SPLENECTOMY IN IMMUNE THROMBOCYTOPENIA: DO CHANGING TREATMENT PATTERNS FOR ITP AFFECT OUTCOMES? DATA FROM THE UK ITP REGISTRY
Author(s): ,
Sophie Todd
Affiliations:
Royal London Hospital, Barts Health NHS Trust,London,United Kingdom
,
Sofia Sardo Infirri
Affiliations:
Royal London Hospital, Barts Health NHS Trust,London,United Kingdom
,
Haroon Miah
Affiliations:
Royal London Hospital, Barts Health NHS Trust,London,United Kingdom
,
Atiqa Miah
Affiliations:
Royal London Hospital, Barts Health NHS Trust,London,United Kingdom
,
Abbas Zaidi
Affiliations:
Royal London Hospital, Barts Health NHS Trust,London,United Kingdom
,
Louise Taylor
Affiliations:
Royal London Hospital, Barts Health NHS Trust,London,United Kingdom
,
Frederick Chen
Affiliations:
Royal London Hospital, Barts Health NHS Trust,London,United Kingdom
,
David Allsup
Affiliations:
Castle Hill Hospital,Cottingham,United Kingdom
,
Tina Biss
Affiliations:
Royal Victoria Infirmary,Newcastle,United Kingdom
,
Catherine Bagot
Affiliations:
Glasgow Royal Infirmary,Glasgow,United Kingdom
,
Marie Scully
Affiliations:
University College London Hospitals,London,United Kingdom
,
Sonia Garcia
Affiliations:
Northwick Park Hospital,London,United Kingdom
,
Nichola Cooper
Affiliations:
Imperial College Healthcare NHS Trust,London,United Kingdom
,
Quentin Hill
Affiliations:
The Leeds Teaching Hospitals NHS Trust,Leeds,United Kingdom
,
Mohan Mahalakshmi
Affiliations:
Colchester General Hospital,Colchester,United Kingdom
,
Claire Hall
Affiliations:
Harrogate and District Hospital,Harrogate,United Kingdom
,
Mamta Garg
Affiliations:
Leicester Royal Infirmary,Leicester,United Kingdom
,
Shikha Chattree
Affiliations:
Sunderland Royal Hospital,London,United Kingdom
,
Jamie Wilson
Affiliations:
St Richard's Hospital,Chichester,United Kingdom
,
Oliver Chapman
Affiliations:
Worcestershire Royal Hospital,Worcester,United Kingdom
,
Bipin Vadher
Affiliations:
Princess Royal University Hospital, Kings College Hospital NHS Foundation Trust,Orpington,United Kingdom
,
Sara Greig
Affiliations:
Milton Keynes Hospital,Milton Keynes,United Kingdom
,
Sarah Johns
Affiliations:
Royal Cornwall Hospital,Truro,United Kingdom
,
Helen Jackson
Affiliations:
Aneurin Bevan University Health Board,Nevill Hall,United Kingdom
,
Steve Austin
Affiliations:
St George's Hospital,London,United Kingdom
,
Joseph Chacko
Affiliations:
Royal Bournemouth Hospital,Bournemouth,United Kingdom
,
Maria Mushkbar
Affiliations:
University Hospitals Coventry and Warwickshire NHS Trust,Coventry,United Kingdom
,
Vanessa Martlew
Affiliations:
Royal Liverpool and Broadgreen University Hospital Trust,Liverpool,United Kingdom
,
Laura Munro
Affiliations:
Scarborough Hospital,Scarborough,United Kingdom
,
Jim Seale
Affiliations:
Betsi Cadwaladr University Health Board,Bangor,United Kingdom
,
Ciro Rinaldi
Affiliations:
University Lincolnshire Hospitals,Grantham,United Kingdom
,
Gwynn Matthias
Affiliations:
Portsmouth Hospitals NHS Trust,Portsmouth,United Kingdom
,
Rachel Rayment
Affiliations:
Cardiff and Vale, University of Wales,Cardiff,United Kingdom
,
Fergus Jack
Affiliations:
Poole Hospital NHS Foundation Trust,Poole,United Kingdom
,
Nigel Sargant
Affiliations:
Basingstoke & North Hampshire Hospital,Basingstoke,United Kingdom
,
Charlotte Bradbury
Affiliations:
University Hospitals Bristol NHS Foundation Trust,Bristol,United Kingdom
,
Muttuswamy Sivakumaram
Affiliations:
North West Anglia Foundation Trust,Peterborough,United Kingdom
,
Josephine Crowe
Affiliations:
Royal United Hospital Bath NHS Trust,Bath,United Kingdom
,
Ray Dang
Affiliations:
The James Cook University Hospital,Middlesborough,United Kingdom
,
Gillian Evans
Affiliations:
East Kent Hospitals University NHS Foundation Trust,Canterbury,United Kingdom
,
Susan Robinson
Affiliations:
Guys and St Thomas' NHS Foundation Trust,London,United Kingdom
,
Sudhakaran Makkuni
Affiliations:
Basildon University Hospital,Basildon,United Kingdom
,
Lisa Cooke
Affiliations:
King's Lynn NHS Trust,King's Lynn,United Kingdom
,
Mari Kilner
Affiliations:
Northumbria Healthcare NHS Foundation Trust,Northumbria,United Kingdom
,
Mike Murphy
Affiliations:
Oxford University Hospitals NHS Foundation Trust,Oxford,United Kingdom
,
Will Lester
Affiliations:
Queen Elizabeth Hospital,Birmingham,United Kingdom
,
Magda Alobaidi
Affiliations:
West Middlesex University Hospital,Isleworth,United Kingdom
,
Anupama Jaggia
Affiliations:
Ealing Hospital NHS Trust,London,United Kingdom
,
Jason Coppell
Affiliations:
Royal Devon & Exeter Hospital,Exeter,United Kingdom
,
Muhsin Almusawy
Affiliations:
Bedford Hospital,Bedford,United Kingdom
,
Hamish Lyall
Affiliations:
Norfolk and Norwich University Hospital,Norwich,United Kingdom
,
Lisa Robinson
Affiliations:
Wye Valley NHS Trust,Hereford,United Kingdom
,
Simon Davies
Affiliations:
Taunton and Somerset NHS Foundation Trust,Taunton,United Kingdom
,
Humayun Ahmad
Affiliations:
Queen's Hospital,Burton,United Kingdom
,
Mamatha Karanth
Affiliations:
West Suffolk Hospital,Bury St Edmunds,United Kingdom
,
Adrian Newland
Affiliations:
Queen Mary University of London,London,United Kingdom
,
Drew Provan
Affiliations:
Royal London Hospital, Barts Health NHS Trust,London,United Kingdom
Vickie McDonald
Affiliations:
Royal London Hospital, Barts Health NHS Trust,London,United Kingdom
EHA Library. Todd S. 06/14/19; 266490; PF691
Dr. Sophie Todd
Dr. Sophie Todd
Contributions
Abstract

