Service de Médecine Interne, Centre national de référence des cytopénies auto-immunes de l'adulte, Hôpital Henri Mondor, Fédération Hospitalo-Universitaire TRUE InnovaTive theRapy for immUne disordErs, Assistance Publique Hôpitaux de Paris (AP-HP), Université Paris Est Créteil, Créteil, France.
Université de Paris, Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Paris, F-75015, France.
Clin Interv Aging. 2023 Jan 26;18:115-130. doi: 10.2147/CIA.S369574. eCollection 2023.
Many epidemiological studies have shown that the incidence of immune thrombocytopenia (ITP) increases after age 60 years and peaks in patients over age 80 years. Therefore, ITP is a concern for physicians taking care of older patients, especially regarding its diagnosis and management. The diagnostic work-up should exclude other causes of thrombocytopenia and secondary ITP, including myelodysplastic syndrome and drug-induced ITP. The treatment decision is influenced by an increased risk of bleeding, infectious diseases and thrombosis in this population and should take into account comorbidities and concomitant medications such as anticoagulant drugs. First-line treatment is based on short corticosteroids courses and intravenous immunoglobulin, which should be reserved for patients with more severe bleeding complications, with their higher risk of toxic effects as compared with younger patients. Second-line treatment should be tailored to the patient's history, comorbidities and preferences. Preferred second-line treatments are thrombopoietin receptor agonists for most groups and guidelines given their good efficacy/tolerance ratio, but the thrombotic risk is increased in older people. Other second-line options that can be good alternatives depending on the clinical context include rituximab, dapsone, fostamatinib or immunosuppressive drugs. Splenectomy is less often performed but remains an option for fit patients with chronic refractory disease. Emerging treatments such as Syk or Bruton tyrosine kinase inhibitors and FcRn antagonists are becoming available for ITP and may modify the treatment algorithm in the near future. The aim of this review is to describe the particularities of the diagnosis and treatment of ITP in older people, including the response and tolerance to the currently available drugs. We also discuss some situations related to co-morbidities that can frequently lead to adapt the management strategy in older patients.
许多流行病学研究表明，免疫性血小板减少症 (ITP) 的发病率在 60 岁后增加，并在 80 岁以上患者中达到峰值。因此，ITP 是照顾老年患者的医生关注的问题，尤其是在诊断和治疗方面。诊断性检查应排除其他血小板减少症和继发性 ITP 的原因，包括骨髓增生异常综合征和药物诱导的 ITP。治疗决策受到该人群出血、感染性疾病和血栓形成风险增加的影响，应考虑合并症和伴随药物，如抗凝药物。一线治疗基于短期皮质类固醇治疗和静脉注射免疫球蛋白，这些治疗应保留给有更严重出血并发症的患者，因为与年轻患者相比，他们的毒性作用风险更高。二线治疗应根据患者的病史、合并症和偏好进行调整。对于大多数患者来说，血小板生成素受体激动剂是首选的二线治疗药物，因为它们具有良好的疗效/耐受性比，但老年人的血栓形成风险增加。其他二线选择可能是根据临床情况而定的良好替代药物，包括利妥昔单抗、达普司他、 fostamatinib 或免疫抑制药物。脾切除术的应用较少，但对于有慢性难治性疾病的适合患者仍然是一种选择。新兴的治疗方法，如 Syk 或 Bruton 酪氨酸激酶抑制剂和 FcRn 拮抗剂，可用于 ITP，并可能在不久的将来改变治疗方案。本综述的目的是描述老年人 ITP 的诊断和治疗特点，包括对现有药物的反应和耐受性。我们还讨论了一些与合并症相关的情况，这些情况可能经常导致调整老年患者的管理策略。
