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CML-CP with ITP

Saima Humayun Toor
Topic Author

2 weeks 3 days ago - 4 hours 4 minutes ago #2112 by Saima Humayun Toor

CML-CP with ITP was created by Saima Humayun Toor

A 35 yrs female diagnosed with CML-CP in July 2023. She was started on Imatinib 400mg/day. In August 2023, she developed grade III thrombocytopenia, so Imatinib was stopped. Due to persistent thrombocytopenia, BME was done, which showed CML-CP with peripheral destruction of platelets. She was started on steroids, her platelet counts improved, and imatinib was restarted (December 2023). However, counts dropped on steroid tapering. She then lost to follow up in July 2024 and quit her treatment (both imatinib and steroids).

Now presented again in May 2025 with menorrhagia and grade III thrombocytopenia. Repeat BME was consistent with CML-CP with ITP. Initially showed a partial response to steroids but is now resistant to both steroids and Eltrombopag. Platelet Counts 15-20,000. Off TKI.

What should be next line of treatment for ITP - Rituximab vs. Splenectomy?

Last edit: 4 hours 4 minutes ago by arlene.

David Yeung
Topic Author

4 hours 3 minutes ago - 4 hours 1 minute ago #2115 by David Yeung

Replied by David Yeung on topic CML-CP with ITP

Not sure I’m best to answer this - given that the question is: “What’s the next best line of ITP therapy in a 36 yo woman, refractory to steroids and eltrombopeg, in a patient with CML-CP but not currently on TKI?”

I don’t treat ITP much…

Also to confirm – there are megakaryocytes in the BM, and there’s no neutropenia – correct?

I understand that IVIG is out due to resource constraints.

Between splenectomy and ritux – both are reasonable depending on surgical risk and patient preference. Splenectomy – higher risk, slightly higher response rate, more durable response. Rtixu – easier to give.

As for the CML – if you can’t give TKI because of thrombocytopenia – that will cause problems for long-term disease control.

I’d agree with you – the best way to get CML under control, is to fix the platelet count, then give the TKI.
I’d do tissue typing in case the disease progresses (because I work at an alloSCT centre) but I am not sure if this is an option for your patient.

Last edit: 4 hours 1 minute ago by arlene.

Saima Humayun Toor
Topic Author

3 hours 59 minutes ago - 3 hours 58 minutes ago #2116 by Saima Humayun Toor

Replied by Saima Humayun Toor on topic CML-CP with ITP

Thank you for your response, Dr Yeung!

One more question, can we consider starting TKI with these plt counts, as these counts are unrelated to TKI, and secondly, if this thrombocytopenia is due to immune modulation related to CML (though rare and usually reported with MDS/MPN), TKI would help.

What’s your opinion?

Last edit: 3 hours 58 minutes ago by arlene.

David Yeung
Topic Author

3 hours 57 minutes ago - 3 hours 56 minutes ago #2117 by David Yeung

Replied by David Yeung on topic CML-CP with ITP

I had similar thoughts to Dr Toor.

Even if the thrombocytopenia is truly driven solely by ITP, we would still expect TKI to have an additional impact on the thrombocytopenia.

I would think about the following before deciding whether to start TKI now, versus waiting until the platelet count recovers:

• how frequently you can follow up / do blood test
• the baseline platelet count
• the clinical bleeding risk
• capacity for transfusion if thrombocytopenia is profound

Last edit: 3 hours 56 minutes ago by arlene.

Kendra Sweet
Topic Author

3 hours 55 minutes ago - 3 hours 54 minutes ago #2118 by Kendra Sweet

Replied by Kendra Sweet on topic CML-CP with ITP

I think it would be best to try IVIG or rituximab before moving ahead with a splenectomy. If the IVIG and rituximab don’t work, then a splenectomy would make sense and hopefully she could get back on treatment after that is done.

I hope this helps!

Last edit: 3 hours 54 minutes ago by arlene.

Saima Humayun Toor
Topic Author

3 hours 52 minutes ago - 3 hours 48 minutes ago #2119 by Saima Humayun Toor

Replied by Saima Humayun Toor on topic CML-CP with ITP

Hi Dr. Kendra!

Thankful for your response.

One more question, can we consider starting TKI with these plt counts, as these counts are unrelated to TKI, and secondly, if this thrombocytopenia is due to immune modulation related to CML (though rare and usually reported with MDS/MPN), TKI would help??

And as per response and questions with answers when this question was previously asked on this forum:

• how frequently you can follow up / do blood test,? it can be done on weekly basis
• the baseline platelet count? .. it’s less then 10
• the clinical bleeding risk? … low risk for major bleeding according to HAS-BLED . Only have menorrhagia
• capacity for transfusion if thrombocytopenia is profound? …. Platelet Transfusions can done

What’s your opinion on this?

Last edit: 3 hours 48 minutes ago by arlene.

Moderators: Nicola, arlene

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