Slow infusion of vinca alkaloids in the treatment of idiopathic thrombocytopenic purpura

Management of Adult Patients with Immune Thrombocytopenia (ITP): A Review on Current Guidance and Experience from Clinical Practice

Immune thrombocytopenia (ITP) is an autoimmune process resulting in increased destruction and inadequate production of platelets that can result in bleeding, fatigue, and reduced health-related quality of life. While treatment is not required for many patients with ITP, the occurrence of bleeding manifestations, severe thrombocytopenia, and requirement for invasive procedures are among the reasons necessitating initiation of therapy. Corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin are typical first-line and rescue treatments, but these agents typically do not result in a durable remission in adult patients. Most patients requiring treatment therefore require subsequent line therapies, such as thrombopoietin receptor agonists (TPO-RAs), rituximab, fostamatinib, splenectomy, or a number of other immunosuppressive agents. In this focused review, we discuss management of adult ITP in the acute and chronic settings.

American Society of Hematology 2019 guidelines for immune thrombocytopenia

BACKGROUND

Despite an increase in the number of therapies available to treat patients with immune thrombocytopenia (ITP), there are minimal data from randomized trials to assist physicians with the management of patients.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the management of ITP.

METHODS

In 2015, ASH formed a multidisciplinary guideline panel that included 8 adult clinical experts, 5 pediatric clinical experts, 2 methodologists with expertise in ITP, and 2 patient representatives. The panel was balanced to minimize potential bias from conflicts of interest. The panel reviewed the ASH 2011 guideline recommendations and prioritized questions. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence (up to May 2017) and formulate recommendations.

RESULTS

The panel agreed on 21 recommendations covering management of ITP in adults and children with newly diagnosed, persistent, and chronic disease refractory to first-line therapy who have non-life-threatening bleeding. Management approaches included: observation, corticosteroids, IV immunoglobulin, anti-D immunoglobulin, rituximab, splenectomy, and thrombopoietin receptor agonists.

CONCLUSIONS

There was a lack of evidence to support strong recommendations for various management approaches. In general, strategies that avoided medication side effects were favored. A large focus was placed on shared decision-making, especially with regard to second-line therapy. Future research should apply standard corticosteroid-dosing regimens, report patient-reported outcomes, and include cost-analysis evaluations.

Updated international consensus report on the investigation and management of primary immune thrombocytopenia

Over the last decade, there have been numerous developments and changes in treatment practices for the management of patients with immune thrombocytopenia (ITP). This article is an update of the International Consensus Report published in 2010. A critical review was performed to identify all relevant articles published between 2009 and 2018. An expert panel screened, reviewed, and graded the studies and formulated the updated consensus recommendations based on the new data. The final document provides consensus recommendations on the diagnosis and management of ITP in adults, during pregnancy, and in children, as well as quality-of-life considerations.

Treatments for Primary Immune Thrombocytopenia: A Review

Immune thrombocytopenic purpura (ITP) is an autoimmune condition that affects nearly 1:10,000 people in the world. It is traditionally defined by a platelet count of less than 100 x 109L, but treatment typically depends on symptomology rather than on the platelet count itself. For primary idiopathic ITP, corticosteroids have been the standard first-line of treatment for symptomatic patients, with the addition of intravenous immune globulin (IVIG) or Rho(D) immune globulin (anti-RhD) for steroid-resistant cases. In cases of refractory or non-responsive ITP, second-line therapy includes splenectomy or rituximab, a monoclonal antibody against the CD20 antigen (anti-CD20). In patients who continue to have severe thrombocytopenia and symptomatic bleeding despite first- and second-line treatments, the diagnosis of "chronic refractory ITP" is appropriate, and third-line treatments are evaluated. This manuscript describes the efficacy of different treatment options for primary ITP and introduces the reader to various third-line options that are emerging as a means of treating chronic refractory ITP.

How I treat refractory immune thrombocytopenia

This article summarizes our approach to the management of children and adults with primary immune thrombocytopenia (ITP) who do not respond to, cannot tolerate, or are unwilling to undergo splenectomy. We begin with a critical reassessment of the diagnosis and a deliberate attempt to exclude nonautoimmune causes of thrombocytopenia and secondary ITP. For patients in whom the diagnosis is affirmed, we consider observation without treatment. Observation is appropriate for most asymptomatic patients with a platelet count of 20 to 30 × 109/L or higher. We use a tiered approach to treat patients who require therapy to increase the platelet count. Tier 1 options (rituximab, thrombopoietin receptor agonists, low-dose corticosteroids) have a relatively favorable therapeutic index. We exhaust all Tier 1 options before proceeding to Tier 2, which comprises a host of immunosuppressive agents with relatively lower response rates and/or greater toxicity. We often prescribe Tier 2 drugs not alone but in combination with a Tier 1 or a second Tier 2 drug with a different mechanism of action. We reserve Tier 3 strategies, which are of uncertain benefit and/or high toxicity with little supporting evidence, for the rare patient with serious bleeding who does not respond to Tier 1 and Tier 2 therapies.

