When to initiate treatment is not always an easy decision. If the patient is having significant bleeding, then we initiate treatment, but if the patient is not having significant bleeding, we do our best to estimate the risk of bleeding based on factors like platelet count, patient age, whether he or she has had a prior history of bleeding, whether he or she has an indication for concomitant antithrombotic medication, and patient lifestyle. Then we have to incorporate that into the patient’s own values and preferences. We recommend trying to keep the platelet count in most patients above 20 to 30 x 10⁹/L, but I have a couple of patients who have platelet counts lower than that who are young, have never had any bleeding, and have a strong preference for avoiding medications and surgery. For those patients, after discussion of their values and preferences, we’ve made the decision together not to treat. On the other hand, I have other patients who are older, who I would judge to be at higher bleeding risk, who are more comfortable with the idea of taking medications, and who are more adverse to the idea of having a serious bleeding event. In these patients, we might have a relatively higher platelet count threshold for starting treatment, along with a higher target platelet count. For example, we might want to keep the platelet count above 50 x 10⁹/L.