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Salvatrice Mancuso,1 Melania Carlisi,1 Nicola Serra,2,3 Mariasanta Napolitano,1 Simona Raso,3 Ugo Consoli,4 Roberto Palazzolo,5 Maria Rosa Lanza Cariccio,6 Sergio Siragusa1 1Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) Department, University of Palermo, Palermo, Italy; 2Department of Molecular Medicine and Medical Biotechnology, University Federico II of Naples, Naples, Italy; 3Department of Surgical, Oncological and Stomatological Disciplines, University of Palermo, Palermo, Italy; 4UOC Ematologia ARNAS Garibaldi, Catania, Italy; 5UOS Ematologia, Asst Valtellina e Alto Lario, Sondrio, Italy; 6Dipartimento Oncologico, La Maddalena, UOC Di Oncoematologia e TMO, Palermo, ItalyCorrespondence: Melania CarlisiHealth Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE) Department, University of Palermo, 129 Via del Vespro, Palermo 90127, ItalyTel +39 091-655-4504Fax +39 0916554502Email melania.carlisi@unipa.itPurpose: Insufficient knowledge of primary immune thrombocytopenia purpura (ITP) in the elderly, together with a lack of clinical trial data, has resulted in wide variation in treatments. Here, we present a study focused on clinical characteristics of ITP in older subjects at diagnosis integrated with the subsequent course of the disease and treatment history.Methods: In a retrospective monoinstitutional study, we evaluated > 65-year-old patients with primary ITP. Clinical characteristics at the time of diagnosis were described and analyzed. We aimed to delineate whether subsequent lines of therapy influenced the number of relapses. In addition to initial regimens, we reported subsequent treatments and the impact on relapse trends.Results: A total of 50 patients (56% males, mean age 78 years) were included. With regard to clinical variables at diagnosis, statistical significance was found for Eastern Cooperative Oncology Group performance status 1 (46% of patients, p< 0.0001), presence of three comorbidities (36% of patients, p< 0.0001), World Health Organization grade 0 bleeding (46%, p=0.0001), and World Health Organization grade 1 bleeding (42%, p=0.0009). For bleeding sites, the most frequent were skin or mucosa (40%, p=0.0477). A decrease in platelet count was correlated with moderate or severe bleeding (ρ=− 0.52, p=0.0001) and viscera or skin/mucosa + viscera site (ρ=− 0.50, p=0.0002). Finally, a decreasing number of patients required treatment from first-line therapy to sixth (p< 0.0001). Relapse was most frequent before second-line therapy (54%, p< 0.0001) and less frequent before fivth and sixth (4%, p=0.0072; 2%, p=0.0027).Conclusion: ITP in older age poses considerable challenges, so specific management strategies should be considered to optimize outcomes. Our findings provide evidence of an inverse relationship between lines of therapy and timing of relapses. This study does not exclude the possibility that agents used after first-line therapy may have an impact on the response and modify the unfavorable course of ITP.Keywords: primary immune thrombocytopenia, ITP, immunogeriatrics, Tpo-receptor agonist, ITP treatment, aging