High Remission Rate of Chronic Immune Thrombocytopenia in Children: Result of 20-Year Follow-Up

PURPOSE

This study examined the outcomes of children with chronic immune thrombocytopenia (ITP).

MATERIALS AND METHODS

We retrospectively analyzed the medical records of all patients diagnosed with ITP from January 1992 to December 2011 at our institution.

RESULTS

A total of 128 patients (64%) satisfied the criteria for newly diagnosed ITP, 31 (15%) for persistent ITP, and 41 (21%) for chronic ITP. The median age at diagnosis was 4.5 years (range, 1 month to 18 years). The median platelet count at diagnosis was 32×10⁹/L. A comparison of the initial treatment data from 2001 to 2011 with those from 1992 to 2000 showed that the number of bone marrow examinations decreased, whereas observation increased. Chronic ITP presented at an older age than newly diagnosed and persistent ITP (6.6 years vs. 3.8 years vs. 4.1 years, respectively); however, the difference did not reach statistical significance (p=0.17). The probability of complete remission of chronic ITP was 50% and 76% at 2 and 5 years after diagnosis, respectively. Patients aged <1 year at diagnosis had a significantly better prognosis than did older patients (hazard ratio, 3.86; p=0.02).

CONCLUSION

Children with chronic ITP showed a high remission rate after long-term follow-up. This study suggests that invasive treatments such as splenectomy in children with chronic ITP can be delayed for 4 to 5 years if thrombocytopenia and therapeutic medication do not affect the quality of life.

Vincristine efficacy and safety in treating immune thrombocytopenia: a retrospective study of 35 patients

Although vincristine (VCR) is sometimes prescribed for newly diagnosed immune thrombocytopenia (ITP), its efficacy in refractory ITP and sustained efficacy has yet to be demonstrated. We describe our clinical experience and recommend vincristine's correct place in ITP management. This retrospective study analysed data from 35 patients with newly diagnosed (ND), persistent (P) or chronic (C) ITP treated with VCR. The initial response rate, defined as >30 × 10(9) platelets/L, reached 86% after a median of 7 [interquartile range (IQR) 6-13] days. In ND and P ITP, even when previous therapies were inefficient, initial response was 87.5%, suggesting that this treatment could be used particularly in rescue. Median survival time, without failure or relapse, was 15 months (Kaplan-Meier curve). Predictive factors (univariate analysis) of an initial and long-term response were a small number of prior treatments received. However, at 2 yr, only seven patients had sustained response. Eight (23%) patients experienced adverse events: neuropathy for seven and bowel obstruction for one. Vincristine efficacy in ITP was confirmed, and it could be a good strategy for treating resistant ITP, especially in emergencies. In this era of new therapeutics, VCR deserves to remain on the list of ITP treatments because of its initial efficacy, safety and low cost.

Spontaneous improvement of chronic immune thrombocytopenia in children: experience of 56 patients at a single institute

Spontaneous improvement (SI) occurs more frequently in children with chronic immune thrombocytopenia (cITP) than in adults. It is generally accepted that, with the exception of splenectomy, conventional medical approaches for cITP do not change the natural course of the disease. Previous studies on pediatric cITP have reported prognostic factors associated with SI; however, it is important to know when such improvement occurs to enable optimal treatment strategies for cITP. Here, we report results of retrospective analysis of 56 consecutive pediatric patients with cITP at our institution. The median follow-up period after ITP diagnosis was 67 months (11-185 months). Of the 44 patients without splenectomy, 17 achieved SI at a median age of 8.5 years (2.3-16.5 years). The estimated incidence of SI was 24.6 ± 6.0 % at 36 months. In 16 of the 17 patients with SI, the recovery was achieved within 18 months from diagnosis, or at an age of less than 10 years, whereas among the 24 who did not achieve spontaneous improvement both at "an age of 10 years or more" and at "18 months or more from ITP diagnosis", only one recovered spontaneously. A treatment decision tree, including the indication for splenectomy, should be considered based on this watershed point.

The use of vinca alkaloids in adult patients with refractory chronic idiopathic thrombocytopenia

The aim of the study was to evaluate the application of vincristin or vinblastin in patients with chronic idiopathic thrombocytopenic purpura (ITP), resistant to corticosteroids or with partial contraindication to their application. Twenty-two patients were treated with vincristin or vinblastin in doses of 2 and 10 mg, respectively. Eight of these patients were additionally administered prednisone in an oral dose of 0.5 mg/kg body mass (bm). Two-hour intravenous infusions of drugs were made once a week, at least three times. In every patient, the platelet count was evaluated before and after the three infusions. A rise of the platelet count of at least 100 x 10(9)/l was assumed to signify improvement. Statistically significant improvement (P <0.01) was obtained in nine (41%) patients (including five (35%) patients treated with vinca alkaloids only and in four (50%) patients treated with vincristin and corticosteroids). On the average, 8 weeks after the termination of the treatment there was a 40% drop in the platelet. Patients with a shorter duration of the disease and without detectable platelet antibodies responded well to the treatment more frequently. Minor complications were observed in five patients (23%), notably in the form of paresthesia. Leukopenia was not present. Vinca alkaloids could find their application in clinical situations requiring short-term increase of the platelet count in chronically ill patients with ITP, resistant to corticosteroids or with counterindication to their application.

