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Review
. 2023 Jan 26:18:115-130.
doi: 10.2147/CIA.S369574. eCollection 2023.

Older Adults and Immune Thrombocytopenia: Considerations for the Clinician

Etienne Crickx  1   2 , Matthieu Mahévas  1   3   4 , Marc Michel  1 , Bertrand Godeau  1
Affiliations
Review

Older Adults and Immune Thrombocytopenia: Considerations for the Clinician

Etienne Crickx et al. Clin Interv Aging. .

Abstract

Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.

Keywords: ITP; IVIg; elderly; immune thrombocytopenia; intravenous immunoglobulin; rituximab; splenectomy; thrombopoietin receptor agonists.

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Conflict of interest statement

Mahévas received funds for research from GSK and fees from Amgen and Novartis for lectures. Bertrand Godeau served as an expert for Amgen, Novartis, Grifols and Sobi. Marc Michel received honoraria (advisory boards, speaker fees) from Novartis, Amgen, UCB, Argenx, Alexion and Sanofi, and personal fees from Sobi. Etienne Crickx received honoraria (advisory boards, speaker fees) from Novartis, UCB, and Sanofi. The authors report no other potential conflicts of interest in this work.

Figures

Figure 1
Figure 1
Proposed algorithm for treatment decision. In patients with immune thrombocytopenia (ITP) without anticoagulant drugs and with platelet counts of 20 to 50 x109/L, treatment can be delayed if there are no bleeding risk factors but should be considered if there are more than 2 bleeding risk factors.
Figure 2
Figure 2
Proposed therapeutic strategy for ITP in older patients.
See this image and copyright information in PMC

References

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