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.

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?

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!

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

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?

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.