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

Abstract

We analysed the impact of older age on the management of immune thrombocytopenia (ITP) in 465 adult patients diagnosed between 1995 and 2017 and followed at our institution for a minimum of 12 months. Over a follow-up of 4248 patient-years, front-line corticosteroids therapy was required in 334 patients (71Á8%), mainly (85Á3%) within 1 year from diagnosis. Need for first-, second-and third-line therapy was comparable in younger and older (age ≥65 years, n = 154) patients. Older patients presented more frequently with severe haemorrhages, started therapy with a higher platelet count and received lower dose front-line corticosteroids; thereafter, they were preferentially treated with mild immunosuppressive therapies/thrombopoietin-receptor agonists. Conversely, younger patients were more frequently treated with rituximab and splenectomy, achieving higher rates of complete responses. Incidence rates of ≥grade 2 complications were: 2Á87 (haemorrhages), 1Á55 (infections) and 0Á66 (thromboses) per 100 patient-years. Older age (P = 0Á01) and active haemorrhages at diagnosis (P = 0Á01) significantly predicted grade ≥2 haemorrhages during follow-up. Older age (P = 0Á01), male gender (P = 0Á01), and thrombopoietin receptor agonist use (P = 0Á02) were significantly associated with a higher probability of thrombosis over time. Older age is a significant driver of diagnostic/therapeutic strategy in ITP resulting in different responses and complications rates.

Use of eltrombopag for patients 65 years old or older with immune thrombocytopenia

“…Similarly, romiplostim has also demonstrated a low risk of grade ≥3 bleeding in adults aged ≥65 years . Given that elderly patients with low platelet counts have an increased risk of bleeding, great efficacy, and low bleeding rates of eltrombopag in our elderly ITP cohort confirm usefulness of the drug, as previously reported by other groups…”

“…However, given the elevated age of our population and its high number of comorbidities, we consider safety profile of eltrombopag in this scenario is good and comparable to our previous observations with younger cohorts . Similarly, prior publications confirm low overall survival in the elderly compared to younger patients …”

“…A classic analysis focused on eltrombopag usefulness in elderly patients (ie, results from 5 eltrombopag clinical trials) as reported in abstract form by Olney et al Nevertheless, recently a very interesting manuscript has been published reporting treatment decision strategies in the elderly ITP. Authors studied TPO‐RA use in patients aged >75 years vs <65 years showing a higher use of TPO‐RAs in the elderly, probably because of comparable response rates of these drugs in older and younger patients . However, no clear data are achieved about eltrombopag effectiveness in daily clinical practice in ITP patients aged ≥65 years.…”

“…Although elderly and super‐elderly patients were enrolled in clinical trials, (eg, maximum age of 86 years in EXTEND trial), these studies may not reflect reality in over 65‐year‐old ITP patients. Nevertheless, in last years good few studies regarding eltrombopag use in primary ITP beyond clinical trials were published and increasing number of papers is available for elderly situations . Regarding secondary ITP, lack of clinical trials and shortage of publications outside of clinical trials avoid a clear demonstration of eltrombopag usefulness for this type of patients …”

“…Nevertheless, in last years good few studies regarding eltrombopag use in primary ITP beyond clinical trials were published [17][18][19] and increasing number of papers is available for elderly situations. [20][21][22][23][24][25][26][27] Regarding secondary ITP, lack of clinical trials and shortage of publications outside of clinical trials avoid a clear demonstration of eltrombopag usefulness for this type of patients. 28,29 The aim of our present study is to evaluate safety and efficacy of eltrombopag for primary and secondary ITP in patients aged ≥65 years in Spanish routine clinical practice.…”