Fate of therapy failures in adult idiopathic thrombocytopenic purpura

Long-term fostamatinib treatment of adults with immune thrombocytopenia during the phase 3 clinical trial program

Two randomized, double-blind, placebo-controlled studies demonstrated responses (≥50 000/μL) to fostamatinib in adults with long-standing immune thrombocytopenia (ITP). The long-term safety and efficacy of fostamatinib were evaluated in a follow-on, open-label extension (OLE) study. Patients received double-blind fostamatinib in the randomized trials, and responders continued the same dose, 100 to 150 mg BID, in the OLE study. Nonresponders received 100 mg BID for 4 weeks and could escalate to 150 mg BID at week 4. Endpoints included stable response, platelet count ≥50 000/μL at 4/6 biweekly (randomized trials) or 2/3 monthly visits (OLE), and overall response, ≥1 platelet count ≥50 000/μL during weeks 1 to 12. A total of 146 patients received fostamatinib including 123 in the OLE study. Median treatment duration was 6.7 months. Baseline median ITP duration was 8 years and median platelet count was 16 000/μL; prior treatments included thrombopoietic (TPO) agents (47%), splenectomy (35%), and rituximab (32%). Twenty-seven (18%) patients achieved a stable response with median duration of >28 months and a median platelet count of 89 000/μL. Sixty-four (44%) patients achieved an overall response (including stable responders) with a median platelet count of 63 000/μL and a median response duration of >28 months. Twenty-four of 71 (34%) patients who had failed TPO agents achieved overall responses to fostamatinib. The most common adverse events (AEs) were diarrhea, hypertension, nausea, epistaxis, and abnormal liver function tests. Most AEs were mild/moderate and resolved or were managed with dose reduction, dose interruption, and/or secondary medication. Almost half of the patients achieved an overall response, and most of these maintained their responses for >2 years. No new or increased frequency of AEs was seen at up to 31 months of treatment.

Rituximab in immune thrombocytopenia: transient responses, low rate of sustained remissions and poor response to further therapy in refractory patients

Management of patients with immune thrombocytopenia (ITP) refractory to standard treatment is difficult. Recent studies show that rituximab, a chimeric anti-CD20 monoclonal antibody, is useful in the treatment of ITP. We retrospectively studied 24 patients who received 29 rituximab treatments for relapsed or refractory ITP. Patients had received a median of 3 treatment regimens before (range 1-8) and 11 patients had prior splenectomy. Responses were achieved in 19 of 29 (66%) treatments. The median time to response was 3 weeks (range 1-20) from the start of therapy and median duration of response was 13 weeks (range 1 week-55 months). Responses were mostly short lived and after a median follow-up of 22 months (range 2-70), 10 (34%) responses were sustained after 6 months, 7 (24%) responses sustained after 1 year and only 5 patients continued to have a response at last visit after 8, 10, 24, 30 and 54 months of follow-up. Previous splenectomy was associated with a poor response (p=0.034). Patients who failed rituximab and had prior multiple treatments including splenectomy, had a poor outcome of further therapies. We conclude that rituximab is well tolerated and is useful in some patients with relapsed or refractory ITP; however, only about one-fifth of patients achieved sustained remissions. Patients refractory to rituximab had a poor response to further treatment.

Prediction of response to splenectomy in patients with idiopathic thrombocytopenic purpura

BACKGROUND

Chronic immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by destruction of opsonized platelets in the reticuloendothelial system, particularly the spleen, and by resulting low platelet counts. Splenectomy is the standard second-line treatment for patients with ITP who do not respond to corticosteroids. In the present study we determined predictive factors for the response of patients with ITP to splenectomy.

MATERIALS AND METHODS

For thirty-one patients with ITP referred from the Hematology Department of Shariati Hospital, open surgical splenectomy was performed between February 2002 and December 2004. All potentially important variables of response were collected and analyzed to determine predictive parameters.

RESULTS

Older patients (>52) responded less positively than younger patients (<52) to splenectomy (p<0.01). Likewise, patients with a sustained remission after splenectomy had a significantly shorter interval of diagnosis of ITP to splenectomy (p<0.05) and shorter duration of corticosteroid therapy before splenectomy (p<0.05).

CONCLUSIONS

This study confirms that splenectomy is an effective treatment for patients with ITP. Our findings highlight age as the major predictive factor of long-term response to splenectomy in patients with ITP.

