Evaluation of treatment plan by three-period pulses of high-dose dexamethasone among patients with primary immune thrombocytopenia on platelet count response and adverse events: A randomized Clinical trial

Platelet response following dexamethasone in obese vs nonobese patients with primary, acute immune-mediated thrombocytopenia

Background

Immune thrombocytopenia (ITP) is a rare autoimmune disorder defined as a platelet count <100,000/μL, where secondary causes of thrombocytopenia have been excluded. Glucocorticoids are firstline therapy for ITP; however, data and recommendations on the impact of body weight and repeat steroid courses remain limited.

Objectives

We aimed to evaluate if body weight altered the response rates to dexamethasone (DEX) in the treatment of ITP.

Methods

We conducted a retrospective review to evaluate the effects of body weight on response to DEX in ITP. Patients were compared based on body mass index, presentation of ITP (acute or chronic), and cause of ITP (primary or secondary). Initial response, complete response, and relapse rates were among the outcomes investigated among the primary acute ITP population.

Results

Overall, 117 patients with ITP were identified, 49 of whom had primary acute ITP. Of these, 28 were categorized as nonobese, while 21 were obese. Nonobese patients were more likely to experience an initial platelet response to DEX than obese patients (93% vs 71%; P = .04), with 68% of nonobese patients also demonstrating a complete response compared with 48% of obese patients. Among patients who did not respond after 1 course of DEX, only 2 patients received another course prior to the initiation of alternative therapies. This is the second study to show that obese patients with primary acute ITP have significantly lower initial response rates and lower complete response rates to DEX compared with nonobese patients and that repeat DEX courses may be underutilized across all body mass index subgroups.

Conclusion

This study further highlights the need for additional data and guidance on optimal glucocorticoid dosing, especially in patients with obesity.

Should dexamethasone alone or in combination be the initial steroid for adult ITP: Still a relevant question

Corticosteroids are used in first-line treatment in newly diagnosed immune thrombocytopenia. The goal of treatment is primarily to decrease autoantibody-mediated platelet clearance. Ideally initial treatment would not just increase the platelet count but also provide a long-term sustained remission. While many clinicians use prednisone (PDN) as their first choice of corticosteroid, others prefer dexamethasone. The controversy is the subject of debates. Short courses of higher-dose corticosteroids were first reported by the Andersen study in 1994. The study posited high-dose dexamethasone as a 'cure' for all ITP patients. Later, studies addressed the number of dexamethasone cycles, indications to repeat cycles and timing between cycles, with varied long-term results. The results with dexamethasone were compared to PDN in some studies: the four-day cycles of dexamethasone work faster in increasing platelet counts and appear to reduce the occurrence of severe adverse events. Therefore, it is probably a better option for patients with low platelet counts and bleeding diathesis; however, curative superiority, the initial reason to administer it, compared to PDN is not well demonstrated. Across the studies, treatment with high-dose dexamethasone seems to be safer, with lower incidence of all adverse events compared to PDN, which might be a reflection of shorter treatment duration and possibly also lower cumulative steroid dose. Dexamethasone in combination with rituximab in first-line treatment produced higher response rates with better long-term results compared to high-dose dexamethasone alone and is a particularly good option in younger women.

Clinical efficacy of high-dose dexamethasone with sequential prednisone maintenance therapy for newly diagnosed adult immune thrombocytopenia in a real-world setting

OBJECTIVE

As first-line treatments for newly diagnosed adult immune thrombocytopenia (ITP), high-dose dexamethasone (HD-DXM) and conventional-dose prednisone achieve good initial responses, but their long-term efficacy is poor. To improve the long-term outcome of newly diagnosed ITP, we explored the efficacy and safety of HD-DXM with sequential prednisone maintenance therapy.

METHODS

This retrospective study in a real-world setting assessed 72 consecutive newly diagnosed ITP patients administered first-line HD-DXM with sequential prednisone maintenance therapy from 1 June 2016 to 31 December 2019.

RESULTS

Seventy patients obtained response (97.2%), and 55 achieved sustained response (SR) (76.4%). Fifty-three obtained complete remission (CR) (73.6%), and 39 achieved continuous CR at 6 months (54.2%). Among 36 anti-nuclear antibody-positive patients, 100% achieved response, and 28 achieved CR (77.8%). Among 24 antithyroid antibody-positive patients, 23 (95.8%) achieved response, and 20 achieved CR (83.3%). For patients with initial response, the 12-month probability of SR was 78.6%. For patients with initial CR, the 12-month probability of continuous CR was 64.2%. At 12 months, 21.4% of patients with initial response and 11.3% of patients with initial CR showed loss of treatment response.

CONCLUSIONS

HD-DXM with sequential prednisone as the first-line treatment for newly diagnosed ITP patients may achieve good clinical efficacy.