Tailored blood thinning helps man, 65, with ITP, recurrent strokes
Case highlights 'lack of guidelines' for treatment of bleeding disorder
A man in his 60s with immune thrombocytopenia (ITP) experienced repeated strokes even while taking anticoagulant medications — commonly known as blood thinners — so doctors had to tailor his treatment, adjusting the intensity of blood thinning while keeping signs of ITP under control.
That’s according to a new case report from clinicians in New Jersey, who noted that, while ITP is “typically associated with bleeding, [it] can paradoxically increase thrombotic [blood clotting] risk” for certain patients.
Less than one year after receiving treatment to raise his counts of platelets — small cell fragments that help the blood to clot — the man had another stroke, the researchers reported. Further episodes were prevented, however, by once again adjusting his medications, according to the team.
“Multidisciplinary management, including individualized … treatment of ITP … led to improved outcomes,” the researchers wrote, noting, however, that “this case underscores the need for personalized anticoagulation strategies in ITP patients and highlights the lack of standardized guidelines.”
The report detailing the man’s case, titled “Recurrent Ischemic Strokes In A Patient With ITP: A Case Report,” was published in the journal Medical Reports.
In ITP, the immune system mistakenly destroys platelets, leading to symptoms such as easy bruising and prolonged bleeding. While rare, ITP patients can also develop clots that block blood vessels, leading to strokes or heart attacks.
Patient experienced another stroke while on blood-thinning meds
Here, researchers in the U.S. described the case of a 65-year-old man with a history of ITP, chronic obstructive pulmonary disease — a lung disease that makes breathing difficult — and recurrent blood clots who sought hospital treatment for worsening headaches.
A CT scan of his brain showed recent strokes in both frontal lobes, likely caused by small blood clots.
Blood tests showed the man had low platelet counts, while a bone marrow biopsy revealed the presence of immature megakaryocytes, or cells that develop into platelets, but no other abnormalities. Based on these results, doctors made a diagnosis of ITP.
Because the man experienced another stroke despite being on rivaroxaban — an anticoagulant sold as Xarelto — he was switched to warfarin, another anticoagulant, with a target international normalized ratio (INR) of 2-3. INR is a test that measures how fast blood clots; a target INR of 2-3 is usually recommended for patients taking anticoagulants so as to prevent dangerous blood clots from forming.
The man also was given treatment for ITP with steroids and rituximab, which led to an increase in platelet counts.
Eight months later, the man experienced another stroke in the pons, a part of the brainstem that is involved in regulating the sleep-wake cycle, breathing, and other functions in the body. This happened even though his INR was within the therapeutic target range, showing that standard anticoagulation may not always be sufficient in ITP.
There is a lack of evidence-based guidelines regarding anticoagulation use in the setting of ITP. … Further research is needed to clarify the optimal choice of anticoagulant agents [blood thinners] and define appropriate treatment goals for this unique population.
His doctors then tailored his anticoagulation goals, adjusting the intensity of blood thinning while continuing treatment for ITP. Close monitoring allowed the clinicians to prevent further strokes, which the team said illustrates the importance of personalized care.
“To our knowledge, there is a lack of evidence-based guidelines regarding anticoagulation use in the setting of ITP,” the researchers wrote. “Further research is needed to clarify the optimal choice of anticoagulant agents and define appropriate treatment goals for this unique population.”
Overall, according to the team, this case highlights that “personalized anticoagulation goals and multidisciplinary care are critical for optimal management.”
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