First-line therapies for immune thrombocytopenic purpura: re-evaluating the need to treat

Immune thrombocytopenic purpura (ITP) can be challenging to both diagnose and treat: despite the ability to detect anti-platelet antibodies, the diagnosis of ITP remains one of exclusion. Management of ITP is similarly difficult as many therapies pose potential risks that may be worse than the disease. It has been generally agreed that bleeding - not platelet count - should be the rationale for treatment. Despite the absence of prospective, controlled studies, there is consensus that bleeding risks are significantly greater in patients with platelet counts <20 x 10(9)-30 x 10(9)/L, and therefore treatment is indicated for these patients; for those with platelet counts that are higher, but still <50 x 10(9)/L, treatment is also indicated if accompanied by substantial mucous membrane bleeding. The standard initial treatment for ITP is oral corticosteroids to increase platelet counts. Intravenous immunoglobulin or anti-D immunoglobulin can also increase platelet counts and are particularly useful for stimulating rapid platelet increases before planned procedures. Splenectomy, which produces a long-lasting response in a majority of patients, is still commonly used for those who do not have long-term responses to steroid therapy and it should remain the gold standard therapy. However, splenectomy is an invasive procedure with some patients relapsing even after several years. Very rare cases of life-threatening or lethal infections may also occur at any time after splenectomy and thus physicians and patients are increasingly reluctant to advise or agree to this treatment approach. Other treatments have been evaluated to prevent or delay splenectomy, including high-dose dexamethasone, intermittent anti-D immunoglobulin infusions, and rituximab. There have been few randomized, placebo-controlled studies of these approaches, and they cannot currently be recommended as their efficacy and safety remain unclear. Thrombopoietin receptor agonists are currently under clinical investigation for the treatment of ITP and may represent an alternative treatment option in the future. The criteria for treating ITP and the benefits and risks of therapies are discussed here. Ongoing and future studies will help define the best strategies for increasing platelet counts and reducing the risk of bleeding in ITP patients.

Rituximab therapy for chronic and refractory immune thrombocytopenic purpura: a long-term follow-up analysis

The aim of this study was to evaluate the long-term response to rituximab in patients with chronic and refractory immune thrombocytopenic purpura (ITP). Adults with ITP fail to respond to conventional therapies in almost 30% of cases, developing a refractory disease. Rituximab has been successfully used in these patients. We used rituximab at 375 mg/m², IV, weekly for a total of four doses in 18 adult patients. Complete remission (CR) was considered if the platelet count was >100 × 10⁹/l, partial remission (PR) if platelets were >50 × 10⁹/l, minimal response (MR) if the platelet count was >30 × 10⁹/l and <50 × 10⁹/l, and no response if platelet count remained unchanged. Response was classified as sustained (SR) when it was stable for a minimum of 6 months. Median age was 43.5 years (range, 17 to 70). Median platelet count at baseline was 12.5 × 10⁹/l (range, 3.0 to 26.3). CR was achieved in five patients (28%), PR in five (28%), MR in four (22%), and two patients were classified as therapeutic failures (11%). Two additional patients were lost to follow-up. The median time between rituximab therapy and response was 14 weeks (range, 4 to 32). SR was achieved in 12 patients (67%). There were no severe adverse events during rituximab therapy. During follow-up (median, 26 months; range, 12 to 59), no other immunosuppressive drugs were used. In conclusion, rituximab therapy is effective and safe in adult patients with chronic and refractory ITP. Overall response rate achieved is high, long term, and with no risk of adverse events.

Late spontaneous remissions in severe adult autoimmune thrombocytopenia

We report on four cases (three women, one man, age at diagnosis 26-61 years) with severe autoimmune thrombocytopenia (AITP) who were refractory to initial steroid therapy (n = 4), to subsequent splenectomy (n = 2), azathioprine (n = 1), and cyclosporine (n = 1). Over years they received low-dose continuous or intermittent steroid therapy. After 6 to 31 years these patients achieved a "spontaneous" complete remission (CR) (n = 3) or partial remission (PR) (n = 1) unrelated to any specific second or third line treatment; CR/PR are sustained for 0.5+ to 9+ years. These data indicate that spontaneous remissions may occur in AITP even after a long duration of the disease.

