Do the acute platelet responses of patients with immune thrombocytopenic purpura (ITP) to IV anti‐D and to IV gammaglobulin predict response to subsequent splenectomy?

Bussel, James B.; Kaufmann, Craig P.; Ware, Russell E.; Woloski, B.M.R.N.J.

doi:10.1002/ajh.1072

Cited by 43 publications

(27 citation statements)

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“…There is at present no widely accepted and reliable test to identify patients who will fail splenectomy. It is unclear whether indiumlabelled autologous platelet scanning [19] or response to high-dose IVIg [20,21] can accurately predict response. Moreover, platelet scanning is expensive and not yet widely available and results may be poor at very low platelet counts.…”

Section: Splenectomy Results Are Unpredictable and It Is Associated Wmentioning

confidence: 99%

Should medical treatment options be exhausted before splenectomy is performed in adult ITP patients? A debate

et al. 2010

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Patients with primary immune thrombocytopenia (ITP) may require treatment to reduce the risk of serious bleeding if platelets remain consistently below 30 x 109/L. While approximately 70-80% of patients respond to an initial course of corticosteroids, relapse is common. For steroid-refractory patients, there is a choice between surgical splenectomy and further medical treatments, based on many factors including the patient's bleeding history, fitness for surgery, comorbidities, tolerance of adverse events, lifestyle and preferences. Treatments that have traditionally been used (corticosteroids, azathioprine, danazol) suppress the immune system, potentially predisposing patients to infection. Recent insights into the underlying pathophysiology of the disease have allowed the development of targeted therapies, including the thrombopoietin (TPO) receptor agonists, which enhance platelet production. Phase III trials have found romiplostim and eltrombopag to be well tolerated and effective in elevating platelet counts and reducing bleeding in both splenectomised and nonsplenectomised patients with chronic ITP. The B-cell targeted monoclonal antibody rituximab has also shown some potential in this setting, although data are currently limited and there are toxicity concerns. The decision whether to proceed to splenectomy or try other medical therapies in corticosteroidrefractory patients remains patient-specific. Splenectomy has its risks (including perioperative and long-term risks), and relapse/nonresponse are relatively common, but it offers the possibility of cure in the majority of patients. However, newer treatments may potentially allow splenectomy to be deferred for prolonged periods, as well as providing alternative treatment options for patients who fail splenectomy . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 However, newer treatments may potentially allow splenectomy to be deferred for prolonged periods, as well as providing alternative treatment options for patients who fail splenectomy.

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Section: Splenectomy Results Are Unpredictable and It Is Associated Wmentioning

confidence: 99%

Should medical treatment options be exhausted before splenectomy is performed in adult ITP patients? A debate

et al. 2010

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“…There is no widely accepted test predicting response to splenectomy. Response to oral corticosteroids or high-dose IVIg has a low predictive value 110,111 (evidence level IIb). Indium-labeled autologous platelet scanning may be the most sensitive predictor of response to splenectomy, but here too studies vary.…”

Section: Second-line Treatment Options For Adult Itp Patientsmentioning

confidence: 99%

International consensus report on the investigation and management of primary immune thrombocytopenia

