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Summary: Combining drugs could be an effective option for treating multirefractory ITP, that is, patients not responding to rituximab, thrombopoietin receptor agonists (TPO‐RA) and splenectomy. We conducted a retrospective, multicenter, observational study including multirefractory ITP patients who received a combination of a TPO‐RA and an immunosuppressive drug. We included 39 patients (67% women, median age 59 years [range 21–96]), with a median ITP duration of 57 months [3–393] and a median platelet count at initiation of 10 × 109/L [1–35]. The combination regimen was given for a median duration of 12 months [1–103] and included eltrombopag (51%) or romiplostim (49%), associated with mycophenolate mofetil (54%), azathioprine (36%), cyclophosphamide (5%), cyclosporin (3%) or everolimus (3%). Overall, 30 patients (77%) achieved at least a response (platelet count ≥30 × 109/L and at least doubling baseline during at least 3 months), including 24 complete responses (platelet count >100 × 109/L during at least 3 months) with a median time to response of 30 days [7–270] and a median duration of response of 15 months [4–63]. Severe adverse event related to ITP treatment was observed in 31%. In conclusion, this study confirms that some patients with multirefractory ITP can achieve long lasting response with this combination. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Deficiency in regulatory B cells has been suggested in immune thrombocytopenia. In this study, Stimpson et al. emphasize the importance of considering the treatments received for immunological analyses. Commentary on: Stimpson et al. Systemic immunosuppression depletes peripheral blood regulatory B cells in patients with immune thrombocytopenia. Br J Haematol 2024;204:644‐648. [ABSTRACT FROM AUTHOR]

Keywords: ITP; SARS-CoV; vaccines EN ITP SARS-CoV vaccines 703 705 3 11/30/21 20211201 NES 211201 Severe coronavirus disease 2019 (COVID-19), due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), may be associated with mild thrombocytopenia,1,2 and some COVID-19-induced immune thrombocytopenia (ITP) cases have been reported.3,4 Some reports suggest that patients with pre-existing ITP may experience a relapse5 in the case of SARS-CoV-2 infection that could be prevented by vaccination. Interestingly, all ITP relapses occurred within the week after vaccination, as previously described for thrombocytopenia in patients with no pre-existing ITP6 and in a recent series,8 and in two out of three patients after the second dose. Furthermore, the proportion of patients who received non-RNA-based vaccines in our present study was too low (nine patients) to draw any definite conclusion on the safety of non-replicating adenovirus-based vaccines in patients with ITP. [Extracted from the article]