Identification of a morphometrical parameter that predicts the response to splenectomy in patients with idiopathic thrombocytopenic purpura

Idiopathic thrombocytopenic purpura (ITP) is an isolated thrombocyte disease that has no correlation with other causes of clinical thrombocytopenia in adults. About 70% of patients with ITP were successfully treated by medical care and splenectomy, but nearly 30% of ITP patients do not respond to these treatments. The aim of this study is to evaluate the predictive factors that affect the success of treatment in 26 patients with ITP. Thirteen patients with ITP responded to splenectomy (responsive group), whereas 13 other patients were resistant to medical treatment and splenectomy (resistant group). The control group consisted of 13 patients who had undergone posttraumatic splenectomy. Age, sex, spleen weight, the number of follicles per mm(2), and the length of time between diagnosis and splenectomy were retrospectively analyzed. No significant difference was found between the groups with respect to these variables. Mean maximum follicle diameter (MMaFD), mean minimum follicle diameter (MMiFD), and the number and distribution of CD56 (+) cells were evaluated for each spleen specimen. There was no statistical difference in the distribution of CD56 (+) cells between the ITP patients and the control group, but the number of CD56 (+) cells was significantly higher in the control group than in patients with ITP. While MMiFD showed no statistical difference between the groups of ITP patients, a MMaFD of 350 microm and above was significantly more likely in the resistant group than in the other groups. In conclusion, this study has shown that the MMaFD is a significant predictor of the response to splenectomy.

Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications

Splenectomy has been a standard treatment for adult patients with idiopathic thrombocytopenic purpura (ITP) for more than 50 years. However, the durability of responses, the ability to predict who will respond, and the frequency of surgical complications with splenectomy all remain uncertain. To better interpret current knowledge we systematically identified and reviewed all 135 case series, 1966 to 2004, that described 15 or more consecutive patients who had splenectomy for ITP and that had data for 1 of these 3 outcomes. Complete response was defined as a normal platelet count following splenectomy and for the duration of follow-up with no additional treatment. Forty-seven case series reported complete response in 1731 (66%) of 2623 adult patients with follow-up for 1 to 153 months; complete response rates did not correlate with duration of follow-up (r = -0.103, P = .49). None of 12 preoperative characteristics that have been reported consistently predicted response to splenectomy. Mortality was 1.0% (48 of 4955 patients) with laparotomy and 0.2% (3 of 1301 patients) with laparoscopy. Complication rates were 12.9% (318 of 2465) with laparotomy and 9.6% (88 of 921 patients) with laparoscopic splenectomy. Although the risk of surgery is an important consideration, splenectomy provides a high frequency of durable responses for adult patients with ITP. (Blood. 2004; 104:2623-2634)

Successful treatment of idiopathic thrombocytopenic purpura-like syndrome in a cancer patient with low-dose interferon: case report and review of the literature

Idiopathic thrombocytopenic purpura (ITP)-like syndrome is a rare complication of carcinomas, and its treatment usually precedes cancer therapy in order to make further procedures safe. We describe the case of a 78-year-old man with a small-cell lung cancer of extended stage, associated with ITP-like syndrome, which proved resistant to treatment with corticosteroids and vincristine, short-responsive to IV immunoglobulin, but quickly and steadily responsive to low-dose interferon (ld IFN, 3 million IU, sc, twice weekly, for 8 weeks), until the patient's death, due to his primarily chemoresistant cancer. This case is, to our knowledge, the second reported ITP-like syndrome in a cancer patient who had been successfully treated with ld IFN. The excellent and cost-effective therapeutic index of ld IFN makes it an attractive alternative treatment in patients with this specific complication and calls for further investigation regarding its potential use as a first-line treatment.

Clinically significant newly presenting autoimmune thrombocytopenic purpura in adults: a prospective study of a population-based cohort of 245 patients

The true incidence and prognosis of autoimmune thrombocytopenic purpura (ITP) in adults is unknown. We present the results of a prospective study in a population-based cohort of newly presenting adults (> or = 16 years) with ITP and platelet count of < 50 x 109/l, which took place between 1 January 1993 and 31 December 1999 in the former Northern Health Region in the UK (population 3.08 million). A total of 245 cases were confirmed by bone marrow examination with a median follow-up of 60 months (range 6-78 months). There were 134 females/111 males (1.2:1). Overall incidence was 1.6 per 105 per annum. Absolute incidence was similar for both sexes, with highest age-specific incidence in those aged > 60 years. Thirty patients (12%) presented with frank bleeding, and 28% were asymptomatic. Forty-five patients (18%) received no treatment, and 135 (55%) received first-line treatment only. Thirty patients (12%) underwent splenectomy. There were four deaths (1.6%) from bleeding and/or the complications of therapy in this cohort, but only one was in the acute phase of the illness. The majority of patients (155 out of 245) achieved remission (platelet count > 100 x 109/l), with a further 59 (24%) in partial remission with no symptoms (platelet count 30-100 x 109/l). This population-based study suggests that the traditional view of adult ITP as being a predominantly chronic disease that preferentially affects females needs to be modified.

