Management of Low-Risk Polycythemia Vera

Harry P. Erba, MD, PhD: Krisstina, coming back to you, I want you to concentrate now on a low-risk patient. They don’t have any cardiovascular risk factors, and they’re not as aged as most of the panel members today: over 60. They haven’t had a thrombotic episode. They might be having microcirculatory symptoms, dizziness, fatigue, or confusion, trouble finding words, whatever it might be. Migraine headaches, for example. Comment on the use of phlebotomy and low-dose aspirin in that group of patients. Does the patient have to have symptoms for you to initiate phlebotomy and aspirin therapy for that low-risk patient?

Krisstina Gowin, DO: For low-risk polycythemia vera patients, we approach all patients with low-dose aspirin, 81 mg or 100 mg daily, with concurrent phlebotomy, with that important hematic profile that Dr Jamile Shammo mentioned, or that 4-fold increase in thrombotic events or cardiovascular death. As a blanket recommendation, for those who are diagnosed with low-risk PV, we approach those patients in that way.

Regarding the symptoms, certainly there are a group of patients who will have significant associated microvascular symptoms: pathognomonic aquagenic pruritus and very symptomatic fatigue. In fact, this is the most commonly associated symptom, which was beautifully shown in a landmark study that patients are afflicted with it, and it can affect their activities of daily living.

In these patients, although we are definitely treating them and optimizing their hematic profile and decreasing their thrombotic risks with recurrent aspirin, we need to be assessing their symptom burden as an end point of care in combination with the hematologic parameters we’re targeting.

Regarding the microvascular symptoms, you can increase the dose of aspirin in some patients and have some modest benefit. There are some additive, supportive care maneuvers that you can certainly entertain for the pruritus, and gabapentin has been used to some additional help. I’d be interested in some of the other panel members’ unique supportive care maneuvers that they’re doing for symptom burden.

Thinking about symptom burden as equally important as the hematologic profile. Direct your therapy for your low-risk disease, and if it’s not adequately controlled, then think about second-line therapies.

Harry P. Erba, MD, PhD: Krisstina, give our viewers a bit more understanding: How often are you monitoring a CBC or a hematocrit in your patients with PV?

Krisstina Gowin, DO: There are different phases. As you’re initially meeting a patient, you’re in an induction phase. You’re trying to be more aggressive: assess more aggressively and treat more aggressively, perhaps with more frequent phlebotomies.

For those patients, I’m seeing them every 2 to 4 weeks and making adjustments and recommendations for phlebotomy until we obtain adequate control. Once they’ve attained adequate hematologic and symptomatic control, you can start stretching out that monitoring frequency to every 2 to 3 months.

Transcript Edited for Clarity