Management of antithrombotic therapy in adults with immune thrombocytopenia (ITP): a survey of ITP specialists and general hematologist–oncologists

  • Allyson M. Pishko
  • Mudi Misgav
  • Adam Cuker
  • Douglas B. Cines
  • James N. George
  • Sara K. Vesely
  • Deirdra R. Terrell
Article

Abstract

While patients with immune thrombocytopenia (ITP) and low platelet counts are at risk for bleeding, they are not protected against arterial and venous thrombotic events. Frequently, hematologists are asked to consult on a patient with ITP requiring an antiplatelet (AP) agent or anticoagulant (AC). No direct evidence exists to guide hematologists in weighing the risk of thrombosis against the risk of bleeding in patients with ITP. Therefore, we performed a survey to determine the preferred management of AP/AC therapy in ITP patients. The survey described hypothetical patient scenarios and asked respondents to recommend a minimum platelet count for initiation of AP/AC therapy. We surveyed both hematologists with an international reputation in treatment of ITP (n = 48) and also general hematologist–oncologists in Oklahoma (n = 97). Response rates were 38/48 (79%) for the ITP specialists and 46/97 (47%) for general hematologist–oncologists. Overall, recommended platelet thresholds for antithrombotic therapy were similar between ITP specialists and general hematologist–oncologists. Although both groups recommended a minimum platelet count of 50 × 109/L for AP and AC therapy in most scenarios, there was great variability in individual practice patterns among respondents. This study highlights the need for studies of patients with ITP who require AP/AC therapy to provide high-quality evidence for establishing optimal management strategies.

Keywords

Immune thrombocytopenia ITP Antithrombotic therapy Anticoagulant therapy Antiplatelet therapy 

Notes

Acknowledgements

This work was supported in part by 1K01HL135466-01 (DT) and T32 HL 0007971-16A1 (AP), both from the National Heart, Lung, and Blood Institute.

Compliance with ethical standards

Conflict of interest

AC has served as a consultant for Kedrion and Synergy and has received research support from Bayer, Bioverativ, Novo Nordisk, Pfizer, Shire, and Spark Therapeutics. DC has served as a consultant for Amgen, Bayer, Rigel, Astellas and Ionis and has received research support from Syntimmune, Momenta, T2 Biosystems and Sanofi.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards or institution and/or national research committee and with the 1964 Helinski declaration and its later amendments or comparable ethical standards.

Supplementary material

11239_2018_1649_MOESM1_ESM.docx (30 kb)
Supplementary material 1 (DOCX 29 KB)
11239_2018_1649_MOESM2_ESM.xls (66 kb)
Supplementary material 2 (XLS 65 KB)