Long-term results of initial and repeated partial splenic embolization for the treatment of chronic idiopathic thrombocytopenic purpura

OBJECTIVE

Although splenectomy is a standard surgical treatment for chronic idiopathic thrombocytopenic purpura, partial splenic embolization is another treatment option. We retrospectively studied the long-term results of initial and repeated partial splenic embolization.

MATERIALS AND METHODS

Thirty-nine patients, 15 men and 24 women, underwent initial embolization; 12 of the 39 underwent a repeated embolization. The therapeutic effects of the initial and repeated embolization were classified as a complete response if the patient's platelet count rose to more than 10 x 10(4)/ micro L without medication 1 year after the initial or repeated embolization, as a partial response if the platlet count reached 5-10 x 10(4)/ micro L under the same circumstances, or as no response.

RESULTS

Twenty patients (51%) responded to the initial embolization (complete response in 11 and partial response in nine). No significant differences were found between those patients who responded to the treatment (responders) and those who did not respond to the treatment (nonresponders) in age, sex, lowest platelet counts, and steroid response before embolization. Peak platelet response was significantly higher in the responders (p = 0.029). One of the 11 complete responders and five of the nine partial responders relapsed after a median follow-up period of 34 months (range, 15-23 months) and underwent repeated embolization, resulting in complete response in one patient, partial response in the remaining four patients, and no response in one patient. However, in the six nonresponders (to the initial embolism), repeated embolization elicited a partial response in only one patient. The remission rate of 51% was maintained by means of repeated embolization for a median follow-up period of 76 months after the initial embolization.

CONCLUSION

Partial splenic embolization combined with repeated embolization may be an effective alternative to splenectomy in the treatment of chronic idiopathic thrombocytopenic purpura.

Role of splenectomy in immune (idiopathic) thrombocytopenic purpura

Idiopathic thrombocytopenic purpura (ITP) is an immune disorder, which causes an acute or chronic thrombocytopenia, and may result in potentially life-threatening hemorrhage. Splenectomy is one of the treatment options that needs to be weighed in the treatment of ITP, particularly in cases that have shown response failure to medical modalities such as prednisone, i.v.Ig, or anti-D globulin therapy. Although most studies demonstrate good early response following splenectomy, the long-term outcome is less favorable. Furthermore, other negative factors, such as rendering the patient ineligible for anti-D globulin or oral tolerance therapy and vulnerable to possible life-threatening sepsis, must be weighed prior to splenectomy.

Long-term salvage therapy with cyclosporin A in refractory idiopathic thrombocytopenic purpura

Treatment of severe, chronic idiopathic thrombocytopenic purpura (ITP) refractory to most usual therapies is a difficult challenge. Little information exists on the clinical use of cyclosporin A (CyA) in the treatment of ITP. This report describes long-term treatment with CyA (median, 40 months) and follow-up (median, 36.8 months) in 12 adult patients with resistant ITP. CyA used in relatively low doses (2.5-3 mg/kg of body weight per day) led to a clinical improvement in 10 patients (83.3%). Five had a complete response (41.1%), 4 a complete response to maintenance therapy (33.3%), and one a partial response (8.3%). Two patients had no response. Most patients with a response (60%) had a long-term remission (mean, 28.6 months) after discontinuation of CyA. One patient had a relapse of ITP 4 years after CyA therapy was stopped. Side effects were moderate and transient, even in patients dependent on continued CyA treatment. CyA seems to represent reasonable salvage treatment in severe, potentially life-threatening, refractory ITP.

