Variation in the use of platelet transfusions and transfusion thresholds in myelodyspastic syndromes (MDS): An Australasian clinician practice survey to inform future clinical trials.

Abstract

Background: Thrombocytopenia (TP) and bleeding are common in MDS patients but optimal management of chronic TP, including use of prophylactic platelet transfusions (PLT Tx) or antifibrinolytics such as tranexamic acid (TXA), is unclear and few data exist describing current practice. Aim(s): The Australasian Leukaemia and Lymphoma Group (ALLG) Supportive Care Group conducted a clinical practice survey aiming to describe current use of prophylactic PLT Tx and TXA to inform future design of trials investigating management of chronic TP in MDS. Method(s): Following ethics approval, a 25-question online survey was developed and piloted within the Supportive Care group, then distributed to all 436 ALLG members in December 2020 and July 2021. Result(s): 64 clinicians across Australia, New Zealand and Singapore responded (response rate 15%); consisting of 60(94%) specialists, 2 (3%) trainee haematologists, 2(3%) nurses. Clinicians treated a median of 15(IQR10-20) MDS patients annually, including median 5(IQR 3-8) patients receiving disease-modifying therapies and median 2 patients (IQR1-4) with thrombocytopenic bleeding. Institutional guidelines Availability of institutional guidelines for PLT Tx, and the recommended PLT thresholds (x109/L), varied: - 29(45)% had guidelines for prophylactic PLT Tx in stable MDS patients with PLT thresholds of <10(24/29;83%),<20(1/29.3%), other (4/29.13%). - 36(56%) had guidelines for therapeutic PLT Tx in bleeding MDS patients with PLT thresholds of <20(16/36, 44%), <30(5/36.14%), <50(7/36.19%), other (8/36.22%). - 13(20%)had guidelines for prophylactic PLT Tx prior to bone marrow biopsy, with PLT thresholds of <10(2/13.15%), <20(4/13.30%), <30 (3/13, 23%), <50(1/13.7%), other (3/13.23%). - 41(64%) had guidelines for prophylactic PLT Tx prior to central line insertion, with PLT thresholds of <10(1/41.2%), <20(5/41.12%), <30 (6/41.15%), <50(26/41.64%), other (3/41.7%). - Only 10% had guidelines for using TXA prophylaxis in MDS. Clinical practice A median 80% (IQR 65%-90%) of patients were reported to not need regular treatment for TP; 5% (IQR 0%-20%) received prophylactic PLT Tx, 5% (IQR 0%-10%) received regular TXA, 0% (IQR 0%-10%) received both TXA and prophylactic PLT Tx. 3 scenarios involving MDS patients with TP were presented (Table 1); respondents were more likely to give prophylactic PLT Tx during disease-modifying therapy such as azacitidine (76%, commonest PLT threshold was <10x109/L) or patients with minor bleeding (50% transfusing at a PLT threshold <20x109/L and 35% at <10x109/L). For stable patients not on treatment, responses varied; 45% reported they would not give prophylactic PLT Tx and 50% would give PLT Tx. Clinical trials 72% respondents were interested in recruiting patients to trials in this area. Potential barriers to participation included resource limitations, funding, patient and clinician acceptance. Summary/Conclusions: This survey confirms the lack of a standardized approach to management of TP in MDS patients, including significant variation in use of prophylactic PLT Tx, thresholds and institutional guidelines. Clinical trials are needed to inform practice, and respondents indicated interest in enrolling patients in clinical trials. (Table Presented).