Issn Print: 0192-8562
Publication Date: 1997/07/01
#627 Bone marrow aspiration in children with idiopathic thrombocytopenic purpura (ITP): a decision analysis
Excerpt
Introduction: Steroid therapy is increasingly being used as initial therapy for ITP because of concern regarding the safety of blood products such as immunoglobulin. Bone Marrow Aspiration (BMA) is routinely performed prior to starting steroid therapy in children with idiopathic thrombocytopenia, primarily to rule out leukemia. Patients and Methods: We constructed a decision tree for the initial management of a child presenting with probable ITP. The three strategies are: 1. All patients receive an initial BMA, with leukemia negative patients then being treated with steroids; 2. Only patients at high risk for leukemia receive a BMA, with low risk patients empirically receiving steroids; or 3. All patients are empirically treated with steroids, with no initial BMA. High risk criteria include any of: platelet count >50×109/L; Haemoglobin <100g/L (6m-12m) or <110g/L (>1yr); white blood cell count <5×109/L (6m-6yr) or <4 (>6yr); or absolute neutrophil count <1.5×109/L (6m-6yr) or <2 (>6yr). The analysis considers the short-term morbidity of BMA versus the anxiety of the uncertainty of the diagnosis, as well as the long-term implications of inappropriately giving steroids to a patient with undiagnosed leukemia. Results: The base case results are as follows: 1. BMA all -64.179 quality adjusted life years (QALYs); 2. BMA high risk -64.280 QALYs; 3. BMA none -64.130 QALYs. These results indicate a toss-up between strategy 1 and 2, as there is less than a one day difference in QALYs. Both options are slightly preferred over strategy 3, with an 18 day difference. The choice of preferred strategy is sensitive to: the duration and extent of anxiety related to the uncertainty of the diagnosis; the sensitivity of the leukemia risk assessment; the increased chance of dying from leukemia after inappropriately receiving steroids; and the negative impact on the quality of life of receiving a BMA. Conclusion: Performing a BMA only in children with high risk laboratory features for leukemia appears to be a clinically valid alternative to performing a BMA on all children presenting with features of ITP. If economic considerations were taken into account, the high risk strategy would appear to be the preferred initial management strategy.
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