Is hydroxyurea initiation still recommended for a 23-year-old paraplegic patient?

Hydroxyurea Initiation in a 23-Year-Old Paraplegic Patient

Yes, hydroxyurea should be initiated in this 23-year-old paraplegic patient if they have indications for cytoreductive therapy in polycythemia vera or other myeloproliferative neoplasms. Paraplegia is not a contraindication to hydroxyurea therapy, and the benefits of preventing thrombotic complications outweigh potential risks 1.

Indications for Hydroxyurea in Myeloproliferative Neoplasms

• Hydroxyurea is indicated as first-line cytoreductive therapy for high-risk patients with polycythemia vera (PV) or essential thrombocythemia (ET), defined as those with age >60 years and/or history of thrombosis 1, 2
• Additional indications for cytoreductive therapy include poor tolerance of phlebotomy, frequent phlebotomy requirement, symptomatic or progressive splenomegaly, severe disease-related symptoms, platelet counts >1,500 × 10^9/L, and progressive leukocytosis 1
• The primary goal of hydroxyurea therapy is to reduce the risk of thrombotic complications, which is a major cause of morbidity and mortality in these conditions 1, 2

Considerations for Young Patients

• While the European LeukemiaNet guidelines suggest using hydroxyurea with caution in young patients (age <40 years), they do not contraindicate its use 1
• For younger patients, interferon-α may be considered as an alternative first-line therapy, particularly in women of childbearing age, due to its non-leukemogenic properties 1, 2
• The decision between hydroxyurea and interferon-α should be based on patient-specific factors, including disease severity, comorbidities, and reproductive plans 1

Special Considerations for Paraplegic Patients

• Paraplegic patients may have additional risk factors for thrombosis due to immobility, making thrombosis prevention particularly important 1
• Careful monitoring for potential side effects is essential, particularly leg ulcers or other cutaneous manifestations, which could be more problematic in patients with decreased mobility and sensation 3
• Regular assessment of hematologic parameters is crucial, as myelosuppression is a common side effect that requires dose adjustment 3

Monitoring and Dose Adjustments

• Before initiating hydroxyurea, baseline complete blood count should be obtained 1
• The European LeukemiaNet criteria should be used for monitoring response to therapy 1
• Dose adjustments may be necessary based on renal function; reduce the dose by 50% in patients with creatinine clearance less than 60 mL/min 3
• Response is defined as hematocrit <45% without phlebotomy, platelet count <400 × 10^9/L, WBC count <10 × 10^9/L, and no disease-related symptoms 1

Potential Side Effects and Management

• Common adverse effects include myelosuppression (leukopenia, thrombocytopenia, anemia), gastrointestinal symptoms, and cutaneous manifestations 3
• Leg ulcers are a concerning side effect that requires special attention in paraplegic patients who may have decreased sensation 3
• Long-term use of hydroxyurea has raised concerns about potential leukemogenicity, but analysis from the ECLAP study identified that hydroxyurea alone was not an independent risk factor for leukemic transformation 1
• Regular monitoring for secondary malignancies is recommended, particularly skin cancer 3

Conclusion

Hydroxyurea should be initiated in this 23-year-old paraplegic patient if they meet the criteria for cytoreductive therapy. The paraplegia itself is not a contraindication but may actually represent an additional risk factor for thrombosis that would benefit from cytoreductive therapy. Close monitoring for side effects, particularly cutaneous manifestations, is essential due to the patient's paraplegia. If concerns arise about long-term use in a young patient, interferon-α could be considered as an alternative therapy.