How we manage immune thrombocytopenia in the elderly

Abstract

SummaryWith prolonged life expectancy, immune thrombocytopenia (ITP) is frequent in elderly people. In this setting, ITP diagnosis is challenging because of the concern about an underlying myelodysplastic syndrome. Studies of older adults are lacking, and recommendations for treatment are based mainly on expert opinion. The therapeutic strategy differs from that for younger patients and must take into account the greater risk of bleeding and thrombosis, presence of comorbidities, possible impaired cognitive performance or poor life expectancy and concomitant medications, such as anticoagulant and antiplatelet therapy. Steroids and intravenous immunoglobulin (IVIg) therapy remain the first-line treatments in elderly patients, but prolonged treatment with steroids should be avoided and IVIg treatment may lead to renal failure. Splenectomy is less effective than in young patients and risk of thrombosis is increased. Severe co-morbidities can also contraindicate surgery. Therefore, other second-line treatments are frequently preferred. Danazol and dapsone can be an option for the less severe ITP form. Rituximab is a good option except in patients with a history of infection or with hypogammaglobulinaemia. Thrombopoietin agonists are attractive, especially for patients with severe comorbidities or with limited life expectancy but the risk of thrombosis is a concern.

Newly diagnosed immune thrombocytopenia adults: Clinical epidemiology, exposure to treatments, and evolution. Results of the CARMEN multicenter prospective cohort

“…Interestingly, 4 patients had myelodysplastic syndrome revealed by ITP. This confirms that myelodysplastic syndrome is an emerging cause of ITP . The rarity of serious bleeding at ITP onset is fully in accordance with previous studies, with central nervous system bleeding in <1% of patients and gastrointestinal bleeding in about 2‐4% .…”

Understanding how older age drives decision‐making and outcome in Immune Thrombocytopenia. A single centre study on 465 adult patients

“…The second result is that older age was a crucial factor in therapeutic decision‐making. Younger patients were more frequently underwent a boosted immunosuppressive therapy, including higher dosages of corticosteroids front‐line and rituximab and/or splenectomy thereafter (Mahevas et al , ). This approach could more frequently achieve a “cure” in younger patients, while the elderly presented a significantly higher rate of drug‐independent responses at last contact.…”

“…Finally, we observed an excess of severe haemorrhages in older patients. The association between age and risk of haemorrhage may be linked to patient frailty and comorbidities, concomitant medications including antiplatelet/anticoagulant therapy, or to a more aggressive form of ITP (Vianelli et al , ; Bizzoni et al , ; Moulis et al , ; Mahevas et al , ). Additionally, older age, male gender and use of TPO‐ra correlated with increased rate of subsequent severe thromboses.…”

The Efficacy of Colchicine and Dapsone Combination Therapy in Relapsed Immune Thrombocytopenia

“…8 Since there are no preoperative characteristics to help predict patient response to a splenectomy, 8 which may lead to bleeding complications, many medical treatments have been investigated to facilitate second-line treatment of ITP enabling a splenectomy to be deferred until the chronic phase of disease (12 months). 2,14 In one large cohort study, carried out over the last 35 years, use of a splenectomy tended to delay second- to third-line therapy but the overall rate of operation remained steady at around 15-25%. 15 The emerging therapies as a second-line treatment were rituximab and thrombopoietin receptor agonists.…”