Splenectomy vs TPO-RA and rituximab in refractory/relapsed ITP
| Therapy . | Response rate and durability . | Time to response . | Adverse effects . | Contraindications . | Preferred in . | Approximate cost . |
|---|---|---|---|---|---|---|
| Splenectomy | Overall response rate >80%, 50%-75% at 5 y | Days | Surgical mortality (<0.2% with laparoscopic splenectomy), surgery-related complications (9.6%; bleeding, infection, thrombosis) | Multiple comorbidities, poor surgical candidate | Fulminant ITP refractory to corticosteroids/IVIg with poor response to TPO-RA, desire to avoid drug therapy or close medical monitoring, uncertain compliance with medical therapy, prohibitive cost of medical therapy | 20 000 USD |
| Lifetime risk of overwhelming sepsis | Relative: advanced age (higher rate of complications, lower response rate at age >60-70) | |||||
| Possible vascular complications: VTE, ATE | Helicobacter pylori, hepatitis C (treat underlying cause first) | |||||
| TPO-RA (eltrombopag and romiplostim) | 80% overall response rate, high rates of durable response on continued therapy | 10-14 d | Headache, rebound thrombocytopenia, elevated liver enzymes (eltrombopag), bone marrow reticulin fibrosis, possible small increased risk of venous thrombosis | Pregnancy (category C) and lactation, MDS | Patient preference, patients not interested in or unable to undergo splenectomy | Annually ∼108 000 USD* |
| Caution in patients with liver disease and a history of thrombosis | ||||||
| Rituxima | 60% overall response rate; 21%-26% of responders at 1 y have responses at 5 y | 1-8 wk | Infusion-related adverse events (fever, chills, dyspnea, hypotension), neutropenia, hypogammaglobulinemia, reactivation of viral infections (hepatitis B), progressive multifocal leucoencephalopathy (rare) | Active hepatitis B infection, pregnancy (category C) and lactation | Patient preference, patients not interested in or unable to undergo splenectomy, patient seeks medical long-term remission | 10 000-40 000 USD per 4-infusion course |
| Therapy . | Response rate and durability . | Time to response . | Adverse effects . | Contraindications . | Preferred in . | Approximate cost . |
|---|---|---|---|---|---|---|
| Splenectomy | Overall response rate >80%, 50%-75% at 5 y | Days | Surgical mortality (<0.2% with laparoscopic splenectomy), surgery-related complications (9.6%; bleeding, infection, thrombosis) | Multiple comorbidities, poor surgical candidate | Fulminant ITP refractory to corticosteroids/IVIg with poor response to TPO-RA, desire to avoid drug therapy or close medical monitoring, uncertain compliance with medical therapy, prohibitive cost of medical therapy | 20 000 USD |
| Lifetime risk of overwhelming sepsis | Relative: advanced age (higher rate of complications, lower response rate at age >60-70) | |||||
| Possible vascular complications: VTE, ATE | Helicobacter pylori, hepatitis C (treat underlying cause first) | |||||
| TPO-RA (eltrombopag and romiplostim) | 80% overall response rate, high rates of durable response on continued therapy | 10-14 d | Headache, rebound thrombocytopenia, elevated liver enzymes (eltrombopag), bone marrow reticulin fibrosis, possible small increased risk of venous thrombosis | Pregnancy (category C) and lactation, MDS | Patient preference, patients not interested in or unable to undergo splenectomy | Annually ∼108 000 USD* |
| Caution in patients with liver disease and a history of thrombosis | ||||||
| Rituxima | 60% overall response rate; 21%-26% of responders at 1 y have responses at 5 y | 1-8 wk | Infusion-related adverse events (fever, chills, dyspnea, hypotension), neutropenia, hypogammaglobulinemia, reactivation of viral infections (hepatitis B), progressive multifocal leucoencephalopathy (rare) | Active hepatitis B infection, pregnancy (category C) and lactation | Patient preference, patients not interested in or unable to undergo splenectomy, patient seeks medical long-term remission | 10 000-40 000 USD per 4-infusion course |
MDS, myelodysplastic syndrome; USD, United States dollars.
Cost is estimated based on average wholesale cost for the following doses: eltrombopag 50 mg daily and romiplostim 3 μg/kg per week for a 70-kg individual.