Morbidity and mortality in adults with idiopathic thrombocytopenic purpura

To study outcomes of adults with idiopathic thrombocytopenic purpura (ITP), we performed a follow-up study in a cohort of 152 consecutive patients who were treated according to a well-defined algorithm. Long-term outcomes were determined relative to the response 2 years after diagnosis, because most (93%) patients who ultimately attained platelet counts above 30.0 x 10(9)/L (30 000/microL) did so within this time frame. Complete follow-up for mortality could be studied in 99% of patients and for morbidity in 95% of patients, with a mean of 10.5 years. Within 2 years after diagnosis, 4 patients died, 2 were lost to follow-up, and 12 were reclassified as having secondary immune thrombocytopenia. Of the remaining 134 patients, 114 (85%) had obtained platelet counts above 30.0 x 10(9)/L while all therapies had been discontinued. These patients had a long-term mortality risk equal to the general population. Twelve of 134 patients (9%), all with severe thrombocytopenia, had refractory disease and suffered a mortality risk of 4.2 (95% confidence interval, 1.7-10.0). Bleeding and infection equally contributed to the death of these patients. Another 8 patients (6%) had platelet counts above 30.0 x 10(9)/L while on maintenance therapy. Similar to patients with refractory disease, these latter patients had considerably increased ITP-related hospital admissions, but mortality was only slightly higher than in the general population. In conclusion, most adults with ITP have a good outcome with infrequent hospital admissions and no excess mortality. The absence of gross morbidity and mortality in patients with moderate thrombocytopenia supports clinical practice refraining from further treatment.

Long-term outcome of splenectomy for idiopathic thrombocytopenic purpura

Idiopathic thrombocytopenic purpura (ITP) is an illness of primary acquired thrombocytopenia occurring in the absence of marrow failure. Splenectomy was first used as a treatment for ITP in 1913. However, with the realization that opsonin (critical for the optimal killing of invasive micro-organisms by white blood cells) is manufactured only in the spleen, spontaneous splenic removal was reevaluated and questioned. Splenectomy has a success rate that remains nearly identical (about 50% to 60%) whether it is performed soon after diagnosis or several months or years later. As yet, there is no consistently effective method to predict an individual ITP patient's response to splenectomy. As the time since splenectomy increases, however, the rate of excellent response decreases. Despite pneumococcal vaccination prior to splenectomy, fatal fulminant sepsis is an omnipresent possibility. Because a number of published studies, including the Johns Hopkins experience, have questioned the long-term outcome of splenectomy, splenectomy should not be the first treatment option for ITP patients. It should be performed only after all other therapeutic modalities have been exhausted, and the patient has a platelet count less than 25,000/microL and is hemorrhaging. Once patients have undergone splenectomy, they are Ineligible for potentially excellent treatment such as anti-D globulin or oral tolerance therapy.

Long-term observation of 208 adults with chronic idiopathic thrombocytopenic purpura

PURPOSE

To define response to therapy and ultimate outcome of adults with idiopathic thrombocytopenic purpura (ITP).

PATIENTS AND METHODS

We retrospectively analyzed patients with ITP diagnosed between 1978 and 1988, and reexamined them between June 1992 and March 1993. Data from 208 cases were collected. Median patient age was 44 years (range 14 to 78) at the time of diagnosis, and 51 years (range 19 to 86) at reexamination. Length of follow-up ranged from 48 to 151 months (median 92) and was longer than 10 years in 26 patients (12.5%). Reexamination included a careful interview, physical examination, complete blood count, screening for HIV infection, determination of platelet-bound IgG, and, in persistently thrombocytopenic patients, autoimmunity markers and routine laboratory investigations.

RESULTS

A total of 121 patients with fewer than 50 x 10(9) platelets per liter received an initial treatment with prednisone (PDN) at a dosage of 1 mg/kg of body weight for 1 month. Refractory or relapsed cases underwent splenectomy and/or other therapeutic modalities. In 87 patients with greater than 50 x 10(9) platelets per liter, no therapy was scheduled. An initial complete response to PDN was observed in 38.8% cases. A sustained complete remission (CR) lasting more than 6 months with no maintenance therapy was attained in 18.7%. At the time of last follow-up only 11 of these patients remained in CR. Sixty-three patients underwent splenectomy. Forty-seven (74.6%) had a CR, with 41 achieving a prolonged recovery (> 6 months). Twelve other cases attained a sustained partial remission. Long-lasting recoveries were observed in 7 other cases following alternative treatments. Spontaneous remissions occurred in 8 of 87 untreated cases after observation periods of 6 months or more. Eleven deaths were recorded (6 women and 5 men, median age 73), but only 5 were attributable to thrombocytopenia. At last control, 43 patients were in complete remission and free from therapy, and 52 were still on therapy. Four thrombocytopenic patients had laboratory features and a clinical history consistent with an autoimmune disease.

