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

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Abstract

Patients with primary immune thrombocytopenia (ITP) may require treatment to reduce the risk of serious bleeding if platelets remain consistently below 30 × 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 corticosteroid-refractory 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.

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Acknowledgements

This article is based on a debate between the authors, which took place in Berlin, Germany on June 4th 2009 during the 14th European Haematology Association Congress and was supported by Amgen Europe GmbH, Zug, Switzerland. The authors thank Julia Balfour, Medical Writer, Kilconquhar, Scotland for assistance with the preparation of the manuscript, with financial support from Amgen.

Conflicts of interest disclosures

Authors conflict of interest declarations are as follows: Prof. Newland—Research funding from Amgen, Baxter, GSK and Genentech; consultant and speaker for Amgen and GSK; advisory board for GSK and Pangenetics; Dr. Stasi—advisory boards and/or speaker for GSK and Amgen. Dr. Pabinger—speaker and advisory boards for Amgen and GSK. Dr. Thornton has no conflicts of interest to declare.

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Authors and Affiliations

  1. Department of Haematology, St. George’s Hospital, London, UK

    Roberto Stasi

  2. Department of Haematology, Royal London Hospital, London, UK

    Adrian Newland

  3. Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland

    Patrick Thornton

  4. Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria

    Ingrid Pabinger

  5. Department of Haematology, St George’s Healthcare NHS Trust, Blackshaw Road, Tooting, London, SW17 0QT, UK

    Roberto Stasi

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  1. Roberto Stasi
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Correspondence to Roberto Stasi.

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Stasi, R., Newland, A., Thornton, P. et al. Should medical treatment options be exhausted before splenectomy is performed in adult ITP patients? A debate. Ann Hematol 89, 1185–1195 (2010). https://doi.org/10.1007/s00277-010-1066-2

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  • DOI: https://doi.org/10.1007/s00277-010-1066-2

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