Abstract: PF691

Type: Poster Presentation

Presentation during EHA24: On Friday, June 14, 2019 from 17:30 - 19:00

Location: Poster area

Background
The advent of medical alternatives to splenectomy, particularly the thrombopoietin receptor agonists (TPO-RA) has seen reduction in its use for ITP.  It is now generally reserved in the UK for patients who fail multiple lines of therapy.

Aims
We aimed to evaluate practices around splenectomy in the UK and long term response rates using data from the UK ITP registry, a large national database of primary ITP cases set up in 2007.

Methods
We analysed all splenectomy cases from the UK ITP registry entered to December 2018. Data was studied on demographics, response rates, relapse rates and influence on response to medical therapies. Statistical analysis was performed using STATA. To identify the influence of medical therapies, we divided patients into treatment time brackets: 1989-1998, 1999-2008 and 2009-2018. The following response criteria were used:Complete response (CR platelets>100 x 109/l),partial response (PR platelets>30 but <100x109/l or doubling from baseline),overall response (OR=PR+CR).

Results
Of 3236 registered patients(ITP diagnosis date ranging 1951 – 2018), 321(9.92%)(62%F/38%M) had undergone splenectomy with a total of 4611patient-years follow-up(Median 13.2 years, IQR 6.68,23.6). Median age at splenectomy was 40 years(y)(IQR27.0, 55.5).86.2%(268 patients) were <65y old and 13.8%(43 patients) 65y or older.72 patients were excluded from subsequent analysis due to incomplete data(including patients who had splenectomy <1989).

Number of patients undergoing splenectomy decreased over time:1989-1998 34.1%;1999-2008 14.8%;2009-2018 4.8%. Median time from ITP diagnosis to splenectomy was 1.46y(IQR 0,20.3) increasing from 1.51y(IQR0,9.23.) in 1989-1998 to 1.69y(IQR0.14,18.5) in 2009-2018. This was associated with an increase in median number of treatment modalities from 2(IQR1,3) in 1989-1998 to 3 (IQR1,7) in 2009-2018 and median number of treatment episodes from 1(IQR1,2) in 1989-1998 to 3 (IQR1,11) in 2009-2018 pre-splenectomy. The most common treatment modalities pre-splenectomy were prednisolone(92%),IV immunoglobulin(50%),Azathioprine(27%),Rituximab(21%),Dexamethasone(12%),Mycophenolate(10%) and Romiplostim(10%).

CR/PR and OR rates post-splenectomy were 63.1%/24.3%/87.4% at 1month and 52.2%/15.3%/67.5% at 6months.67.2% of patients who had OR to splenectomy at 1month still had OR at latest follow-up(median follow-up 10.5y,IQR4.37,14.4).OR in patients <65y old were 86.8% at 1month and 51.8% at 6months post-splenectomy.OR in those 65y and older were 73.9% at 1month and 46.2% at 6months post-splenectomy.Beyond 6 months there is a trend towards reducing response in >65y group, but currently further analysis is limited by missing data.Overall median duration of response(DOR) was 2.5y(IQR0.51,7.01).The median DOR fell over time from 7.35y(1989-1998) to 0.52y(2009-2018).Median DOR was 3.02y in <65y old(IQR0.60,7.70) and 0.76y in 65y or older(IQR0.17,4.2.93).In patients who relapsed post-splenectomy, median time to treatment was 2.56y(IQR0.09,35.48).

