Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy.
Clinica Ematologica, Centro Trapianti e Terapie Cellulari "C. Melzi", DAME, Università degli Studi, Udine, Italy.
Eur J Intern Med. 2018 Dec;58:70-76. doi: 10.1016/j.ejim.2018.09.005. Epub 2018 Sep 29.
Despite the improvement in understanding its pathogenesis and the introduction of novel treatment options, the management of primary immune thrombocytopenia (ITP) still remains challenging. Considering its increased incidence with aging and prolonged life-expectancy, ITP is often diagnosed in elderly patients, a subset that deserves some special precautions. Ensure the diagnosis is a crucial step, and carefully attention must be given in excluding other causes of thrombocytopenia, especially among older people that frequently suffer from many comorbidities. When it comes to treatment decision, it is worth keeping into account that the elderly have an increased risk of bleeding, thrombosis and infections, that they often require many concomitant therapies, including antiplatelet or anticoagulant agents, and that treatment-related toxicities are often increased and sometimes more dangerous that the disease itself. There are not dedicated guidelines, and only few specific studies. Steroids with or without IVIG remain the first-line treatment. Splenectomy is less effective than in youngers and burdened by an increased thrombotic and infectious risk. Rituximab is a good option in non-immunocompromised patients, but long-term remissions are few. Eltrombopag and romiplostim have a good safety and efficacy profile, and have become a prominent drug in this subset, even if they are associated with a possible increased risk of thrombosis, and long-term toxicity is unknown. Other drugs, such as dapsone and danazol, have a well-known efficacy and safety profile, and still represent a valid option among elderly patients.
尽管人们对原发性免疫性血小板减少症（ITP）的发病机制有了更多的了解，并且出现了新的治疗选择，但该病的治疗仍然具有挑战性。由于其发病率随年龄增长而增加，且预期寿命延长，因此 ITP 常发生于老年患者，老年患者这一亚组需要特别注意。确保诊断正确是至关重要的一步，必须仔细排除其他引起血小板减少的原因，尤其是在经常患有多种合并症的老年人中。在治疗决策时，值得考虑的是，老年人出血、血栓形成和感染的风险增加，他们经常需要同时接受多种治疗，包括抗血小板或抗凝药物，并且治疗相关的毒性通常增加，有时比疾病本身更危险。目前尚无专门的指南，只有少数特定的研究。类固醇联合或不联合 IVIG 仍然是一线治疗。脾切除术的效果不如年轻人，而且伴有更高的血栓形成和感染风险。利妥昔单抗是免疫功能正常患者的一个不错选择，但长期缓解的情况很少。依洛尤单抗和罗米司亭具有良好的安全性和疗效，并且已成为该亚组的突出药物，尽管它们与血栓形成风险增加有关，且长期毒性未知。其他药物，如达那唑和氨苯砜，具有良好的疗效和安全性，在老年患者中仍然是有效的选择。
