Adult Immune Thrombocytopenia Purpura - Episode 4

Adult ITP: When Is It Appropriate to Initiate Therapy?

Transcript: Ivy Altomare, MD: Let’s move on to treatment. Rick, let’s start with you. When do you decide to initiate treatment for a patient, assuming that you’ve made the diagnosis, assuming that you think that a patient has ITP [immune thrombocytopenic purpura]? And because you mentioned earlier, lifestyle considerations, and activity level of the patient, and all of those other features that come in to the decision. How do you approach that?

Richard F. McDonough, MD: Clinical features are going to be at the forefront on that. Certainly, if you have a patient with a low platelet count, under 50, and who is bleeding, you’re going to look closely at trying to initiate therapy for them.

Ivy Altomare, MD: So under 50.

Richard F. McDonough, MD: Under 50 and bleeding. Even if they’re in their 40s, or we talked earlier about patients who are on other therapies. But for initiation of therapy, asymptomatic, then I’ll look at clinical factors, look at how the patient is doing, and I’ll choose a cutoff of 20 or 30.

Ivy Altomare, MD: I’m curious. Just an estimate, what percentage of patients, not even in the frontline setting but overall, do you feel can be safely monitored without treatment?

Richard F. McDonough, MD: Looking at all-comers who fit into this category, I think the majority are going to be observed as your first approach to them. I think it’s actually going to be maybe in the 30% range who are actually going to be either in a clinical situation or a count that’s low enough that they need to begin therapy.

Ivy Altomare, MD: Yes. Does anyone else have a platelet threshold where above they watch, below they treat?

Terry B. Gernsheimer, MD: I think that depends on whether they’re newly diagnosed. First of all, if they’re newly diagnosed, you don’t know how they’re going to act. But the other thing I think is that some of my patients are professionals at this, and they know their bleeding risks better than I do. And so that’s something once somebody has clearly had the diagnosis, they’ve had this for a while, it’s persistent or chronic, we’ll certainly lower our threshold and maybe treat more for bleeding. And I am willing to go 20, sometimes below that, depending on how the patient is doing clinically and also what kind of therapy we’re talking about. If the only way I’m going to get their platelet count up is by continual steroids, I’m not going to do it if they’re safe. Or if we’re getting really toxic from other therapies, I’m going to be much less likely to feel like I have to treat a number.

Ivy Altomare, MD: Right.

Ralph V. Boccia, MD: And I’ll interject by saying that since there is a fraction of these people who will be cured with corticosteroid therapy, I tend to use the 30,000 platelet count level, and then look at the patient and ask myself the question, is it worth a course of high-dose dexamethasone to see if we can actually make this person one of the 20% who’s going to respond for a long period, with a remission from that? I often think about that and have that help me make a decision of when to start the patient. If they don’t, and they’re in the 30,000 range, and they’re not symptomatic, and they’ve failed basically that, then I’ll back off.

Amit Mehta, MD: If I can comment.

Ivy Altomare, MD: Yes, please.

Amit Mehta, MD: The crucial thing is first-line treatment versus later-line treatment as far as decision to treat. My threshold to treat is lower for the first-line patient because often they can have such robust destruction going on in the peripheral bloodstream that the platelet count will go rapidly from 50,000 to 20,000 to 2000. And they could quickly get into trouble as opposed to, as we all know, the chronic ITP patient where they may be stable at 26,000 for years and maybe minimally symptomatic and have no bleeding symptoms. But the first-line initial presentation patient, they can often crash quite rapidly in terms of their platelets, so we have to be watching them carefully. I use 20,000 personally. The ASH [American Society of Hematology] guidelines suggest 30,000. I think it just depends on your own training and mentors and so forth and how we practice.

Ivy Altomare, MD: And personal experience with other patients, that always informs what you do for your next patient.

Amit Mehta, MD: And the other big pillar of it is what’s the patient’s risk profile in the first place? Is there an 85-year-old patient who’s a fall risk and also on NSAIDs [nonsteroidal anti-inflammatory drugs] prn as needed for osteoarthritis? Very different situation than the 35-year-old healthy woman, for example.

Ralph V. Boccia, MD: I would just say we want to remember that the ASH guidelines are just that— guidelines.

Ivy Altomare, MD: Absolutely.

Richard F. McDonough, MD: Another factor is obviously the patient. The patient will have their own mindset. I’m sure you guys have all had this. We walk into the room, we have in mind what we’re planning, and they say, “No, I’m not doing that.”

Ivy Altomare, MD: Yes.

Richard F. McDonough, MD: OK, “Then we’ll be observing you then.”

Ivy Altomare, MD: Yes, absolutely.

Terry B. Gernsheimer, MD: I think that’s very true with steroids. There are many patients who say, “I’m not taking those again.”

Richard F. McDonough, MD: Right.

Ivy Altomare, MD: I hear the same thing with IVIg [intravenous immunoglobulin therapy]. They get terrible headaches, and they just don’t want to do it sometimes.

Transcript Edited for Clarity