Immune Thrombocytopenia: Risks and Impact on Patients
A discussion on the risks of bleeding episodes and venous thromboembolism associated with immune thrombocytopenia.
Bhavesh Shah, RPh, BCOP: It’s interesting how many of these patients will probably need anticoagulation. David, I was going to ask you about the complexity of being on anticoagulation and having ITP [immune thrombocytopenia]. How do you manage these patients in practice?
David Hughes, PharmD, BCOP: Yes, it’s an interesting question, and 1 that comes up more frequently than not. A lot of these patients end up having a procoagulable state based on underlying comorbidities or conditions that are predisposed for patients with ITP, such as lupus, Evans syndrome, or syndromes that put patients in more of a thrombotic state. Then they’re ultimately put on anticoagulation. These patients can still experience venous thromboembolisms [VTE] or clots, even when their platelets are below the normal limit. A lot of this comes when you end up anticoagulating a patient. It’s to be done with extreme caution. Our thresholds end up being a little lower because, as we’ll talk about, the goal is not necessarily normal platelets in ITP but preventing symptoms of bleeding. It’s important to take a fine balance with these patients and understand that we have to think of it as how do we maximize treatment for patients with ITP, prevent bleeding episodes, and at the same time anticoagulate them for a known event.
Bhavesh Shah, RPh, BCOP: Yeah, I’m sure. Sorry, go ahead, Ali.
Ali McBride, PharmD, MS, BCOP, FASHP, FAzPA: That’s a great point and 1 that’s often unseen. When you have low platelets—David really talked about this—you are still at high risk for VTE. Even though a patient has a platelet count of 5000 per mm3, that risk is a component of that patient. We always say that ITP won’t clot. But if we don’t treat or evaluate, there’s always a high risk for clotting, because 5 is a much larger number when you’re looking at millions vs 5000 or 5 per mm3 in itself. Great point.
Bhavesh Shah, RPh, BCOP: Go ahead, David.
David Hughes, PharmD, BCOP: I think it’s something we’ve seen in practice. We see patients, as I said, clot at 5000, 10,000 per mm3. They don’t necessarily need that higher than normal, 800,000 to a 1 million per mm3 platelet count. A lot of people might think, “That’s where they’re going to clot, when they’re on a therapy that’s making their platelets that much higher.” But we know in practice, that is not always the case.
Bhavesh Shah, RPh, BCOP: It seems challenging to manage these patients who are balancing their thrombocytopenia, and then you’re balancing their bleeding risk in addition to the existing bleeding. I would be curious to know what you think about the quality of life that these patients have. What quality-of-life factors are taken into consideration?
David Hughes, PharmD, BCOP: One factor that’s commonly seen in ITP—which I feel is often underrecognized in clinic—is fatigue. When a lot of these patients present with lower platelet counts, fatigue is a hallmark symptom. Patients who have lower platelets and have had chronic ITP for years can get a sense if they are feeling really tired. They’re going to see this debilitating effect, because they’re going to feel more fatigued when their platelets are lower.
Having said that, there’s many quality-of-life measures that go into the overall treatment, not just with the disease itself and being in a place where you’re going to have low platelets. You have to be more cognizant of physical activity and the things you’re out doing. A typical nosebleed that someone may have in allergy season may be more detrimental to a patient with ITP.
But there’s a lot of push. I know we’ll talk later about this, but many treatments require ongoing monitoring, frequent clinic visits, and potentially some hospitalization. These are patients that live with a chronic condition that ultimately affects their quality of life, whether it’s fatigue, symptoms from the disease itself, or from treatment that’s arguably helping their disease, but necessarily interfering with other aspects of their quality of life.