Strategy Changes in Chinese Hematologists’ Diagnosis and Treatment of Primary Immune Thrombocytopenia Across 10 Years (2009–2018)
Primary immune thrombocytopenia (ITP) is a common hemorrhagic disease that poses a significant burden on both patients and the social economy. Characterized by bleeding in the mucosa, skin, brain, and other vital organs, ITP can lead to severe hemorrhage and even death. Despite its seriousness, there is no universally accepted gold standard for the diagnosis and treatment of ITP. Consequently, the management of ITP often relies heavily on the experience of physicians and the preferences of patients and their families. The first significant guideline for ITP was published by the American Society of Hematology in 1996, which set the stage for standardized approaches to diagnosis and treatment. However, the extent to which hematologists adhere to these guidelines, particularly in China, has not been extensively studied. This paper aims to explore the strategies employed by Chinese hematologists in diagnosing and treating ITP over a decade, from 2009 to 2018, and to assess how these strategies have evolved in response to updated guidelines.
Background and Context
ITP is a complex autoimmune disorder where the immune system mistakenly attacks and destroys platelets, leading to a decreased platelet count and increased risk of bleeding. The disease can be acute or chronic, and its management requires a delicate balance between controlling bleeding and minimizing treatment-related side effects. In China, the diagnosis and treatment of ITP have been influenced by both international guidelines and local practices. The Chinese Society of Hematology (CSH) published its first guideline for ITP in 2011, with an update in 2016. These guidelines aimed to standardize the approach to ITP management in China, but their impact on clinical practice has not been thoroughly investigated.
Study Design and Methodology
To understand how Chinese hematologists diagnose and treat ITP, two surveys were conducted in 2009 and 2018. The 2009 survey involved 534 questionnaires, with 246 (46.1%) recovered and 241 available for analysis. In 2018, 150 questionnaires were issued, with 70 (46.6%) recovered and used for analysis. The same questionnaire was used in both surveys to ensure comparability. Data were analyzed using SPSS 18.0, with statistical significance determined using the Chi-squared test or Fisher’s exact test, where a p-value of less than 0.05 was considered significant.
Diagnosis of ITP
The surveys included three key questions about ITP diagnosis. The first question asked whether respondents would prescribe peripheral blood smears for patients suspected of having ITP. In both 2009 and 2018, a similar percentage of doctors answered affirmatively (72.2% in 2009 and 77.6% in 2018, p > 0.05). The second question explored the laboratory tests that doctors would prescribe for suspected ITP cases. In 2018, doctors reported prescribing more tests than in 2009, with 14 tests preferred by over half of the respondents in 2018 compared to only seven in 2009.
One notable finding was the high rate of bone marrow puncture prescriptions across both surveys. In 2009, 95.8% of respondents reported using bone marrow puncture, and this figure increased to 97.1% in 2018. This practice contradicts international guidelines, which recommend bone marrow puncture only under specific conditions, such as in patients over 60 years old or those considering splenectomy. However, in China, bone marrow puncture is often deemed necessary to rule out other diseases and to prevent potential conflicts between doctors and patients.
Another significant deviation from international guidelines was the dismissal of ineffective splenectomy as a key criterion for diagnosing refractory ITP. In both 2009 and 2018, most respondents disagreed with this criterion (76.8% in 2009 vs. 73.0% in 2018, p = 0.536). This practice may be related to the fact that Chinese patients are more likely to reject splenectomy compared to their Western counterparts.
Treatment of ITP
The treatment strategies for ITP also showed notable changes over the decade. The primary goal of treatment shifted from controlling the bleeding degree in 2009 (40.2% of respondents) to a more stringent approach in 2018 (68.3% of respondents, p < 0.001). This trend aligns better with international literature on ITP treatment, which emphasizes the importance of managing bleeding risk.
Glucocorticoids remained the most commonly prescribed treatment for ITP in both surveys. However, the dosing and duration of glucocorticoid therapy differed from the recommendations in the CSH 2016 guideline. While the guideline recommends a high dose of dexamethasone (HD-DXM) at 40 mg/day for four days as the initial treatment, most respondents in both surveys preferred a small dose of prednisone for a longer period. This discrepancy highlights a gap between guideline recommendations and clinical practice in China.
Discussion
The findings of this study reveal both similarities and differences in the strategies employed by Chinese hematologists in diagnosing and treating ITP over the decade from 2009 to 2018. While there has been an increase in the use of laboratory tests for diagnosis, the persistent use of bone marrow puncture and the dismissal of ineffective splenectomy as a diagnostic criterion for refractory ITP indicate a deviation from international guidelines. These practices may be influenced by local factors, such as the need to rule out other diseases in Asian patients and the reluctance of Chinese patients to undergo splenectomy.
In terms of treatment, the shift towards more stringent criteria for starting treatment and hospitalization in 2018 reflects a better alignment with international standards. However, the continued preference for a small dose of glucocorticoids over the recommended high-dose dexamethasone suggests that there is still room for improvement in adhering to guideline recommendations.
Limitations
This study has several limitations. The sample size in the 2018 survey was relatively small, and the recovery rate of the questionnaires was low. These factors may limit the generalizability of the findings. Additionally, the study did not explore the reasons behind the deviations from guideline recommendations, which could provide valuable insights for improving clinical practice.
Conclusion
Over the decade from 2009 to 2018, Chinese hematologists have made progress in aligning their strategies for diagnosing and treating ITP with international guidelines. However, significant deviations remain, particularly in the use of bone marrow puncture and the choice of glucocorticoid therapy. These findings underscore the need for further education and training to improve adherence to guideline recommendations and to ensure that patients receive the most effective and evidence-based care.
doi.org/10.1097/CM9.0000000000000511
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