High-dose methylprednisolone is an alternative treatment for adults with autoimmune thrombocytopenic purpura refractory to intravenous immunoglobulins and oral corticosteroids

Update on diagnosis and treatment of immune thrombocytopenia

BACKGROUND

Immune thrombocytopenia (ITP) is a heterogeneous acquired disorder characterized by isolated thrombocytopenia whose exact pathogenesis is not yet clear. Depending upon the presence or absence of an underlying treatable cause, ITP can be categorized as primary or secondary. Primary ITP is a diagnosis of exclusion and there is no gold standard test for its confirmation. Recent drug intake, infections, lymphoproliferative disorders, and connective tissue disorders should be ruled out before labeling a patient as primary ITP.

AREA COVERED

This review summarizes a comprehensive update on the diagnostic and therapeutic modalities for ITP. We reviewed the literature using GOOGLE SCHOLAR, PUBMED and ClinicalTrial.gov databases as needed to support the evidence. We searched the literature using the following keywords: 'immune thrombocytopenia,' 'idiopathic thrombocytopenic purpura,' 'thrombocytopenia,' 'immune thrombocytopenic purpura,' and 'isolated thrombocytopenia'.

EXPERT OPINION

We believe that more detailed studies are required to understand the exact pathophysiology behind ITP. The first-line drugs like corticosteroids have both short-term and long-term adverse effects. This brings the need to explore effective alternative medications and to reconsider their role in ITP treatment algorithm if guidelines can be modified based on new studies.

Intravenous Immunoglobulin for Autoimmune Thrombocytopenic Purpura

Severe autoimmune thrombocytopenic purpura is now commonly treated with high doses of intravenous immunoglobulins (IVIGs). Twenty-four years after this treatment was first demonstrated to be effective, several questions remain to be resolved. We review here current knowledge concerning the frequency and type of side effects and the likely mechanism of action of IVIGs. We suggest that the currently recommended dose of IVIG (2 g/kg) could be halved, that the total dose of IVIG should be administered as a single infusion, that nonresponders could be provided another equal dose on day 3, and that IVIG plus prednisolone should be considered the gold standard for treatment of the most severe forms of the disease. Treatment with anti-D immunoglobulin could be proposed as an alternative if the results recently obtained with high doses (75 microg/kg) are confirmed. Finally, because IVIG has only a transient effect, it cannot be considered a curative treatment for patients with chronic autoimmune thrombocytopenic purpura.

Intravenous immunoglobulin and autoimmune thrombocytopenic purpura: 22 years on

Autoimmune thrombocytopenic purpura is now commonly treated with high doses of intravenous immunoglobulins. Twenty-two years after this treatment was first shown to be effective, several questions remain. We review here current knowledge concerning the frequency and type of side-effects and the probable mechanism of action of intravenous immunoglobulins. We suggest that the currently recommended dose of intravenous immunoglobulins (2 g/kg body weight) could be halved, that the total dose of intravenous immunoglobulins should be administered as a single infusion, that non-responders could be given another equal dose on day 3, and that intravenous immunoglobulins plus prednisolone should be considered as the gold standard for treatment of the most severe forms of the disease. Finally, as intravenous immunoglobulins have only a transient effect, they cannot be considered as a curative treatment for patients with chronic autoimmune thrombocytopenic purpura.

Intravenous immunoglobulin or high-dose methylprednisolone, with or without oral prednisone, for adults with untreated severe autoimmune thrombocytopenic purpura: a randomised, multicentre trial

BACKGROUND

Treatment of adults with autoimmune thrombocytopenic purpura (AITP) is based more on individual experience than on results of controlled studies. We compared intravenous immunoglobulin with high-dose methylprednisolone in untreated adults with severe AITP and assessed efficacy of subsequent oral steroids compared with placebo. Primary outcome was number of days with platelet count greater than 50 x 10(9)/L within the first 21 days.

