What lifestyle measures should be recommended for a 72‑year‑old woman with polycythemia vera who is being treated with hydroxyurea (Hydrea)?

Lifestyle Modifications for a 72-Year-Old Woman with Polycythemia Vera on Hydroxyurea

All patients with polycythemia vera, including this 72-year-old woman on hydroxyurea, must aggressively manage cardiovascular risk factors through smoking cessation, blood pressure control, lipid management, diabetes control, and weight optimization—these lifestyle interventions are as critical as pharmacologic therapy for reducing thrombotic risk. 1, 2

Mandatory Cardiovascular Risk Factor Management

Smoking Cessation

• Smoking cessation is absolutely mandatory and non-negotiable for all polycythemia vera patients, as smoking compounds the already elevated thrombotic risk inherent to the disease. 1, 2, 3
• Provide intensive counseling and pharmacologic support (nicotine replacement, varenicline, or bupropion) to achieve complete cessation. 2

Blood Pressure Control

• Target blood pressure should be maintained below 130/80 mmHg to reduce recurrent vascular events. 2
• First-line antihypertensive agents should include renin-angiotensin system blockers, calcium-channel blockers, or diuretics. 2
• Monitor blood pressure regularly and adjust medications to maintain strict control. 2

Lipid Management

• Achieve and maintain LDL cholesterol below 70 mg/dL (1.8 mmol/L) through statin therapy and dietary modification. 2
• This aggressive lipid target is essential given the patient's high thrombotic risk from polycythemia vera. 2

Diabetes and Metabolic Syndrome Control

• Screen for and aggressively treat diabetes mellitus, as it represents an additional thrombotic risk factor. 1
• Address components of metabolic syndrome including central obesity, insulin resistance, and dyslipidemia. 1

Hydration and Fluid Management

Daily Fluid Intake

• Maintain adequate hydration to prevent hemoconcentration, which can exacerbate hyperviscosity. 2, 3
• Critical consideration during phlebotomy: Ensure careful fluid replacement during therapeutic phlebotomy procedures to prevent hypotension, particularly important in this 72-year-old patient with potential cardiovascular disease. 2
• Inadequate fluid replacement during phlebotomy can precipitate dangerous hypotension in elderly patients. 2

Physical Activity and Exercise

Regular Exercise Program

• Encourage regular moderate-intensity aerobic exercise to improve cardiovascular health and reduce thrombotic risk. 2, 3
• Avoid extreme physical exertion or dehydration during exercise, which could worsen hyperviscosity. 2

Mobility and Thrombosis Prevention

• Maintain regular physical activity and avoid prolonged immobility, which increases venous thrombosis risk. 4, 5
• During travel or prolonged sitting, perform leg exercises and maintain hydration. 4, 5

Dietary Modifications

General Nutritional Approach

• Follow a heart-healthy diet (Mediterranean or DASH diet) to support cardiovascular risk reduction. 2
• Limit saturated fats, trans fats, and refined carbohydrates to optimize lipid profile and metabolic control. 2

Weight Management

• Achieve and maintain healthy body weight (BMI 18.5-24.9 kg/m²) to reduce metabolic syndrome components. 1, 2
• Weight loss, if overweight, improves blood pressure, lipid profile, and insulin sensitivity. 1, 2

Symptom-Specific Lifestyle Measures

Pruritus Management

• Avoid hot baths or showers, as heat can trigger or worsen aquagenic pruritus (present in approximately 33% of polycythemia vera patients). 4, 5
• Use lukewarm water for bathing and apply emollients immediately after to maintain skin barrier. 4, 5
• If pruritus persists despite these measures, selective serotonin receptor antagonists, antihistamines, or consideration of interferon-α or JAK2 inhibitors may be warranted. 2

Erythromelalgia Prevention

• Avoid heat exposure and maintain cool ambient temperatures, as erythromelalgia (occurring in approximately 5.3% of patients) is triggered by warmth. 2, 5
• The patient's low-dose aspirin therapy should effectively manage platelet-mediated microvascular symptoms. 2

Monitoring and Adherence

Regular Follow-Up

• Maintain scheduled appointments every 3-6 months for hematocrit monitoring, complete blood count assessment, and evaluation for thrombotic or bleeding complications. 2, 3
• Ensure hematocrit remains strictly below 45% (or approximately 42% for women due to physiological differences). 2, 3

Medication Adherence

• Continue hydroxyurea as prescribed—this patient is appropriately treated given her age of 72 years (high-risk by age ≥60 years). 1, 2, 3
• Maintain daily low-dose aspirin (81-100 mg) unless contraindicated by major bleeding. 1, 2, 3

Critical Pitfalls to Avoid

Dehydration

• Never allow dehydration, especially during illness, travel, or hot weather, as this worsens hyperviscosity and thrombotic risk. 2, 3

Inadequate Phlebotomy Fluid Replacement

• During therapeutic phlebotomy, inadequate fluid replacement can precipitate hypotension—particularly dangerous in this elderly patient with potential cardiovascular disease. 2

Ignoring Cardiovascular Risk Factors

• Do not accept suboptimal control of hypertension, hyperlipidemia, or diabetes—these modifiable factors significantly impact thrombotic outcomes. 1, 2

Extreme Thrombocytosis Precautions

• If platelet count exceeds 1,000 × 10⁹/L, avoid aspirin due to acquired von Willebrand disease risk and increased bleeding. 5
• Monitor for extreme thrombocytosis (>1,500 × 10⁹/L), which may require cytoreductive therapy intensification. 1