Keira Smith: Hi. I'm Keira Smith from Oncology Data Advisor. I'm here today with Allison Imahiyerobo.
Allison Imahiyerobo: Hi Keira, my name is Alli Imahiyerobo. I'm a nurse practitioner, and I practice at Hematology Oncology Physicians of Englewood in New Jersey. I focus on both benign and malignant hematology.
Keira Smith: What are some of the most challenging aspects of treating patients with immune thrombocytopenia, or ITP?
Allison Imahiyerobo: I think that it's really twofold. The first challenging thing that comes to mind is the refractory patients: the patients for whom you've tried almost everything and nothing seems to work, and they have a low platelet count with bleeding symptoms. You're really trying to figure out what to do next. That's where combination therapy becomes very helpful. Then I think the second most challenging part of treating patients with ITP is really waiting for their platelet counts to improve and trying to reassure them in that process that they're going to be okay and that the likelihood of severe bleeding occurring in that time period is still low.
Keira Smith: What are some of the factors that go into the selection of treatment for patients with ITP?
Allison Imahiyerobo: Well, I think lifestyle, comorbidities, the age of the patient, other medical problems they have—if they have neuropathy, if they have a history of diabetes—those are all things that I think of quite a bit. What kind of work do they do? Do they have time to take off of work to receive certain treatments? Many of the ITP treatments take all day, so you're asking patients to miss almost a day of work, sometimes every week or every month. That's not feasible for many people. If it's a child, are they missing school for that time period? That, over the long haul, in a patient with chronic ITP, becomes quite a burden and affects the quality of life. Mostly time, then expense, is also a factor when it comes to ITP: the expense of the treatment and how well it's covered by their insurance plan.
Keira Smith: Are there any treatment considerations that go into account for pregnant patients with ITP?
Allison Imahiyerobo: Yes, the treatment options are actually quite limited for pregnant women. In particular, right now, the mainstay is actually treating with corticosteroids, so prednisone. Also, we use intravenous immune globulin (IVIG) in pregnancy. There has been some limited data showing that thrombopoietin (TPO) agents can be used in pregnancy, but the sample size is quite small, so that's not routinely recommended at this time and would be more reserved for refractory patients. In particular, you really want to think about safe platelet count for delivery.
Keira Smith: What are some of the points that are important to address when counseling patients with ITP about their treatment plans?
Allison Imahiyerobo: I think the most important thing to counsel them about is that although the number can seem quite low, usually patients with ITP have minor bleeding. The first thing I like to counsel my patients on is actually the true bleeding symptoms and what they mean—so what a platelet count of 50,000 means as far as what you see on your body. For me, that would be mostly bruising. If a patient has petechiae, then I think of the count being sometimes lower, anywhere from 20,000 to 50,000; whereas if the patient has blood blisters in their mouth and blood in their urine, to me that generally indicates a platelet count of less than 10,000, in most patients. I like to spend a lot of time educating the patients on this so that they are not worried when they see bruises, so that they hold their concern for when they see more severe bleeding.
I think a lot of education upfront goes a long way with these patients and helps them feel reassured. Otherwise, every Friday, they want another platelet count because the weekend can be scary when they don't have access to their medical team and knowing what their platelet count's going to be. They also need a plan for what to do if they do see these symptoms: what the treatment plan is, how we're going to check the platelet count and how frequently, and so on and so forth.
Then the other thing I like to educate my patients on is expectation for how long it takes for these treatments to work. Some treatments work quickly with steroids. Often it's days to weeks, whereas with a treatment like rituximab, they may need to wait up to a month from completion to actually see an improvement in their platelet count. It's really important to educate them. Otherwise, they're saying, "Why are you giving me this treatment that's not working?" whereas TPO agents have a timeframe of working within one to two weeks.
Keira Smith: What are some of the treatment considerations that should be taken into account in light of the COVID-19 pandemic?
Allison Imahiyerobo: Some of the things that I'm thinking about in particular are what medications you give to a patient with ITP around the time of vaccination. When we think about response to vaccination, if you're on an immunosuppressive medication, how well will you respond to the vaccine? Right now, response to the COVID-19 vaccine is really important for all of our patients because they want to be protected from COVID-19.
One considerations for medical practitioners is whether immunosuppressive medications should be held around COVID-19 vaccination. What happens to the platelet count after vaccination? There's very limited data about whether the platelet count drops or not. There has been some research that shows that for most patients, the platelet count remains stable around the time of COVID-19 vaccination. Finally, it may be a factor to consider giving things like TPO agents, because those will not interfere with immune response around the time of COVID-19 vaccination.
There's actually been an app developed for patients with ITP that is a really great way for patients to track their symptoms. It's called the Florio® ITP, and it's an app that's been designed for patients to log their treatments and their platelet counts. It's a way to track their symptoms, because oftentimes our patients with ITP have pages and pages of treatments and platelet counts, and it can be hard for doctors and nurses to interpret what caused what. Now with everything being digital, it's really nice to be able to have this application for patients to track themselves. I would encourage patients to check this out.
Keira Smith: Great. Thank you so much for sharing all this valuable information with us.
Allison Imahiyerobo: You're welcome.
Keira Smith: If you'd like to hear more expert perspectives, you can check out our free ITP activity on the i3 Health website. Thank you.
About Ms. Imahiyerobo
Allison Imahiyerobo, APN, is an advanced practice nurse at Hematology Oncology Physicians of Englewood in New Jersey. She specializes in the treatment of patients with benign and malignant hematologic disorders, with particular expertise in ITP. Ms. Imahiyerobo is a member of the American Academy of Nurse Practitioners and the Oncology Nursing Society, and she was the recipient of the 2018 Columbia University Irving Medical Center Liquid Nurse Practitioner of the Year Award. She has authored or coauthored several publications focusing on improving outcomes in patients with hematologic malignancies.
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This transcript has been edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of i3 Health.