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CML-CP with ITP

  • Kendra Sweet
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1 month 2 weeks ago #2121 by Kendra Sweet
Replied by Kendra Sweet on topic CML-CP with ITP
I would probably hold off on the TKI until there has been some response to IVIG or rituximab. Usually, we can see a response relatively quickly in these patients. If the patient is still transfusion dependent, I would avoid a TKI in case it might cause some degree of myelosuppression.
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  • Jeff Lipton
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1 month 1 week ago - 1 month 1 week ago #2122 by Jeff Lipton
Replied by Jeff Lipton on topic CML-CP with ITP
There is a lot of good advice here. We can break down the problem as follows. The limiting feature here is the ITP. IM makes this worse and there is really no advantage to changing the TKI. ITP must be controlled first. Even an allograft would likely be ineffective as the ITP could easily have its target in donor cells., unless there is a specific host target. Go with the ritux and if no response splenectomy, although the latter may be faster and have better success, and I would actually favor it. Try to continue with IM with plt support. If splenectomy is done, the success would be known immediately as there would be a positive post transfusion plt increment and less risky CML therapy could be continued. The mechanisms of thrombocytopenia are different - destruction in the case of ITP and probable absence of normal stem cells in the case of IM and the solution is to dissect the treatments.
Last edit: 1 month 1 week ago by arlene.
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  • Delphine Rea
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1 month 1 week ago - 1 month 1 week ago #2123 by Delphine Rea
Replied by Delphine Rea on topic CML-CP with ITP
Dear colleague,

First of all, this case discussion forum is dedicated to CML and not, ITP, and most of the experts are not strongly involved in internal medicine.

Second, as this patient has a non-adherent behavior, I would make sure that "resistance" to steroids and eltrombopag is true resistance and not non-adherence.

Third, make sure that it is pure ITP and not ITP associated with a more global autoimmune disease, such as lupus or sarcoidosis, as the treatment options will differ.

Four: If pure ITP and true resistance, discuss with internal medicine specialists. There are cheap and safe options, such as disulone (if no G6PD deficiency), before considering higher-dose Revolade, Nplate, or rituximab (usually, the response rate is quite poor with ritux). Alternatively, immunosuppressive drugs may be considered. Splenectomy would require making sure that platelet destruction takes place 100% in the spleen (by nuclear medicine imaging), otherwise it will be inefficient and harmful.
Last edit: 1 month 1 week ago by arlene.
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