see me again. My patients say, “I really like you, Dr. Gernsheimer, but I’d really rather not see you as often as I have to.” I think that the idea of cure is probably not realistic for the majority of patients, unless we can find some underlying reason for it. I think the long-term goals are to minimize steroids. I think that’s incredibly important. And it’s to get people back to living their lives normally. Also, it is to ensure that their treatments affect their lives as little as possible. I’m looking for a safe platelet count, not a normal platelet count. Sometimes, patients have trouble with that idea. I’ll tell them, “Oh well, you’re up to 80,000. I’m so pleased.” And they’ll say, “But it’s still in the red.”

Ivy Altomare, MD: Right, it’s not normal.

Terry Gernsheimer, MD: They don’t like that.

Ivy Altomare, MD: Yes.

Terry Gernsheimer, MD: But I think that over time, people begin to understand that the goal is to keep them safe.

Ivy Altomare, MD: How about you, Dr. McCrae?

Keith R. McCrae, MD: I agree with that. I tell patients, “You’re probably going to have this disease for a long time.” I suppose I’m a little more idealistic. I still have this hope that I can make their ITP go away. I don’t know what the correct approach is. There’s conflicting data and emerging data on early treatment, but I am a proponent, I think, of aggressive treatment early in the course of the disease with more than just the standard of care. Some of that is out of my hands. It’s in the hands of the insurers because these approaches are not inexpensive. But in general, I do agree with what Dr. Gernsheimer said. You tell patients that this is probably a long-term disease. I tell them there may, with the right patient, be some things we could do, upfront, if the conditions are right and they are willing to take a little more medication and allow for discomfort.

Ivy Altomare, MD: I’m glad you mentioned more aggressive up-front therapy. We will get to that because I’m very interested to hear what you have to say. In your experience, how do patients present with this disease? Is it that patients present with symptomatic bleeding? Or is it just detected through the laboratory value on a complete blood count?

Keith R. McCrae, MD: I think it depends on your practice, to some extent. We certainly get a lot of asymptomatic thrombocytopenias that are discovered incidentally on the annual physical exam and annual blood count. On the other hand, in my practice, probably the most common source I see is people who have been hospitalized for an initial course of ITP, or have failed early treatment. The patients who are initially hospitalized are often symptomatic, at the time. Maybe the symptoms don’t include life-threatening bleeding, but certainly bruising. And perhaps, epistaxis, or things like that. We all have different thresholds for admissions. When you come to an emergency room with a certain level of platelet count, you’re probably going to get admitted. Hematologists might not admit for that. I probably get about 50/50, of those different types of patients.

Transcript Edited for Clarity 
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