MEETING NEWS
To gather information about hematologists ’ decisionmaking process for patients with hematologic malignancies and thrombocytopenia , the researchers first created 18 clinical vignettes , based on interviews with 11 Israeli or Dutch hematologists . Each case scenario addressed five relevant clinical attributes :
• antiplatelet drug indication
• gastrointestinal ( GI ) bleeding ( either within 3 weeks or within 4 months of presentation )
• malignancy and treatment type
• platelet level
• time since indication
These vignettes were designed to reveal patient- and physicianrelated characteristics associated with choice of antiplatelet therapy , as well as how physician assessment of bleeding and / or thrombotic risks correlate with antiplatelet therapy choice .
Next , the authors sent the survey to hematologists in Israel , the Netherlands , and Italy , asking them about their management strategy for each patient scenario . Patient management was defined as three consecutive steps , with each step comprising a choice between two different options :
• hold antiplatelet therapy vs . continue antiplatelet therapy
• continue same antiplatelet therapy ( without transfusion ) vs . transfusion or modifying antiplatelet therapy
• modifying antiplatelet therapy ( with or without transfusion ) vs . transfusion and continuing same antiplatelet therapy
A total of 145 physicians participated in the survey , and 434 cases were answered in full .
There was ” surprisingly little variance between physicians ” in their antiplatelet management choices .
Choice of antiplatelet therapy in the vignette cases varied widely by patient presentation . In patients with platelet counts of 20 × 10 9 / L , for example , physicians were 3.45 times more likely to hold antiplatelet therapy versus continuing therapy , compared with patients presenting with platelet counts of 40 × 10 9 / L ( odds ratio [ OR ] = 0.29 ; 95 % CI 0.12-0.70 ; p = 0.006 ).
In patients with major gastrointestinal ( GI ) bleeding , physicians also were more likely to hold antiplatelet therapy rather than continuing antiplatelet therapy ( OR = 0.22 ; 95 % CI 0.07-0.68 ; p = 0.008 ).
Comparatively , in patients with ST-elevation myocardial infarction ( STEMI ) who received drug-eluting stents ( DES ) and dual aspirin and clopidogrel therapy , physicians were more likely to continue antiplatelet therapy versus holding treatment ( OR = 33.13 ; 95 % CI 6.26-175.34 ; p < 0.0001 ).
The researchers also determined that physicians who practiced at institutions with management protocols were more likely to continue antiplatelet therapy ( OR = 4.22 ; 95 % CI 1.17-15.21 ; p = 0.0277 ).
The following patient attributes emerged as the factors significantly associated with physicians choice to modify therapy ( with platelet transfusion or changing from dual to single antiplatelet therapy ) or not :
• platelets 20,000 /µ L ( OR = 16.65 ; 95 % CI 5.07-54.72 ; p < 0.0001 )
• STEMI with DES on dual aspirin and clopidogrel ( OR = 61.03 ; 95 % CI 14.03-265.57 ; p < 0.0001 )
• major GI bleeding within three weeks of presentation ( OR = 2.63 ; 95 % CI 1.10-6.33 ; p = 0.0304 )
• major GI bleeding within four months of presentation ( OR = 2.95 ; 95 % CI 1.04-8.38 ; p = 0.0423 )
While the researchers concluded that there was “ surprisingly little variance between physicians ” in their management choices , they noted that the study might not be reflective of the choices made by these physicians in real-world practice , given the limitations of using survey responses rather than previous patient cases .
In the future , Dr . Leader said , he would like to see prospective studies about the incidence and predictors of bleeding and thrombosis in this patient setting . “ Our research group is currently performing a prospective observational study – the MATTER study – with these exact goals ,” he added . “ This study also will evaluate outcomes based on management , using the management strategies chosen by physicians in the present study .” Based on the results reported with this study , he noted , the researchers will include the clinical variables identified in this current study as possible confounders .
Dr . Leader also identified additional research avenues for this patient population , like assessing safety outcomes associated with platelet transfusions – particularly those used to enable antiplatelet therapy continuation . “ Our study suggests that this strategy is widely used , even though no evidence supports or refutes its use ,” he concluded .
The authors report no conflicts of interest .
REFERENCE
Leader A , Cate VT , Cate-Hoek AT , et al . Factors influencing management of antiplatelet drugs in thrombocytopenic patients with hematological malignancy . Abstract # S140 . Presented at the 23rd Congress of the European Hematology Association , June 15 , 2018 ; Stockholm , Sweden .
14 Focus on Classical Hematology