Provan¹,

Stasi

Newland³

et al. 2010

Blood

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1,835

1,954

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IntroductionPrimary immune thrombocytopenia (ITP) is an acquired immunemediated disorder characterized by isolated thrombocytopenia, defined as a peripheral blood platelet count less than 100 ϫ 10 9 /L, and the absence of any obvious initiating and/or underlying cause of the thrombocytopenia. 1 Until recently, the abbreviation ITP stood for idiopathic thrombocytopenic purpura, but current awareness relating to the immune-mediated nature of the disease, and the absence or minimal signs of bleeding in a large proportion of cases have led to a revision of the terminology. 1 Concepts surrounding the mechanisms of thrombocytopenia in ITP have shifted from the traditional view of increased platelet destruction mediated by autoantibodies to more complex mechanisms in which both impaired platelet production and T cell-mediated effects play a role. [2][3][4][5][6] Recent epidemiologic data suggest that the incidence in adults is approximately equal for the sexes except in the mid-adult years (30-60 years), when the disease is more prevalent in women. 7,8 ITP is classified by duration into newly diagnosed, persistent (3-12 months' duration) and chronic (Ն 12 months' duration). 1 Whereas ITP in adults typically has an insidious onset with no preceding viral or other illness and it normally follows a chronic course, 9 ITP in children is usually short-lived with at least two-thirds recovering spontaneously within 6 months. 10 Signs and symptoms vary widely. Many patients have either no symptoms or minimal bruising, whereas others experience serious bleeding, which may include gastrointestinal hemorrhage (GI), extensive skin and mucosal hemorrhage, or intracranial hemorrhage (ICH). The severity of thrombocytopenia correlates to some extent but not completely with the bleeding risk. 7,11 Additional factors (eg, age, lifestyle factors, uremia) affect the risk and should be evaluated before the appropriate management is determined.The investigation and management of ITP patients vary widely. The purpose of this consensus document is to comment on new data and provide recommendations relating to diagnosis and treatment. Final judgment regarding care of individual patients should, however, lie with the responsible health care professional and be based on careful investigation of individual circumstances. MethodsComposition of the panel. The panel included 22 members with recognized clinical and research expertise in ITP representing North America (United States, 7; Canada, 1), Europe (France, 1; Italy, 2; Spain, 1; Switzerland, 1; United Kingdom, 8), and Australia (1).Assessment of the literature. Articles were identified by a computer-assisted search of the literature published in English using the National Library of Medicine PubMed database. The For personal use only. on May 7, 2018. by guest www.bloodjournal.org From search criteria were: 'immune thrombocytopenic purpura', 'idiopathic thrombocytopenic purpura', 'ITP', and 'autoimmune thrombocytopenic purpura'. A subsequent search was performed using the corresponding MedLin...

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“…33 A small, retrospective series of 14 adults reported that a response to the last dose of anti-D was predictive of response to splenectomy, though there was no overall correlation between anti-D use and splenectomy responses. 34 Taken together, we believe that previous response to these therapies helps to confirm the diagnosis of ITP, 35 thus making a response to splenectomy somewhat more likely in these patients compared to patients who do not respond.…”

Section: Prior Therapiesmentioning

confidence: 99%

Splenectomy for immune thrombocytopenia: down but not out

Chaturvedi

Arnold

McCrae

2018

Blood

158

154

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word count: 239Word count: 4298 ABSTRACTSplenectomy is an effective therapy for steroid-refractory or dependent immune thrombocytopenia (ITP). With the advent of medical alternatives such as rituximab and thrombopoietin receptor antagonists (TPO-RA), the use of splenectomy has declined and is generally reserved for patients that fail multiple medical therapies. Splenectomy removes the primary site of platelet clearance and autoantibody production, and offers the highest rate of durable response (50-70%) compared to other ITP therapies. However, there are no reliable predictors of splenectomy response, and long-term risks of infection and cardiovascular complications must be considered. Since the long-term efficacy of different second-line medical therapies for ITP have not been directly compared, treatment decisions must be made without supportive evidence. Splenectomy continues to be a reasonable treatment option for many patients, including those with an active lifestyle who desire freedom from medication and monitoring, and patients with fulminant ITP that does not respond well to medical therapy. We try to avoid splenectomy within the first 12 months after ITP diagnosis for most patients to allow for spontaneous or therapy-induced remissions, particularly in older patients who have increased surgical morbidity and lower rates of response, and in young children. Treatment decisions must be individualized based on patients' comorbidities, lifestyles and preferences. Future research should focus on comparing long-term outcomes of patients treated with different second line therapies, and on developing personalized medicine approaches to identify subsets of patients most likely to respond to splenectomy or other therapeutic approaches.

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Do the acute platelet responses of patients with immune thrombocytopenic purpura (ITP) to IV anti‐D and to IV gammaglobulin predict response to subsequent splenectomy?

Cited by 43 publications

References 28 publications

Should medical treatment options be exhausted before splenectomy is performed in adult ITP patients? A debate

Should medical treatment options be exhausted before splenectomy is performed in adult ITP patients? A debate

International consensus report on the investigation and management of primary immune thrombocytopenia

Splenectomy for immune thrombocytopenia: down but not out

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