59patients(18.4%) had complications post splenectomy.42patients(13.1%) had infections of which 32cases(76.2%) were attributed to splenectomy.53patients(11.2%) had an arterial or venous thrombotic event post-splenectomy. Of 4deaths(1.25%),1 was listed as being attributed to splenectomy.

Conclusion
Splenectomy rates for ITP in the UK have fallen since 1989, associated with increased medical treatment. There appears to be a trend to reduced response rates and shortened remission duration when this is used later in the treatment pathway.

Session topic: 32. Platelets disorders

Keyword(s): Immune thrombocytopenia (ITP), Splenectomy, Treatment

Abstract: PF691

Type: Poster Presentation

Presentation during EHA24: On Friday, June 14, 2019 from 17:30 - 19:00

Location: Poster area

Background
The advent of medical alternatives to splenectomy, particularly the thrombopoietin receptor agonists (TPO-RA) has seen reduction in its use for ITP.  It is now generally reserved in the UK for patients who fail multiple lines of therapy.

Aims
We aimed to evaluate practices around splenectomy in the UK and long term response rates using data from the UK ITP registry, a large national database of primary ITP cases set up in 2007.

Methods
We analysed all splenectomy cases from the UK ITP registry entered to December 2018. Data was studied on demographics, response rates, relapse rates and influence on response to medical therapies. Statistical analysis was performed using STATA. To identify the influence of medical therapies, we divided patients into treatment time brackets: 1989-1998, 1999-2008 and 2009-2018. The following response criteria were used:Complete response (CR platelets>100 x 109/l),partial response (PR platelets>30 but <100x109/l or doubling from baseline),overall response (OR=PR+CR).

Results
Of 3236 registered patients(ITP diagnosis date ranging 1951 – 2018), 321(9.92%)(62%F/38%M) had undergone splenectomy with a total of 4611patient-years follow-up(Median 13.2 years, IQR 6.68,23.6). Median age at splenectomy was 40 years(y)(IQR27.0, 55.5).86.2%(268 patients) were <65y old and 13.8%(43 patients) 65y or older.72 patients were excluded from subsequent analysis due to incomplete data(including patients who had splenectomy <1989).

Number of patients undergoing splenectomy decreased over time:1989-1998 34.1%;1999-2008 14.8%;2009-2018 4.8%. Median time from ITP diagnosis to splenectomy was 1.46y(IQR 0,20.3) increasing from 1.51y(IQR0,9.23.) in 1989-1998 to 1.69y(IQR0.14,18.5) in 2009-2018. This was associated with an increase in median number of treatment modalities from 2(IQR1,3) in 1989-1998 to 3 (IQR1,7) in 2009-2018 and median number of treatment episodes from 1(IQR1,2) in 1989-1998 to 3 (IQR1,11) in 2009-2018 pre-splenectomy. The most common treatment modalities pre-splenectomy were prednisolone(92%),IV immunoglobulin(50%),Azathioprine(27%),Rituximab(21%),Dexamethasone(12%),Mycophenolate(10%) and Romiplostim(10%).

CR/PR and OR rates post-splenectomy were 63.1%/24.3%/87.4% at 1month and 52.2%/15.3%/67.5% at 6months.67.2% of patients who had OR to splenectomy at 1month still had OR at latest follow-up(median follow-up 10.5y,IQR4.37,14.4).OR in patients <65y old were 86.8% at 1month and 51.8% at 6months post-splenectomy.OR in those 65y and older were 73.9% at 1month and 46.2% at 6months post-splenectomy.Beyond 6 months there is a trend towards reducing response in >65y group, but currently further analysis is limited by missing data.Overall median duration of response(DOR) was 2.5y(IQR0.51,7.01).The median DOR fell over time from 7.35y(1989-1998) to 0.52y(2009-2018).Median DOR was 3.02y in <65y old(IQR0.60,7.70) and 0.76y in 65y or older(IQR0.17,4.2.93).In patients who relapsed post-splenectomy, median time to treatment was 2.56y(IQR0.09,35.48).

59patients(18.4%) had complications post splenectomy.42patients(13.1%) had infections of which 32cases(76.2%) were attributed to splenectomy.53patients(11.2%) had an arterial or venous thrombotic event post-splenectomy. Of 4deaths(1.25%),1 was listed as being attributed to splenectomy.

Conclusion
Splenectomy rates for ITP in the UK have fallen since 1989, associated with increased medical treatment. There appears to be a trend to reduced response rates and shortened remission duration when this is used later in the treatment pathway.

Session topic: 32. Platelets disorders

Keyword(s): Immune thrombocytopenia (ITP), Splenectomy, Treatment

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