CONCLUSIONS

This analysis of ITP in adults suggests that splenectomy remains the most effective treatment. The majority of patients who undergo splenectomy can have a CR for many years, while only a minority of those who do not have this therapeutic modality or fail it are likely to attain similar results. The long-term prognosis of ITP is benign even in refractory cases. Spontaneous remissions can be observed in a significant percentage of untreated patients (about 9%). The development of overt autoimmune diseases is relatively uncommon. Particular attention should be given to the management of ITP in the elderly, where bleeding episodes of the central nervous system tend to occur more frequently.

Response of resistant idiopathic thrombocytopenic purpura to pulsed high-dose dexamethasone therapy

BACKGROUND

Most patients with chronic idiopathic thrombocytopenic purpura have a response to corticosteroids or intravenous immune globulin, but improvement is often transitory. Splenectomy may provide only a short-term benefit. Because pulsed high-dose therapy with potent synthetic corticosteroids is inexpensive, well tolerated, and effective in patients with secretory B-cell neoplasms, a similar regimen was examined for its efficacy in patients with chronic idiopathic thrombocytopenic purpura that was resistant to other treatments.

METHODS

Ten consecutively referred patients who had persistent symptomatic idiopathic thrombocytopenic purpura after undergoing at least two standard therapies were treated with six cycles of dexamethasone (40 mg per day for 4 sequential days every 28 days).

RESULTS

All patients had increased platelet counts (mean [+/- SD] count before treatment, 12,000 +/- 8200 per cubic millimeter; after treatment, 248,000 +/- 130,000 per cubic millimeter). The platelet counts remained above 100,000 per cubic millimeter for at least six months after the last cycle of treatment. There were no serious side effects. Features of hyperadrenocorticism due to prior corticosteroid therapy resolved during treatment. The cost of the drug was approximately $100 per patient.

CONCLUSIONS

Although the possibility of spontaneous remission and a delayed benefit from prior therapy cannot be excluded in this small group of patients, pulsed high-dose treatment with dexamethasone may provide a low-cost therapeutic option with minimal side effects in patients with refractory idiopathic thrombocytopenic purpura.

Mortality in immune thrombocytopenic purpura: report of seven cases and consideration of prognostic indicators

ITP (immune thrombocytopenic purpura) is generally considered a benign disease. Despite what may be severe thrombocytopenia, most patients with ITP do not suffer significant bleeding episodes. Mortality is rare, and the majority of cases are managed successfully with conventional treatments. For patients who maintain a platelet count of > 20,000/microliters, aggressive immunosuppressive therapy is usually unwarranted. There are some patients with ITP who are at increased risk of serious morbidity and mortality from their disease. Fatal cases of ITP are rarely mentioned in published reports. In this study we review the incidence of mortality and describe the deaths of seven patients with ITP, with the aim of identifying and improving management of high-risk cases. Based on our review of the literature and analysis of cases at our institution, fatal cases of ITP fall into three groups: death from intracranial hemorrhage with severe thrombocytopenia, death after splenectomy, and death due to infection after cytotoxic treatments. Patients who appear to carry increased risk include: 1) older patients; 2) chronic, refractory patients with a history of hemorrhage; and 3) patients with concomitant bleeding diatheses such as uremia and hemophilia.

Combination chemotherapy in refractory immune thrombocytopenic purpura

BACKGROUND

Chronic idiopathic thrombocytopenic purpura is a destructive thrombocytopenia caused by an autoantibody. About 80 percent of patients with chronic idiopathic thrombocytopenic purpura have remissions after either corticosteroid therapy or splenectomy. Some patients with resistant disease respond to other agents, but a substantial group are refractory to therapy.

METHODS

We used combination chemotherapy to treat 10 patients with refractory immune thrombocytopenia. An average of 6.8 (range, 3 to 10) previous therapies, including corticosteroids and splenectomy, had been unsuccessful in these patients. The patients received from three to eight cycles of therapy consisting of cyclophosphamide and prednisone combined with either vincristine (one patient), vincristine and procarbazine (four patients), or etoposide (six patients, including one patient who received four cycles each containing procarbazine and etoposide).

RESULTS

Among the 10 patients, 6 had complete responses (platelet count, > 180,000 per cubic millimeter); of these, 4 patients had responses that persisted for more than 11, 30, 54, or 126 months, 1 had a relapse 9 months after therapy but had a remission with further therapy and remained in remission for 48 months before dying of an unrelated illness, and another relapsed just before her fifth course of therapy. Two patients had partial responses (platelet count, > 50,000 per cubic millimeter); the platelet counts in one remained stable for more than nine months after the end of therapy, and the other patient relapsed. The remaining two patients had no response. Complete responses were associated with a disappearance or marked decrease in the level of platelet-associated autoantibody.