References

  1. 1.
    Olsson B, Andersson P-O, Jernås M, Jacobsson S, Carlsson B, Carlsson LMS, Wadenvik H (2003) T-cell-mediated cytotoxicity toward platelets in chronic idiopathic thrombocytopenic purpura. Nat Med 9(9):1123–1124CrossRefPubMedGoogle Scholar
  2. 2.
    Cines DB, Bussel JB, Liebman HA, Luning Prak ET (2009) The ITP syndrome: pathogenic and clinical diversity. Blood 113(26):6511–6521CrossRefPubMedCentralPubMedGoogle Scholar
  3. 3.
    Vianelli N, Valdre L, Fiacchini M, de Vivo A, Gugliotta L, Catani L, Lemoli RM, Poli M, Tura S (2001) Long-term follow-up of idiopathic thrombocytopenic purpura in 310 patients. Haematologica 86(5):504–509PubMedGoogle Scholar
  4. 4.
    Cohen YC, Djulbegovic B, Shamai-Lubovitz O, Mozes B (2000) The bleeding risk and natural history of idiopathic thrombocytopenic purpura in patients with persistent low platelet counts. Arch Intern Med 160(11):1630–1638CrossRefPubMedGoogle Scholar
  5. 5.
    Cines DB, Bussel JB (2005) How I treat idiopathic thrombocytopenic purpura (ITP). Blood 106(7):2244–2251.  https://doi.org/10.1182/blood-2004-12-4598 CrossRefPubMedGoogle Scholar
  6. 6.
    Doobaree IU, Nandigam R, Bennett D, Newland A, Provan D (2016) Thromboembolism in adults with primary immune thrombocytopenia: a systematic literature review and meta-analysis. Eur J Haematol 97(4):321–330.  https://doi.org/10.1111/ejh.12777 CrossRefPubMedGoogle Scholar
  7. 7.
    Langeberg WJ, Schoonen WM, Eisen M, Gamelin L, Stryker S (2016) Thromboembolism in patients with immune thrombocytopenia (ITP): a meta-analysis of observational studies. Int J Hematol 103(6):655–664.  https://doi.org/10.1007/s12185-016-1974-6 CrossRefPubMedGoogle Scholar
  8. 8.
    Sarpatwari A, Bennett D, Logie JW, Shukla A, Beach KJ, Newland AC, Sanderson S, Provan D (2010) Thromboembolic events among adult patients with primary immune thrombocytopenia in the United Kingdom General Practice Research Database. Haematologica 95(7):1167–1175.  https://doi.org/10.3324/haematol.2009.018390 CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Feudjo-Tepie MA, Le Roux G, Beach KJ, Bennett D, Robinson NJ (2009) Comorbidities of idiopathic thrombocytopenic purpura: a population-based study. Adv Hematol 2009:963506.  https://doi.org/10.1155/2009/963506 CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Moulis G, Palmaro A, Montastruc JL, Godeau B, Lapeyre-Mestre M, Sailler L (2014) Epidemiology of incident immune thrombocytopenia: a nationwide population-based study in France. Blood 124(22):3308–3315.  https://doi.org/10.1182/blood-2014-05-578336 CrossRefPubMedGoogle Scholar
  11. 11.
    Terrell DR, Beebe LA, Vesely SK, Neas BR, Segal JB, George JN (2010) The incidence of immune thrombocytopenic purpura in children and adults: a critical review of published reports. Am J Hematol 85(3):174–180.  https://doi.org/10.1002/ajh.21616 PubMedGoogle Scholar
  12. 12.
    Matzdorff A, Beer JH (2013) Immune thrombocytopenia patients requiring anticoagulation--maneuvering between Scylla and Charybdis. Semin Hematol 50(Suppl 1):S83–S88.  https://doi.org/10.1053/j.seminhematol.2013.03.020 CrossRefPubMedGoogle Scholar
  13. 13.
    McCarthy CP, Steg G, Bhatt DL (2017) The management of antiplatelet therapy in acute coronary syndrome patients with thrombocytopenia: a clinical conundrum. Eur Heart J.  https://doi.org/10.1093/eurheartj/ehx531 PubMedCentralGoogle Scholar
  14. 14.
    Lu KH, George JN, Vesely SK, Terrell DR (2014) Management of primary immune thrombocytopenia, 2012: a survey of Oklahoma hematologists-oncologists. Am J Med Sci 347(3):190–194.  https://doi.org/10.1097/MAJ.0b013e31827f4dd1 CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Guidry JA, George JN, Vesely SK, Kennison SM, Terrell DR (2009) Corticosteroid side-effects and risk for bleeding in immune thrombocytopenic purpura: patient and hematologist perspectives. Eur J Haematol 83(3):175–182.  https://doi.org/10.1111/j.1600-0609.2009.01265.x CrossRefPubMedGoogle Scholar
  16. 16.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381.  https://doi.org/10.1016/j.jbi.2008.08.010 CrossRefPubMedGoogle Scholar
  17. 17.
    Samuelson BT, Gernsheimer T, Estey E, Garcia DA (2016) Variability in management of hematologic malignancy patients with venous thromboembolism and chemotherapy-induced thrombocytopenia. Thromb Res 141:104–105.  https://doi.org/10.1016/j.thromres.2016.03.011 CrossRefPubMedCentralPubMedGoogle Scholar
  18. 18.
    Carrier M, Khorana AA, Zwicker J, Noble S, Lee AY (2013) Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH. J Thromb Haemost 11(9):1760–1765.  https://doi.org/10.1111/jth.12338 CrossRefPubMedGoogle Scholar
  19. 19.
    Cunningham CT, Quan H, Hemmelgarn B, Noseworthy T, Beck CA, Dixon E, Samuel S, Ghali WA, Sykes LL, Jette N (2015) Exploring physician specialist response rates to web-based surveys. BMC Med Res Methodol 15:32.  https://doi.org/10.1186/s12874-015-0016-z CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of MedicinePerelman School of Medicine, University of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of Pathology and Laboratory Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  3. 3.National Hemophilia Center, Sheba Medical CenterTel Aviv UniversityRamat-GanIsrael
  4. 4.Department of Medicine, College of MedicineUniversity of Oklahoma Health Sciences CenterOklahoma CityUSA
  5. 5.Department of Biostatistics and Epidemiology, College of Public HealthUniversity of Oklahoma Health Sciences CenterOklahoma CityUSA

Personalised recommendations