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

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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.

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References

  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):1123–1124

    Article  PubMed  CAS  Google Scholar 

  2. Cines DB, Bussel JB, Liebman HA, Luning Prak ET (2009) The ITP syndrome: pathogenic and clinical diversity. Blood 113(26):6511–6521

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  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):504–509

    PubMed  CAS  Google Scholar 

  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):1630–1638

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed Central  PubMed  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  PubMed Central  Google Scholar 

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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.

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Authors and Affiliations

  1. Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Allyson M. Pishko, Adam Cuker & Douglas B. Cines

  2. Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Adam Cuker & Douglas B. Cines

  3. National Hemophilia Center, Sheba Medical Center, Tel Aviv University, Ramat-Gan, Israel

    Mudi Misgav

  4. Department of Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA

    James N. George

  5. Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA

    James N. George, Sara K. Vesely & Deirdra R. Terrell

Authors
  1. Allyson M. Pishko
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  2. Mudi Misgav
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  3. Adam Cuker
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  4. Douglas B. Cines
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  5. James N. George
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  6. Sara K. Vesely
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  7. Deirdra R. Terrell
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Correspondence to Allyson M. Pishko.

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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.

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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.

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Pishko, A.M., Misgav, M., Cuker, A. et al. Management of antithrombotic therapy in adults with immune thrombocytopenia (ITP): a survey of ITP specialists and general hematologist–oncologists. J Thromb Thrombolysis 46, 24–30 (2018). https://doi.org/10.1007/s11239-018-1649-7

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  • DOI: https://doi.org/10.1007/s11239-018-1649-7

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