METHODS

We did a randomised multicentre trial based on a 232 design. 122 adults with severe AITP (platelet count < or =20 x 10(9)/L) were randomly assigned to receive either intravenous immunoglobulin or high-dose methylprednisolone on days 1-3 (randomisation A), and then to receive either oral prednisone or placebo (randomisation B) on days 4-21. Analysis was by intention to treat.

FINDINGS

Six patients were excluded from the analysis. The number of days on which platelet counts were above 50 x 10(9)/L was 18 in 56 patients receiving intravenous immunoglobulin and 14 in 60 receiving high-dose methylprednisolone (p=0.02). Percentage of patients who had platelet counts over 50 x 10(9)/L on days 2 and 5 was 7% and 79%, respectively, in the intravenous immunoglobulin group compared with 2% and 60%, respectively, in the high-dose methylprednisolone group (p=0.04). During the second treatment period, prednisone was more effective than placebo for all short-term endpoints. Patients who received intravenous immunoglobulin and prednisone had platelet count greater than 50 x 10(9)/L for 18.5 days (p=0.005), and those treated with high-dose methylprednisolone and prednisone had this count for 17.5 days.

INTERPRETATION

Intravenous immunoglobulin and oral prednisone seems to be more effective than high-dose methylprednisolone and oral prednisone in adults with severe AITP, although the latter treatment is effective and well tolerated.

[Intravenous immunoglobulins and autoimmune thrombopenic purpura]

OBJECTIVE

To determine the usefulness of intravenous immunoglobulin in the treatment of autoimmune thrombocytopenic purpura (AITP).

RESULTS

IVIg infusion is an important agent in managing AITP because most patients experienced a rapid increased platelet count. Its precise place in the management of these patients is however controversial, particularly on account of its high cost and transient effect. It is indicated in the severe form of the disease or before surgery in corticoresistant patients.

PERSPECTIVE

Prospective studied are mandatory to compare the efficacy of IVIg and high dose corticosteroids in this indication.

Efficacy of high-dose methylprednisolone as a first-line therapy in adult patients with idiopathic thrombocytopenic purpura

Fifty-seven adult patients with idiopathic thrombocytopenic purpura (ITP) were treated with either conventional-dose prednisolone (CDP) (1 mg/kg/d, 36 patients) or high-dose methylprednisolone (HDP) (30 mg/kg/d, 21 patients), as first-line treatment. Patients in the HDP arm responded more rapidly (4.7 v 8.4 d), with a higher response rate (80% v 52.7%), and without severe side-effects. One quarter of the patients (3/12) who were non-responsive to CDP achieved complete remission when they were treated with HDP. The findings suggest that HDP may be a more effective first-line treatment than CDP for adult ITP, and it may also be preferred for life-threatening cases of ITP. However, these results must be confirmed by a randomized study prior to any change in the current practice of employing CDP as first-line treatment for adult ITP.

Immune thrombocytopenic purpura in adults: clinical aspects

Immune thrombocytopenic purpura (ITP) is a relatively common immune-mediated disorder characterized by thrombocytopenia due to clearance of opsonized platelets by the reticuloendothelial system. The acute form, more common in children, is a self-limiting, often post-viral disease. In contrast, the adult form is typically a chronic disorder, which initially responds to corticosteroids. Splenectomy offers a 70% chance of cure. Major progress has been achieved in the elucidation of the immune pathology in ITP, and we review contemporary advances in the treatment of chronic ITP. Practical guidelines for the diagnosis and treatment of various aspects of ITP were established in 1996 by the American Society of Hematology. Since these recommendations will most probably substantially influence patient care, they are discussed in detail. Human immunodeficiency virus (HIV)-associated ITP is a common problem in countries with a high prevalence of HIV infection. The pathogenesis of this subtype probably differs from that of classic ITP, and is considered separately.

