Initial Treatment of Immune Thrombocytopenia
Frontline options commonly used to treat immune thrombocytopenia and variables that affect treatment selection.
Bhavesh Shah, RPh, BCOP: Ali, how do you decide which treatment to initiate on a patient with ITP [immune thrombocytopenia] who is in front of you?
Ali McBride, PharmD, MS, BCOP, FASHP, FAzPA: For these cases, nowadays we are faced with insurance. That’s the first thing we can improve. But the normal treatments in these cases include steroids. We know that’s a common utility. When deciding on a treatment, we consider the patient’s age, overall health—their morbidities or comorbidities, medical history—the extent of the disease, and sometimes tolerance if they have been refractory to other therapies. With the patient in front of us, we’re also addressing—especially with counseling, our physician team members and prescribers too—the patient’s expectation for the course of the disease. That really goes into the adherence piece, which we’ll get into when we look at oral therapies. We also consider the patient’s preference—what do they want to get? Do they want to get an IV [intravenous] product, which some patients are already horrified by. Unfortunately, that’s what we have available. Other cases are oral products too, so we have to do that early-on differentiation.
From that standpoint, looking at the patient as a whole, we have to address measures for adherence, insurance, and what they can potentially get. But early on in the diagnosis, the most common forms of treatment, which we’ve been utilizing for many years, have been steroids. Everyone knows how that works. I’m being facetious there. It’s multifocal, and it has pluripotent effects downstream. The steroids help prevent bleeding by reducing the risk of platelet destruction—that inflammatory response, which is a common issue we often talk about.
Additionally, we will address IVIg [intravenous immunoglobulin]. IVIg has been a common mainstay for many patients for many years because it slows destruction of the platelets as well. We time those therapies early on. The question then falls into goals of management of, which you mentioned before, reducing some of those quality-of-life issues as well as purpura or bleeding risk. We want to maintain that by increasing those platelet levels so we have a surrogate end point, and we want to address that with the patient. We have to address their needs, monitoring, maintenance of platelet levels, and how often we see them.
We have to address not only some of the things you can ingest that can cause low platelets but also how far away the patient lives. This is a big issue. We have people come from 4 hours away. I’m sure they drive 3 or 4 hours to your site.
Essentially, looking at this, we have to address those monitoring pieces. Patients may not have a lab near them. They may not have a place that can infuse IVIg. We need to make sure we’re maintaining an appropriate care model for the patient, outlining the goals, and also ensuring appropriate monitoring while they’re on therapy too. That includes not only the therapy we’re giving but also if they’re adherent to those therapies as well.
David Hughes, PharmD, BCOP: That’s a great point. One of the other things that is notoriously a roadblock for us right now is COVID-19 [coronavirus disease 2019] and how it affects many of the challenges you discussed. We’re going to need to monitor the maintenance levels and the platelets. That’s another consideration that we’ll be discussing later in more detail. But right now, when you think about goals of treatment and what the best option is for that patient, COVID-19 surely does affect these patients and what therapies are going to be selected up front.