CONCLUSIONS

Combination chemotherapy is beneficial in some patients in whom immune thrombocytopenia is refractory to corticosteroids and splenectomy.

Lack of useful clinical predictors of response to splenectomy in patients with chronic idiopathic thrombocytopenic purpura

We set out to identify clinical or analytical variables that might predict the response to splenectomy in patients with chronic idiopathic thrombocytopenic purpura (ITP). We retrospectively examined 138 mostly adult patients with chronic ITP, treated with splenectomy. Information was compiled from five Public Health Hospitals from a questionnaire and chart review. Sixty-one potentially prognostic variables were analysed by univariate and multivariate statistical methods. After multivariate analysis, age (relative risk = 1.02; CI 1-1.03) and a severity of the bleeding diathesis (relative risk = 1.6; CI 1.13-2.22) were independent prognostic factors for a sustained response to splenectomy. An independent analysis of the postsplenectomy counts showed that an early (days 1-3) thrombocyte count exceeding 156 x 10(9)/l cells increases the likelihood of a permanent unmaintained response. Our data indicate that the response to splenectomy in patients with chronic ITP cannot be adequately predicted on the basis of pre-splenectomy clinical or analytical variables.

[Splenectomy in idiopathic thrombocytopenic purpura]

In the period between 1978 to 1987 16 female and 11 male patients with a median age of 35 years (range: 14 years to 85 years) underwent splenectomy for ITP. There was no lethality in the postoperative period. 77.8% of all patients are in a complete remission, only 22.2% showed a recurrence and need further conservative therapy.

Persistent remission of adult chronic autoimmune thrombocytopenic purpura after treatment with high-dose intravenous immunoglobulin

Transient efficacy of high-dose intravenous immunoglobulin infusions (HDI) is widely demonstrated in autoimmune thrombocytopenic purpura (AITP). A trial involving repeated injections of HDI was conducted in two adult patients with chronic AITP in order to evaluate their long-term efficacy in refractory forms and their ability to obviate splenectomy. Both patients received 2 g/kg body weight of polyvalent intact intravenous immunoglobulin followed by seven and eight boosters (0.8 to 1.2 g/kg body weight) when the platelet count decreased. It was found that the injections could be spaced progressively. The platelet count remained normal 200 and 800 days after the end of the treatment. The demonstration of the possible long-term efficacy of repeated injections of intravenous immunoglobulin encourages us to recommend this safe therapy for patients with chronic AITP.

The use of danazol in the management of chronic immune thrombocytopenic purpura

Danazol has recently been reported to be an effective mode of treatment for patients with refractory immune thrombocytopenic purpura. Following a 3 month trial of danazol, only one of 10 patients experienced a sustained increase in platelet counts and two other patients had a transient improvement. While the drug was well tolerated, it does not appear to be particularly helpful in the management of these patients.

Treatment of refractory chronic idiopathic thrombocytopenic purpura with high dose intravenous immunoglobulin

Three patients with a history of chronic idiopathic thrombocytopenic purpura stretching back over 20 years are reported. Despite splenectomy and immunosuppressive therapy satisfactory control of their disease has not been achieved. They had remained refractory to all therapeutic manoeuvres with corticosteroids and immunosuppressives for years with thrombocyte counts between 5,000 and 25,000/microliters and the concommitant risk of bleeding. This report describes the treatment of bleeding complications in these patients with high dose intravenous immunoglobulin; the peripheral blood thrombocyte count increased in all three patients from subnormal towards normal, but 2 to 4 weeks later returned to its initial low value. During the therapeutically induced raised thrombocyte count a normal bleeding time and only a moderate inhibition of thrombocyte adhesion and aggregation was observed resulting in reasonable haemostasis. High dose intravenous immunoglobulin is therefore a practical method for the control of bleeding complications in patients with refractory chronic idiopathic thrombocytopenic purpura. A clear explanation for its mode of action has not been found - the lymphocyte subpopulations remained unchanged and immunoglobulin production in vitro during the course of treatment was only minimally decreased.

