Comparison of Eltrombopag and Splenectomy in second-line treatment of itp patients

ABSTRACT COMPARISON OF ELTROMBOPAG AND SPLENECTOMY IN SECOND-LINE TREATMENT OF ITP PATIENTS Immune thrombocytopenic purpura (ITP) is an autoimmune disease characterised by low platelet count and mucocutaneous bleeding. The platelet count threshold for ITP is 100x109/L. The diagnosis of ITP is made by exclusion of secondary causes of thrombocytopenia. In adult ITP, the threshold platelet value that requires initiation of treatment is generally accepted as 30x109/L, although it is controversial; however, the main determinant in treatment is clinical findings. First-line treatment includes corticosteroids, intravenous immunoglobulin (IVIG) and anti-D. Second-line treatment includes splenectomy, rituximab and other immunosuppressive agents, and thrombopoietin (TPO) receptor agonists. In our study, demographic characteristics of patients diagnosed with ITP who were followed up in the Hematology Clinic of Fırat University Faculty of Medicine between 2013 and 2023, time from diagnosis to 2nd line treatment, indication for 2nd line treatment initiation, laboratory findings (platelet, haemoglobin, haematocrit, lymphocyte) at the beginning of treatment, 2nd line treatment options, duration of treatment, treatment options, duration of treatment, 2nd line treatment options applied. Second line treatment options, duration of treatment, response to treatment (1st month, 3rd month, 6th month, and 1st year), and treatment side effects were investigated in this study. In our study, 33 patients over the age of 18 years with a diagnosis of chronic ITP who were diagnosed in accordance with the guidelines of the American Society of Haematology and who received second-line treatment and who were followed up in the Haematology Clinic of Firat University Medical Faculty between 2013 and 2023 were included. Demographic characteristics of patients diagnosed with ITP, time from diagnosis to second-line treatment, indication for initiation of second-line treatment, laboratory findings at the beginning of treatment (platelet, haemoglobin, haematocrit, lymphocyte), second-line treatment options, duration of treatment, response to treatment (1st month, 3rd month, 6th month, and 1st year), and side effects of treatment, were analysed. The data obtained was analyzed with the IBM SPSS v23 program. Thirty-three patients (22 females and 11 males) diagnosed with ITP were included in our study. he median age of the patients was 51 (18-89). Twenty-one (63.6%) of the patients were under 60 years of age. Steroid treatment was initiated in 26 (78.7%) of the patients in first-line treatment. There were 7 (21.2%) patients in whom IVIG was used in combination with steroids as first-line treatment. As second-line treatment, 23 patients received eltrombopag. 10 patients underwent splenectomy. The median time from diagnosis to second-line treatment was 1.67 (0.13-45.17) months. The median age of the patients was 55 (15-71) years at the beginning of eltrombopag treatment and 33.5 (21-84) years at the beginning of splenectomy treatment. Of the 23 patients who received eltrombopag treatment, 73.9% were female and 26.1% were male. In 10 patients who underwent splenectomy, 50% were male and 50% were female. The mean platelet count at the beginning of treatment was 25 (3- 71) x109/L in patients treated with eltrombopag and 24.5 (2-82) x109/L in patients treated with splenectomy. The mean Hb at the beginning of treatment was 12.9 (8.7-16.3) g/dl in patients treated with eltrombopag and 13.6 (10.2-16.1) g/dl in patients treated with splenectomy. The mean Htc at the beginning of treatment was 39% (26.1-49.8) in patients treated with eltrombopag and 42.35% (30.4-46.7) in patients treated with splenectomy. The mean lymphocyte count at the beginning of treatment was 1.86 (0.58-2.71) x103/µL in patients treated with eltrombopag and 1.73 (0.68-2.96)x103/µL in patients treated with splenectomy. The median 1st month platelet response was 137 (7-554) x109/L in eltrombopag treated patients and 62 (6-627) x109/L in splenectomy treated patients. The median 3rd month platelet response was 78.5 (12-380) x109/L in patients treated with eltrombopag and 194 (26-848) x109/L in patients treated with splenectomy. The median 6th month platelet response was 121 (7-359) x109/L in patients treated with eltrombopag and 220 (2-614) x109/L in patients treated with splenectomy. The median 12-month platelet response was 112 (13-399) x109/L in patients treated with eltrombopag and 344.5 (11-554) x109/L in patients treated with splenectomy. When first-line treatment was analysed according to second-line treatment, 8.7% of those who received eltrombopag treatment received immune globulin+prednol, 91.3% received prednol, 50% of those who received splenectomy treatment received immune globulin+prednol and 50% received prednol. Of the 33 patients who received 2nd line treatment, 20 (60.6%) were in remission and 13 (39.4%) patients started 3rd line treatment. Of the 23 patients who received eltrombopag treatment, 18 (78.2%) were in remission and 5 (21.8%) patients received 3rd line treatment. Of the 10 patients who underwent splenectomy, 2 (20%) were in remission and 8 (80%) patients started 3rd line treatment. Of 23 patients receiving eltrombopag treatment, 4 (17.3%) had elevated liver function tests and 1 patient (4.3%) developed splenic vein thrombus. Thrombus developed in 2 (20%) of 10 patients who underwent splenectomy. In our retrospective study in which patients diagnosed with primary ITP were evaluated retrospectively, it was observed that the disease was more frequently observed in women in accordance with the literature and the autoimmune character of the disease. The median age at diagnosis was 51 years and a younger patient population was observed compared to the data in the literature. In our study, consistent with the literature, steroid treatment alone or in combination with IVIG was used in almost all patients as first-line treatment. Eltrombopag was most frequently preferred as the second-line treatment in our patient group. Eltrombopag and splenectomy were used as 2nd and 3rd line treatment in our patients. Second-line treatment options, duration of treatment, response to treatment (1st month, 3rd month, 6th month, 1st year, every year thereafter), side effects of treatment will help to formulate follow-up-treatment plans for these patients. The current data should be supported by retrospective and prospective studies in much larger patient groups. Key words: Immune thrombocytopenic purpura, eltrombopag, splenectomy, platelet