A 64-year-old woman is found to have a persistent platelet count of 780 × 10⁹/L on two occasions. She had an unprovoked deep vein thrombosis two years ago. JAK2 V617F mutation is detected; haemoglobin, hematocrit, and leukocyte count are normal, and no other cause of thrombocytosis is found. What is the most appropriate first-line therapy?

• A Low-dose aspirin alone
• B Observation with repeat counts in 6 months
• C Serial phlebotomy
• D Hydroxyurea plus low-dose aspirin ✓

Explanation

Essential thrombocythaemia patients older than 60 years, or with a prior thrombotic event, fall into the high-risk category and require cytoreduction with hydroxyurea combined with low-dose aspirin. Aspirin alone is adequate only for low-risk patients without thrombosis history or extreme thrombocytosis. Phlebotomy treats polycythaemia vera, not essential thrombocythaemia, and observation ignores her established thrombotic risk.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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