Intravenous immunoglobulin administration in the treatment of severe chronic immune thrombocytopenic purpura

Human immunoglobulin was administered intravenously to nine adult patients having severe chronic immune thrombocytopenia purpura. The response in three patients was an increase in the platelet count to greater than 50,000/mm3, a hemostatically adequate level. Response was associated with a pretreatment platelet-associated immunoglobulin level of more than 5,000 molecules per platelet, and successful treatment resulted in a decrease in that level. In those patients with pretreatment platelet-associated immunoglobulin levels less than 5,000 molecules per platelet, there was neither a significant decrease in that level nor an increase in their platelet count. Immunoglobulin infusion may prove useful for selected patients with severe chronic immune thrombocytopenia.

Long-term follow-up study of 168 patients with immune thrombocytopenia. Implications for therapy

A total of 168 patients (90 adults, 78 children) with immune thrombocytopenia (ITP) and a median follow-up of 75 months were treated with a sequential regimen of corticosteroids (n = 125), splenectomy (n = 83) and immunosuppressives (n = 25). In 43 patients an observation period of a minimum of 1 month preceded the therapy. It is concluded that: (i) withholding therapy in the expectation of spontaneous recovery is at least in children justified in case of limited bleeding tendency; (ii) corticosteroids should be limited in adults to a maximum of 3 weeks and in children to a maximum of 6 weeks; (iii) if corticosteroids fail, splenectomy remains the therapy of choice, especially in patients aged less than or equal to 30 years, and should be performed within 6 months after diagnosis; (iv) after failure of the aforementioned forms of therapy, there is rarely a beneficial effect of treatment with azathioprine and vincristine; (v) no reaction to any form of therapy can be followed by an acceptable long-term outcome.

Intravenous use of gammaglobulin in the treatment of chronic immune thrombocytopenic purpura as a means to defer splenectomy

Intravenous gammaglobulin was used to treat 12 children with chronic immune thrombocytopenic purpura in order to avoid splenectomy. The average rise in platelet count with initial treatment was 226,000/microliters. Currently, one patient is in remission, four patients maintain platelet counts greater than 40,000/microliters without treatment, four patients maintain platelet counts greater than 40,000/microliters with single maintenance infusions of IV IgG at four- or 10-week intervals; three patients did not respond to treatment. In nine of 12 patients, splenectomy was avoided or at least postponed. In responding patients, we were able to discontinue immunosuppressive medication. Platelet count rises with initial IV IgG therapy were correlated with both platelet antibody levels and with a better long-term outcome. Toxicity was minimal.

Primary and secondary autoimmune thrombocytopenia. A serological and clinical analysis

In 357 thrombocytopenic patients, the autoimmune nature of the thrombocytopenia was established with the immunofluorescence test on paraformaldehyde-fixed platelets in suspension (PSIFT). In 142 patients, autoimmune thrombocytopenia (AITP) was accompanied by (an)other disease(s) and thus classified as secondary AITP. No significant difference was found in the distribution of the immunochemical characteristics of the autoantibodies between primary and secondary AITP. The results of survival studies with 51Cr-labelled platelets and organ sequestration measurements in 7 patients with idiopathic thrombocytopenia purpura (ITP) indicated that platelets with IgM autoantibodies were sequestered mainly in the spleen. An increased incidence of AITP was seen at 5 to 10 years of age, in the 3rd decade and in the 6th and 7th decades of life. AITP was slightly more common life in females. The following groups of accompanying diseases in 142 AITP patients were distinguished: autoimmune diseases of the blood, malignant diseases of the blood, generalized and organ-specific autoimmune diseases, carcinoma and a miscellaneous group of diseases. No significant differences were found in the immunochemical properties of the autoantibodies between the various categories of disease. In 7 cases, AITP was preceded by an established viral disease, in 1 case by lepra and in another by a vaccination. The PSIFT was found to be a suitable test for diagnosing AITP not only in idiopathic thrombocytopenia, but also in thrombocytopenia associated with another disease.

Chronic idiopathic thrombocytopenic purpura (ITP:) development of acute non-lymphocytic leukemia subsequent to treatment with cyclophosphamide

Chronic idiopathic thrombocytopenic purpura (ITP) is most often treated successfully with steroids and/or splenectomy. In those who fail to respond with the foregoing treatment, immunosuppressive drugs are sometimes added to the regimen. Cyclophosphamide has been reported heretofore to be effective with a minimum of side effects and complications. However, the use of alkylating agents and the induction of a second malignancy is now well recognized. This report describes three cases of refractory ITP treated with cyclophosphamide who subsequently developed an acute non-lymphocytic leukemia. Cyclophosphamide should be used with discretion in the treatment of chronic idiopathic thrombocytopenic purpura which is a non-neoplastic disorder.