ITP treatment study suggests delaying spleen removal may be worthwhile
Longer time to next treatment seen with TPO-RAs after 2 years
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A South Korean study found that people with immune thrombocytopenia (ITP) who received thrombopoietin receptor agonists (TPO-RAs) as second-line ITP treatment had a longer estimated time to their next recorded treatment after two years than those who underwent surgery to remove the spleen.
Overall, the next treatment was recorded sooner in patients receiving TPO-RAs. However, a separate analysis examining different periods of follow-up revealed a different pattern after two years. Among patients who developed blood clots in their veins, the clots occurred earlier in those receiving TPO-RAs.
Study suggests assessing drug response before spleen removal
The findings suggest it may be worth assessing how patients respond to TPO-RAs before considering surgery to remove the spleen. However, the researchers emphasized that the findings are “exploratory and should be interpreted cautiously.”
The study, “Treatment patterns and safety outcomes after splenectomy or thrombopoietin receptor agonists as second-line therapy for immune thrombocytopenia: Korean claims-based study,” was published in Research and Practice in Thrombosis and Haemostasis.
ITP is an autoimmune disorder in which the immune system destroys platelets, tiny cell fragments that help blood clot. This can cause ITP symptoms such as easy bruising and bleeding. Treatment usually starts with corticosteroids, medications that suppress the immune system to help prevent platelet destruction.
For patients who don’t respond well enough to initial treatment, options include splenectomy, or surgery to remove the spleen, and TPO-RAs. These medications stimulate the bone marrow to produce more platelets. Examples include Nplate (romiplostim) and Promacta (eltrombopag).
Splenectomy can lead to lasting remission without further treatment, but it also carries lifelong risks, including serious infections and blood clots. TPO-RAs are an alternative to surgery, although patients may need to continue taking them.
“Although current guidelines recommend the selection of second-line therapies based on individual patient characteristics, these recommendations are unclear in real-world settings,” the researchers wrote. “Therefore, more objective and clinically viable information is required to support effective treatment decisions.”
To compare these treatments in everyday medical practice, researchers analyzed South Korea’s national health insurance records for people diagnosed with ITP between 2002 and 2021.
More than 500 patients included in matched analysis
Researchers identified 777 people with ITP who underwent splenectomy and 100 who received a TPO-RA, either Nplate or Promacta. After using statistical methods to make the groups more comparable, researchers narrowed the analysis to 447 patients who underwent splenectomy and 57 who received TPO-RAs. All had been previously treated with corticosteroids.
The team looked at how much time passed before another ITP treatment was recorded in patients’ insurance records. They also examined serious bacterial infections and blood clots.
During follow-up, 368 patients (82.3%) who underwent splenectomy received at least one additional ITP treatment, compared with 35 (61.4%) who received TPO-RAs. Corticosteroids were the most common treatment recorded after splenectomy, while TPO-RAs were the most common among patients initially treated with them.
The median time to the next recorded treatment was 5.8 months after splenectomy versus 3 months with TPO-RAs, a statistically significant difference.
However, a separate analysis found no statistically significant differences between the groups during the first two years of follow-up. After two years, the estimated time to the next recorded treatment was significantly longer with TPO-RAs than with splenectomy.
The researchers therefore suggested “that postponing splenectomy until the response to TPO-RAs has been assessed may be cautiously considered.”
Still, the results don’t show whether one treatment is better than the other at controlling ITP. Because the study relied on insurance records, a recorded treatment could reflect continued medication use or dose adjustments rather than the need for a new treatment.
Even after statistical matching, the groups differed in important ways. Patients receiving TPO-RAs were older, with a median age of 64 compared with 42 years for those undergoing splenectomy. They also had more coexisting medical conditions and started treatment longer after their ITP diagnosis.
Blood clots occurred earlier in patients receiving TPO-RAs
Pneumococcal infections were reported in 14 patients (3.1%) who underwent splenectomy, compared with none who received TPO-RAs. Haemophilus influenzae infections occurred in seven patients (1.5%) after splenectomy and one patient (1.7%) after TPO-RA treatment. No meningococcal infections were reported in either group.
Blood clots in the veins, known as venous thromboembolism (VTE), were recorded in 47 patients (10.5%) after splenectomy and nine (15.7%) after TPO-RA treatment. Among patients who developed VTE, blood clots occurred earlier in the TPO-RA group. However, the small number of events and differences between the groups prevented firm conclusions about clotting risk.
“A longer [time to next treatment] after 24 months and earlier VTE occurrence were observed in the TPO-RA group,” the researchers concluded. “However, these findings are exploratory and should be interpreted cautiously” because differences in patients’ characteristics and other factors not accounted for in the analysis may have influenced the results.
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