Immune Thrombocytopenia Risk Stratification

James B. Bussel, MD:In addition to the well-known risk of overwhelming post splenectomy sepsis, which is a lifetime event, there’s a very small risk of problems with the actual procedure even when done laparoscopically. And there’s a small increased risk of stroke, 1.5­-fold times that of other patients with ITP not undergoing splenectomy. So, these are reasons that people hold off, in addition to the fact that there may be other long-term effects that over time will mount up and be significant.

If we consider other factors in her case, she may well be fatigued. If so, that could be iron deficiency if her menses have been heavy for long enough and/or if she was iron deficient to start with. And she may have issues with thyroid disease, especially if she’s overweight. That may have been 1 of the reasons that she’s overweight in the first place. So, these would certainly need to be tested, and even if they were normal at diagnosis, they would need repeated retesting as time goes on. Because of these issues, she would seem to be particularly good candidate for a TPO agent. And as far as efficacy is concerned, there’s really no difference between eltrombopag and romiplostim. That has been clearly demonstrated in ITP. Therefore, the choice would fall into insurance-related issues, diet-related issues, how she would be able to get her weekly injections, and other considerations like that.

Transcript edited for clarity.

Case: A 44-year-old woman presenting with reddish-purple rash on lower legs

February 2017

• Patient presents with complaints of a reddish-purple rash on her lower legs and “constant” bruises appearing “spontaneously” without her remembering any trauma
• Physical evaluation reveals:
  • The rash to be petechiae (subcutaneous bleeding)
  • Slightly overweight (BMI = 26.5 kg/m²)
  • Patient is afebrile, with no splenomegaly
• When asked, reports her menstrual flow is unusually heavy, but says she was evaluated for and had no evidence of fibroids or endometriosis
• No personal or family history of cancer; no recent viral illnesses; no bone pain
• Current medications: no chronic medications; acetaminophen as needed; multivitamin
• Laboratory findings:
  • CBC reveals platelets 21 X 10⁹/L
  • All other findings with normal range
  • Negative forH pylori, HIV, and HCV
• Diagnosis: chronic ITP
  • Started course of prednisone 1 mg/kg X 21 days, then tapered off; at evaluation, platelets: 27 X 10⁹/L
  • Second course of prednisone 1 mg/kg X 21 days; at evaluation, platelets still <30
  • Third course of prednisone 1 mg/kg X 21 days; at evaluation, platelets still <30

February 2018

• &ldquo;Rash&rdquo; partly resolved, bruising still present
• Patient complains of weight gain on treatment and trouble sleeping
• After discussion with patient, she is started on eltrombopag (PROMACTA), at a dose of 50 mg/day