Real-life management of primary immune thrombocytopenia (ITP) in adult patients and adherence to practice guidelines

Abstract

Very few data exist on the management of adult patients diagnosed with primary immune thrombocytopenia (ITP). The objectives of this study were to describe the diagnostic and treatment patterns for ITP and to compare the findings to recent ITP guidelines. We retrospectively analyzed the medical records of adult ITP patients diagnosed with primary ITP between January 2011 and June 2012 and examined whether management strategies were consistent or not with eight recent guideline-recommended practices. Overall, median age at the diagnosis of the disease (n = 101) was 58 years and median platelet count 12 × 10(9)/L with 75.2 % of patients having symptoms of ITP. The study perceived two major shortcomings in the diagnostic approach: (1) failure to perform peripheral blood film examination in 22.8 % of patients, a test that is mandatory by all guidelines, and (2) ordinary bone marrow assessment in more than half of the patients at diagnosis (50.5 %), a test not routinely recommended by guidelines. Low appropriateness in therapeutic management of patients included (1) unjustified use of intravenous immunoglobulin in the absence of bleeding in 54.8 % of patients and (2) splenectomy not being deferred until 6-12 months from diagnosis (median 161 days). Data also reflect a trend towards the early use of thrombopoietin receptor agonists in the treatment of patients who are refractory to any first-line therapy. We have recognized important areas of inapropriateness in the diagnostic and therapeutic management of adult ITP patients. Compliance with established guidelines should be encouraged in order to improve patient outcomes.

Immune Thrombocytopenia - Current Diagnostics and Therapy: Recommendations of a Joint Working Group of DGHO, ÖGHO, SGH, GPOH, and DGTI

“…The most frequent deviations by physicians taking care of ITP patients are [154]: -Blood smear was not examined. -Bone marrow biopsy was performed without a clear indication.…”

A critical appraisal of the evidence for the role of splenectomy in adults and children with ITP

“…Is splenectomy in immune thrombocytopenia (ITP) on the verge of becoming an obsolete practice? (Rodeghiero & Ruggeri, ; Ghanima et al , ; Lozano et al , ; Lee et al , ) The current rate of splenectomy in the UK is around 2% per year (data from the UK ITP registry; Provan D, personal communication 2017). The traditional role of splenectomy has been challenged by more recent treatments, such as the B‐cell depleting anti CD‐20 monoclonal antibody rituximab and the thrombopoietin‐receptor agonists (TPO‐RA) romiplostim and eltrombopag, with most patients and physicians preferring to exploit all medical opportunities before undergoing an irreversible surgical approach.…”

Immune Thrombocytopenic Purpura Splenectomy in the Context of New Medical Therapies

“…Medical therapy is recommended for ITP when a patient experiences a clinically important bleeding event or if the platelet count drops below 30 Â 10 9 /L. 4,24 Corticosteroids constitute the backbone of therapy 24 with longer courses of corticosteroids preferred as first-line treatment over shortcourse corticosteroids. 4 IVIg may be used as a second-line agent or in addition to corticosteroids if a rapid increase in platelets is clinically indicated.…”

“…However, as more medical therapies are approved for the treatment of ITP, common medical practice has pushed splenectomy to third-or fourth-line intervention, with preference of IVIg, anti-D, rituximab, or thrombopoietin receptor agonists (THPO-RA) used as second-line therapy or as a bridge to surgery. 4,24 In addition, some guidelines suggest deferring splenectomy at least 6-12 mo from diagnosis. 24 At this institution, medical therapy for ITP patients has changed over the past 23 y; however, we continue to use corticosteroid therapy as our mainstay initial treatment and have more frequently used THPO-RA agents as a second-line therapy.…”

“…4,24 In addition, some guidelines suggest deferring splenectomy at least 6-12 mo from diagnosis. 24 At this institution, medical therapy for ITP patients has changed over the past 23 y; however, we continue to use corticosteroid therapy as our mainstay initial treatment and have more frequently used THPO-RA agents as a second-line therapy. Decisions regarding other medical therapies and/or splenectomy are made in conjunction with the patient in light of their particular disease course, comorbidities, and preferences.…”