Older Adults and Immune Thrombocytopenia: Considerations for the Clinician

Abstract

Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient’s history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.

The use of splenic embolization in immune thrombocytopenia: A systematic review and meta‐analysis

“…Elderly individuals often encounter significantly higher perioperative risks linked to splenectomy compared to younger patients 58 . This population group are often deemed unsuitable candidates for splenectomy, especially if there is a pre‐existing increased risk of thrombosis or multiple comorbidities, resulting in their management with drug therapy for an extended period 59–61 …”

“…58 This population group are often deemed unsuitable candidates for splenectomy, especially if there is a pre-existing increased risk of thrombosis or multiple comorbidities, resulting in their management with drug therapy for an extended period. [59][60][61] Although post-embolization syndrome is the most common minor complication, typically managed with conservative therapy, 62 major complications such as splenic abscess and splenic rupture may necessitate surgical or other interventional measures. 63 Our review of AEs following SE revealed an incidence of 1.3% of severe AEs requiring intervention.…”

Is splenectomy a good strategy for refractory immune thrombocytopenia in adults?

“…43 However, contradictory data have shown no clear decrease in the effectiveness of splenectomy in older people. 44 Therefore, splenectomy should not reasonably be contraindicated in older patients; the existence of comorbidity and the degree of frailty of the patient should lead more to the rejection of surgery than age alone. In patients with severe comorbidities for whom splenectomy is contraindicated, it has been suggested that partial splenic embolization could be a safe and alternative therapy and generates a long-term durable response.…”

“…Some have suggested that the response to splenectomy is poor in patients over 60 years old and with many complications but still with 56% prolonged response 43 . However, contradictory data have shown no clear decrease in the effectiveness of splenectomy in older people 44 . Therefore, splenectomy should not reasonably be contraindicated in older patients; the existence of comorbidity and the degree of frailty of the patient should lead more to the rejection of surgery than age alone.…”

Hemorragia alveolar difusa en paciente con trombocitopenia inmune primaria refractaria: reporte de caso

“…Después de una búsqueda cuidadosa, existen otras intervenciones que podrían ser útiles, como el uso de agentes biológicos (por ejemplo, Rituximab) y la terapia combinada 10 . Las guías no son claras sobre cómo proceder después de la terapia de segunda línea ni cuando se considera una TIP refractaria 11 ; se han probado múltiples esquemas de combinación con un rango variable de éxito: por ejemplo, el uso de ciclofosfamida, acompañado de prednisona, vincristina, rituximab y otros medicamentos, han demostrado respuestas hasta del 60 % 12,13 . Además, el historial médico, así como los hallazgos físicos y de laboratorio específicos deben evaluarse cuidadosamente, sobre todo cuando los pacientes tienen sospecha de enfermedades infecciosas concurrentes.…”