Morey Blinder, MD: In the second segment, we’re going to talk about the treatment and management of chronic or persistent ITP [immune thrombocytopenia] with second-line therapy. There are 4 therapies. Why don’t we go through the 4 classes of therapy in order? Let’s start with the surgical approach, splenectomy, which is 1 of the second-line therapies. In many of our experiences, it’s at the bottom of the second-line therapy. In my experience, sometimes that’s 1 reason to use those 6-month windows to delay splenectomy. Although you don’t quite reach chronic ITP or persistent ITP. Why don’t we delay thinking about splenectomy? Danny, where does splenectomy fit in for you? How late does it come in or at all? What are your thoughts about that, and what criteria might you use for making somebody consider them for splenectomy?

Daniel Landau, MD: It’s still something we use in our practice. With the advent of oral agents, which can be used in the long term, at least 1 paper has more than 7 years’ worth of data with an oral agent showing relative consistency in terms of platelet response. Splenectomy has been pushed back based on data like this. A number of my patients are very attached to their spleen and don’t like the idea of having it removed, even when they could have long-term responses without the need to take daily or frequent therapy. The bigger issue is often the patient’s perception of having to undergo surgery even though my opinion is it could be beneficial for them. It still plays a major role. I sent a patient for splenectomy last week, and they came out of it doing very well. It comes up, but it’s not the typical second-line option that it may have been earlier in my training days.

Morey Blinder, MD: If I could comment on my experience, 1 main reason I get a consult for a patient with ITP is to determine whether to do a splenectomy. Sometimes patients are absolutely against it but their doctor has recommended it, or the other way around. It goes either way. One thing about the spleen is you can’t put it back. It’s a procedure that’s irreversible. Do you want to comment on splenectomy, Howard?

Howard Liebman, MD: We have 1 of the largest experiences in ITP in the West, based on the numbers. We’re in 1 of the largest metropolitan areas in the United States [in Los Angeles, California], and we’re the referral center. In the last 20 years, we’ve done only 2 splenectomies. They were very complex cases. One had a good outcome, and 1 didn’t have a good outcome and was back. That’s the issue with looking at the historical data of splenectomy.

In Jim George’s classic review, where he was 65 years old, he said it’s chronic at 6 months and there’s not much besides splenectomy. There are a few people who are venturesome and who did azathioprine, even though Robert Schwartz—probably the father of immunotherapy—did it in 1962 and gave it to ITP and hemoglobin anemia. They basically said, “You’re failing steroids. We don’t leave on steroids. Let’s take out your spleen.” That’s reasonable. They may have obtained remission. It’s changed because we know we have alternatives to maintain a safe platelet count from proponent receptor agonists. Some patients will have reasonable responses to rituximab. It’s only 20% for the adults at 5 years, but we can select those high responses. There are other immunomodulating agents, and there are new agents that are very promising. We’re less and less willing to push that.

Also, there’s an age difference. Even in Jim George’s paper, the responses after age 50 go down. I’ve had patients—I’m horrified—who were taken to splenectomy after 3 years of being given steroids and everything else at age 70 and obviously failed it. I’ve seen problems with splenectomy in secondary ITPs. I consider it a potential disaster to do a splenectomy in a patient with lupus who is going to need some immunomodulation and has a higher risk of thrombosis, often with antibodies.

You have to look at whether you want to proceed based on a variety of factors. Age and other disorders contribute to that. In fact, 1 of the biggest risk factors for thrombosis in the United States is obesity. If you a patient is obese, with a BMI [body mass index] above 36, they’re going to have a high risk. When you take out the spleen, as shown in the paper in Blood, there’s a persistent, continuous risk of thrombosis in the long term, even with immunization risk of overwhelming sepsis. You have to discuss these carefully with the patient before you do it. That’s why we’ve done only 2. We felt there’s a greater risk for the patient in trying to manage them without a splenectomy.

Morey Blinder, MD: Those are all good points. Splenectomy still has some role, although it’s limited. There’s probably some definite practice variability at different centers and by different hematologists.

Transcript edited for clarity.