Q: Have recent treatment advances replaced splenectomy as the historic gold standard of treatment for patients with chronic ITP?

Recent advances have absolutely changed the role of splenectomy in chronic ITP, and the proof is in the evidence that splenectomy is being used less frequently than it was historically. There are recently published institutional series where they compare their recent experience with their historical experience, and it is very clear that splenectomy rates have gone down as the use of medical therapies like rituximab and the TPO-RAs have gone up. However, there is an important place for splenectomy in the treatment of ITP. Splenectomy will not go away completely, but it has moved farther down the list with the use of TPO-RAs, and it is the treatment of choice for fewer patients than it was at one time.

I think that they have changed the algorithm about thinking about splenectomy. The historical algorithm is that after 6 months, you can take the patient off of steroids and think about splenectomy. This has changed because of moving the dividing line for chronic ITP out to a year, and also the advantages of other therapies have obviously lowered the use of splenectomy. Also, the Internet has played a big role in lowering the use of splenectomy because patients who always undergo a therapeutic intervention and fail that intervention, such as a surgical intervention, are really going to be very strong advocates against the use of surgery. This has happened with splenectomy, and, therefore, a lot of patients now come to the office with a body of information from the Internet, and one thing they do not want to have is surgery and splenectomy because the Internet says that splenectomy is not as efficacious. I inform them that there are some patients for whom splenectomy offers a chance of an unmaintained remission with the understanding that there are some long-term side effects with patients needing follow-up and immunizations. And that we give them an undated script at home for antibiotics any time they have a febrile illness, and we talk about other risks as if, again, the thrombotic risk that has emerged in long-term data. With the use of TPO-RAs, splenectomy is not even up there as a second-line therapy anymore, and it has now become a third-line therapy.