Management of Patients with Immune Thrombocytopenia - Episode 6

Treatment of Older Patients With ITP

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Drs Bussel, Piatek and Kessler discuss treatment of older patients with ITP.

James Bussel, MD: Craig, you promised to share your wisdom about how to manage the older patients with ITP [immune thrombocytopenic purpura] because there are changes in responses and especially adverse effects for some of the treatments we might use in someone younger. What do you think?

Craig Kessler, MD: The treatment of older individuals with ITP has become a much more relevant topic these days because we know about the bimodal distribution of the onset of ITP. We realize now that the second wave above the young adult population is in the very old. We also know that this group is probably more heterogenous in their presentation. Although in several recent registry studies, there’s an increased incidence of thrombosis and an increased incidence of bleeding complications. Additionally, multiple medical comorbidities complicate the treatment of this population. We don’t have any good clinical trials in the older population. They’ve been excluded from many registration studies because of their medical comorbidities. There’s also a lot of patient selection bias by physicians who don’t want to put these patients in the clinical trials.

One thing about ITP in older patients is that we frequently call these patients primary ITP. As we learn more about the immune system, we’re going to learn that most of the ITP in older patients is probably secondary to other aging effects in the immune system. I call this immunosenescence of the immune system. We’re going to have to be very careful about this. When you take a look at the use of TPO mimetics up front in these populations, it seems to be very good, but you have to be very careful with the increased incidence of thrombotic complications.

What’s the best combination? We don’t know. Several registries, retrospective registries, suggest TPO [thrombopoietin] plus dexamethasone up front is probably a good way of approaching it. Some people think IVIG [Intravenous immune globulin] in this population is the best way to go with a TPO mimetic. We don’t know yet the best way of treating these patients. But there’s 1 thing that’s clear, and this is that older ITP is a heterogeneous group of individuals. Until we know more about the immune system to stratify risk, it’s going to be difficult to treat them.

James Bussel, MD: When would you do a bone marrow in a patient over 65 with ITP?

Caroline Piatek, MD: The main reasons are if there were other cytopenias or there was dysplasia on peripheral smear. What about you?

James Bussel, MD: I mostly end up doing it based on response to treatment, meaning if you have somebody younger or older, if they’re difficult to treat, or if their count won’t go up at all. It makes me think, “I need to look at the marrow.” But I agree, there are many other considerations.

Caroline Piatek, MD: Right, but if you’re using a TPO RA [receptor agonist], they’ll likely respond, right?

James Bussel, MD: Right. It depends on the response. Even though I like the idea of TPO RA—you may know I’ve been involved in the development of the 3 of them—that isn’t what I would use first. You can use steroids or IVIG to get the count up, but it’s a point well taken that TPO RAs are a game changer from the diagnostic point of view.

Craig Kessler, MD: As a person who takes care of a lot of myelodysplasia in older individuals, I think the literature would suggest that 10% to 15% of myelodysplasia is associated with thrombocytopenia without organomegaly or peripheral blood changes. My feeling is that we should be doing bone marrows earlier in our patients. We should certainly be doing visualizations of the spleen, maybe with ultrasound, because many of these patients have splenomegaly that’s not appreciated on physical exam. The new approach to treating older patients is going to be doing next-generation sequencing on bone marrow specimens in order to stratify a patient risk.

Transcript Edited for Clarity