Adult Immune Thrombocytopenia Purpura - Episode 6
Ivy Altomare, MD: Let’s discuss all of the treatments for second-line therapy, in no particular order. But I feel like we always have to start with splenectomy—so, Dr Boccia.
Ralph V. Boccia, MD, FACP, LLC: Put me on the spot, right? Because of all these new agents, splenectomy has been pushed further and further out. And I think you can see from what you’ve heard from Amit about the comment and the preliminary guidelines—as ASH just put them out for comment right now—that they’re still pushing back further on splenectomy.
So, we saw from both the original and the International Working Group recommendations of—whatever that was—6 or 7 years ago, that because we have so many newer agents now available to us, the need for splenectomy is much less so—and as we see longer durations of response that will get pushed out further.
And now…instead of having acute and chronic ITP—right?—we have the acute, persistent, and chronic. And that’s I think further evidence that people are thinking less and less about splenectomy. But it still has a role, there’s no doubt about it. It’s the only currently curative therapy that we have. About 80% of patients will be in remission for about a year. But if you look at 3 or 4 or 5 years down the line, it really is down to 50%.
Ivy Altomare, MD: Right, which is still a sizable number.
Ralph V. Boccia, MD, FACP, LLC: So it still has a role.
Ivy Altomare, MD: Yes.
Ralph V. Boccia, MD, FACP, LLC: We can now do laparoscopic splenectomies, and so the potential morbidity and mortality of the operative procedure is lower, so you can get more frail and more elderly patients through it. The risk is that the encapsulated organ may lack splenic macrophage immunity—but that’s a very low rate.
Ralph V. Boccia, MD, FACP, LLC: Immunizing and taking the spleen out—it still has a role. If you have a patient who doesn’t want to take certain oral medications or is having adverse effects from it, doesn’t want to come to the clinic for weekly therapy, doesn’t want the potential immune issues that rituximab can result in, then that’s a patient, I think, for splenectomy. But for my patient population, the last time I had a patient agree to a splenectomy—and this is now having patients on either eltrombopag or romiplostim for years—it is probably 4 or 5 years since my last patient who we splenectomized.
Ivy Altomare, MD: I’ve had 1 in 11 years—1 that agreed to it in 11 years. And I think that one of the problems is that we don’t have a reliable way to really predict who will have a long-term durable response after splenectomy. So it’s hard to go through an elective procedure with no guarantee that it’s going to work.
Ralph V. Boccia, MD, FACP, LLC: Yeah, and the patients were pretty upset when they had their spleens out and then all of a sudden they were thrombocytopenic and we were coming at them with other recommendations.
Ivy Altomare, MD: Yeah, absolutely. But I agree.
Amit Mehta, MD: I think it’s a good point also…because of the curative potential. I think we still should at least discuss it with the patient, or at least bring it up that, OK, these are some of the things we’re considering, including possibly this, and this is why I may or may not recommend it for that individual patient, but I think it’s at least worth definitely noting because of the curative potential. But again, we don’t have a predictor, but 50% is still, I think, a fair number of patients who may achieve long-term cure who’ve already relapsed or have been refractory to corticosteroids up front.
Ivy Altomare, MD: Yeah, and I think it’s also important to tell patients that it does not appear, at least from data from trials, that if you get your spleen removed, that affects response postoperatively, and the drugs that are effective still have efficacy post splenectomy. So you’re not really decreasing your treatment options.
Amit Mehta, MD: Yeah, I agree totally. And it’s interesting that that’s the case, because…a theoretical question is…, will patients still respond with various drugs post splenectomy? And the answer appears to be yes.
Ivy Altomare, MD: Yes.
Amit Mehta, MD: So it’s interesting, and I think that’s why, not surprisingly, for all the reasons we’re discussing right now, splenectomy has kind of fallen down the list as far as that. I think the last point on that that I have observed is that I feel that there are fewer surgeons nowadays who are perhaps willing to do it, because the frequency of experience has diminished greatly in the past I guess 10 years at least. So especially the new surgeons coming out of training—I think they have much less experience in doing a splenectomy in an ITP patient than perhaps the more experienced surgeons.
Ivy Altomare, MD: Some trauma or something.
Amit Mehta, MD: That’s correct.
Ivy Altomare, MD: I absolutely agree with that.
Transcript Edited for Clarity