Oral high-dose methylprednisolone and intravenous immunoglobulin treatments in adult chronic idiopathic thrombocytopenic purpura

Ten adult patient of chronic idiopathic thrombocytopenic purpura (CITP) used oral prednisone and were treated with seven doses of oral high-dose methylprednisolone (30 mg/kg). Nine of ten patients responded after HDMP treatment (plt > 150 x 10(9)/L). Two patients having 8 and 10 years of history achieved long-term remission after first HDMP treatment. One unresponsive and one responsive patients did not accept IVIG treatment as second therapy and lost the follow-up. The remaining six patients received IVIG (0.5 mg/kg for 5 days) as second therapy after 3 months. Platelet count increased above 150 x 10(9)/L in 4 patients and between 60-80 x 10(9)/L in 2 patients. The peak platelet counts of both therapy users were higher under HDMP than IVIG therapy (252 +/- 110.4 vs 174.2 +/- 83.7 x 10(9)/L), but the difference was not significant. Responses were transient and returned to pretreatment values at 14-30 days, excluding long-term remission of 2 (2/10) patients after HDMP treatment. No side effect was observed. Thus, oral HDMP appears a good initial therapy for continuous remission in a small ratio of patients and a good security for emergency situations and prior to surgery in adult CITP patients.

[Treatment of autoimmune thrombopenic purpura in adults]

Autoimmune thrombocytopenic purpura (AITP) is a common hematological problem. Steroids are the usual first-line treatment but give long-term remission in less than 20% of adults. High doses of human intravenous immunoglobulin G (IVIg) can increase the platelet count in 70 to 80% of patients, but the treatment is expensive and the platelet response usually only transient. Seventy to 80% of the adults have the chronic form of AITP (ie, disease duration of more than 6 months) that only improves on specific treatment. Splenoctomy is the treatment of choice when thrombocytopenia is severe and/or associated with life threatening bleeding, as it cures 60-80% of patients. The best treatment for patients with severe chronic AITP in whom splenectomy is ineffective or contra-indicated is a difficult challenge. In this situation, spontaneous remission is rare and 5% of patients will die from hemmorrhage. However, the treatments so far proposed in refractory chronic AITP (danazol, vinca alcaloids, azathioprine, cyclophosphamide, dapsone, etc) are inconsistently and transiently effective. The aim of the treatments in AITP are thus different in the acute and chronic forms of the disease. In the acute phase, the treatment should quickly increase the platelet count, even if the effect in transient, and aggressive treatments (ie, splenectomy, immunosuppressive drugs) must be avoided since spontaneous remission is possible. On the contrary, splenectomy is the treatment of choice for chronic AITP since it obtains complete persistent recovery in nearly 80% of patients. In the case of unsuccessfullness, treatments should then be administered with the aim to maintain a "safe" platelet count (> 20 to 30 x 10(9)/L).

The thrombocytopenic purpuras. Recognition and management

Idiopathic thrombocytopenic purpura (ITP) and thrombotic thrombocytopenic purpura (TTP), are distinct entities. ITP is a relatively common autoimmune disorder typically manifesting with isolated thrombocytopenia. The acute form, more common in children, is a self-limiting, often post-viral disease. Therapy, if indicated, usually consists of a brief course of steroids or intravenous IgG. Chronic ITP, more common in adults, rarely remits spontaneously. Most patients respond initially to steroids, but generally the disease relapses when steroids are tapered. Splenectomy offers a 70% chance of cure. A variety of treatment options exist for patients not responding to splenectomy. The treating physician must choose the most effective and least toxic treatment for the individual patient. TTP is a rare, often life-threatening, multisystem disease of unknown aetiology. Its hallmark is widespread occlusion of the microcirculation by platelet aggregates. The clinical symptoms usually respond dramatically to plasma exchange therapy. Steroids, antiplatelet agents and vincristine may also be useful. Splenectomy should be considered in patients with multiple relapses. More specific therapy awaits a fuller understanding of the pathogenesis of this disease.