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Strategy changes in Chinese hematologists’ diagnosis and treatment of primary immune thrombocytopenia across 10 years (2009–2018)

Wang, Hong-Hui1; Bi, Hui2; Zhang, Lei3; Li, Hui-Yuan3; Xue, Feng3; Zhou, Ze-Ping2; Yang, Ren-Chi3

Section Editor(s): Lyu, Peng

doi: 10.1097/CM9.0000000000000511
Clinical Observations
Open

1The Second Clinical College, Kunming Medical University, Kunming, Yunnan 650000, China

2Department of Hematology, the Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650101, China

3State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China.

Correspondence to: Prof. Ze-Ping Zhou, Department of Hematology, the Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650101, China E-Mail: zhouzeping@outlook.com

How to cite this article: Wang HH, Bi H, Zhang L, Li HY, Xue F, Zhou ZP, Yang RC. Strategy changes in Chinese hematologists’ diagnosis and treatment of primary immune thrombocytopenia across 10 years (2009–2018). Chin Med J 2019;00:00–00. doi: 10.1097/CM9.0000000000000511

Received 18 July, 2019

Hong-Hui Wang and Hui Bi contributed equally to the work.

Online date: November 12, 2019

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

Primary immune thrombocytopenia (ITP), a common hemorrhagic disease causing a tremendous burden to the social economy, is characterized by the bleeding of mucosa, skin, brain, and/or other important organs.[1] Serious hemorrhage can even lead to death. Despite its seriousness, the golden criteria for ITP diagnosis and treatment are lacking. Consequently, much hinges upon physician experience as well as the willingness of patients and their families. In fact, standards for diagnosis and treatment of patients with ITP only appeared when the American Society of Hematology published a landmark guideline in 1996. It is important to find out hematologists’ routine strategies for managing ITP and the extent they have complied with or deviated from ITP guidelines. However, such research is few and far between. We published such a study in 2009.[2] After that, the context for China-based hematologists diagnosing and treating ITP has undergone fundamental changes, including the publication of the Chinese Society of Hematology (CSH) guideline in 2011 and its update in 2016.[3]

To better understand how Chinese hematologists are informed by the guidelines in diagnosing and treating ITP nowadays, we conducted another survey among Chinese hematologists in 2018, using the same questionnaire for the 2009 survey. About 534 questionnaires were issued in 2009, 246 (46.1%) were recovered and 241 were available for analysis. In 2018, 150 questionnaires were issued with 70 (46.6%) being recovered and used for analysis. Data were processed by SPSS 18.0 (SPSS Inc., Chicago, IL, USA) for statistical analysis. The ratio between the two surveys was compared using the Chi-squared test or Fisher exact test. P < 0.05 was considered significant.

Three questions about ITP diagnosis were asked, with the first one being whether the respondents would prescribe peripheral blood smears if a patient was suspected of ITP. A similar percentage of the doctors in the two surveys answered: “yes” (72.2% in 2009 and 77.6% in 2018, P > 0.05). The second question about diagnosis invited the respondents to choose laboratory tests they would prescribe for patients suspected of ITP. In general, doctors in 2018 reported prescribing more tests than those surveyed in 2009, with 14 of the listed tests being preferred by over half of the doctors in 2018 in contrast to only seven by a similar percentage of those in 2009 [Figure 1].

Figure 1

Figure 1

Noticeably, a surprisingly high rate of doctors would prescribe bone marrow puncture across 10 years, as 95.8% of respondents in 2009 and 97.1% in 2018 reported using it. This trend contradicts the international guidelines which suggest that bone marrow puncture be prescribed only under certain conditions (eg, in patients aged over 60 years or those considering splenectomy) to avoid unnecessary pain and to save medical resources.[4] Nevertheless, bone marrow puncture can be necessary in China for two reasons. Firstly, it can prevent potential conflicts between doctors and patients. Secondly, it helps to rule out many more diseases in Asian patients than in non-Asian ones.

In addition, most respondents dismissed ineffective splenectomy as a key criterion for diagnosing refractory ITP (76.8% in 2009 vs. 73.0% in 2018, P = 0.536). This practice deviated from the recommendations in all major guidelines including CSH ones. We speculate that this may be related to the fact that patients with ITP in China would reject splenectomy more frequently than those in western countries. Therefore, CSH may need to address this issue in its update of the 2016 guideline.

In terms of treatment, the most important goal was to control the bleeding degree as 40.2% of the hematologists in 2009 and 68.3% in 2018 selected it (χ2 = 15.326, P < 0.001). Moreover, the respondents in 2018 held more stringent criteria for starting treatment and hospitalization (P < 0.05). This trend tends to align better with the international literature about ITP treatment.

Most doctors would choose glucocorticoid, usually in a small dose for a long period, as the primary therapy. This choice differs from the CSH 2016 guideline which recommends that a high dose of dexamethasone (HD-DXM) at 40 mg/day for 4 days being used instead of a small dose of prednisone for a long course for initial treatment.[3]

In this study, we surveyed Chinese hematologists’ strategies in diagnosing and treating ITP in 2018 and then compared the results with those obtained from our 2009 survey. There are similarities and differences between Chinese hematologists’ ITP management strategies in 2009 and 2018. For diagnosis, while the practices had changed a decade later due to the increased use of laboratory tests in 2018 in comparison to 2009, Chinese hematologists persisted in using bone marrow puncture and dismissing ineffective splenectomy as a major criterion of diagnosing refractory ITP. For treatment, Chinese hematologists adopted more stringent criteria for starting treatment and hospitalization in 2018 than in 2009. However, they kept on using a small dose of glucocorticoid for a long period as their primary therapy despite the recommendation of the CSH 2016 guideline to use a high dose of HD-DXM for a short course. There are limitations to this study. For instance, the sample size in 2018 was limited, and the recovery rate of the questionnaires was low. Therefore, further studies with larger samples are desirable.

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Acknowledgements

The authors thank Dr. Luo Na at the Chinese University of Hong Kong and Mr. Qi-Yuan Zhou at the University of California, Davis for editing the language of this manuscript.

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Funding

This work was supported in part by grants from the Training Plan of Yunnan Medical leaders (No. L-2017005) and Kunming Medical University Medical Innovation Team (No. CXTD201615).

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Conflicts of interest

None.

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References

1. Cooper N, Ghanima W. Immune thrombocytopenia. N Engl J Med 2019; 381:945–955. doi: 10.1056/NEJMcp1810479.
2. Zhou Z, Yang R. Investigation on the strategy of the diagnosis and treatment of primary immune thrombocytopenia in hematological doctor in our country. Chin J Hematol 2011; 32:201–203. doi: 10.3760/cma.j.issn.0253-2727.2011.03.015.
3. Thrombosis and Hemostasis Group, Hematology Society, Chinese Medical Association. Consensus of Chinese experts on diagnosis and treatment of adult primary immune thrombocytopenia (version 2016) [in Chinese]. Chin J Hematol 2016; 37:89–93. doi: 10.3760/cma.j.issn.0253-2727.2016.02.001.
4. Neunert C, Lim W, Crowther M, et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood 2011; 117:4190–4207. doi: 10.1182/blood-2010-08-302984.
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