Acquired amegakaryocytic thrombocytopenia - four cases and a literature review

Acquired amegakaryocytic thrombocytopenla was diagnosed in four dogs. Initial platelet counts in all four dogs were less than 50,000 x 10(9)/litre and initial bone marrow examinations revealed megakaryocytic hypoplasia with minimal changes in the erythroid and myeloid cell lines. Two dogs had evidence of idiopathic immune-mediated disease and two dogs had evidence of associated infectious disease. One dog had a positive antibody titre to Borrella burgdorferi, and one dog had positive titres to both Ehrlichia canis and B. burgdorferi. Treatment consisted of prednisone and cyclophosphamide for the dogs with presumptive immune-mediated disease, and prednisone and tetracycline for the dogs with positive antibody titres to the Infectious organisms. Both dogs with evidence of associated infectious disease responded to treatment. A postmortem examination did not reveal the underlying aetiology in the two dogs with presumptive idiopathic immune-mediated disease.

Long-term follow-up of chronic autoimmune thrombocytopenic purpura refractory to splenectomy: a prospective analysis

Splenectomy remains the most effective treatment of chronic autoimmune idiopathic thrombocytopenia (ITP) (i.e. of > 6 months duration). Treatment of patients refractory to splenectomy (with absence of response or relapse after initial response) is difficult, and their long-term outcome is not well known. Over a 10-year period, 183 patients with chronic ITP were splenectomized including 158 adults and 25 children (</= 15 years). Forty-seven of them, who were refractory to this treatment, were prospectively followed up for 5-15 years (median 7.5 years). Twelve of them, with moderate thrombocytopenia, remained untreated, and 35 were treated by a median of two regimens (range 1--6), to which 27 responded. Thirty-six (77%) of the refractory cases reached platelet counts durably > 100 x 10(9)/l, nine of them without treatment and 27 of them with low-dose steroids or azathioprine; six (13%) remained moderately thrombocytopenic (35 x 10(9)/l to 100 x 10(9)/l platelets); the last five patients, without response to any treatment (up to six regimens), remained severely thrombocytopenic (platelets < 20 x 10(9)/l), and three of them died from bleeding. Twenty-seven (57%) of the 47 refractory cases required at least one hospitalization, in the majority of cases for intravenous immunoglobulin (IVIg) infusions. Seven of the refractory cases occurred in children. Six of them subsequently reached platelet counts > 100 x 10(9)/l, but one died from bleeding. Our findings confirm the overall favourable long-term prognosis of chronic ITP refractory to splenectomy.

Idiopathic thrombocytopenic purpura: pathophysiology and management

Our understanding of the pathophysiology of ITP owes to pioneering work of W J Harrington in 1951, delineating the immunologic nature of platelet destruction. In ITP, antibody-coated platelets are destroyed by macrophages of RES. However, other mechanisms are also implicated: C-mediated platelet lysis and newly described C-independent peroxide injury. Both induce platelet fragmentation and lysis, generating procoagulant platelet microparticles (PMP). A third mechanism of platelet consumption in the microvasculature is proposed, based on overlapping syndromes of ITP and TTP in some patients. In assessing hemostasis in ITP, platelet counts alone is not sufficient. Evaluation of platelet clumping, giant platelets, and platelet activation, marked by increased PMP is useful. Patients with platelet activation or giant platelets bleed less and detection of clumping prevents unwarranted therapy. Thrombotic complications may develop in ITP. A syndrome, characterized by recurrent TIA-like symptoms, progressive memory loss due to ischemic small vessel disease is described. The management of ITP should include the search for and elimination of underlying causes and careful evaluation of hemostasis. Therapy is divided into definitive vs symptomatic measures. The former including splenectomy, danazol, chemotherapy offers lasting remission after therapy was stopped, while the later including glucocorticoids, gammaglobuin, antiD antibodies and others increases platelet counts but seldom sustains remission upon withdrawal. Danazol therapy is up-dated since it is an effective and safe definite measure in ITP.

Classical management of refractory adult immune (idiopathic) thrombocytopenic purpura

Treatment of chronic immune (idiopathic) thrombocytopenic purpura with corticosteroids and/or splenectomy results in safe platelet counts in over 70% of patients without additional treatment. Therapy of patients who are refractory to these two treatments may be difficult. The treatment approach to refractory ITP patients, described in this report, is arbitrarily divided into four levels: levels 1 through 3 represent treatments with increasing side effects; level 4 therapy may be tried when the others have failed. Patients undergoing these treatments may require concomitant intravenous gammaglobulin, high-dose corticosteroids or platelets, to maintain the platelet count in the setting of mucosal bleeding or severe thrombocytopenia.

Management of patients with chronic, refractory idiopathic thrombocytopenic purpura

Chronic refractory idiopathic thrombocytopenic purpura (ITP) is defined as ITP with persistent thrombocytopenia despite conventional initial management with prednisone and splenectomy. Rare in children, It may occur in as many as one third of adults with ITP. The goal of treatment is not cure of the ITP, but only to achieve a safe platelet count, which is arbitrarily assumed to be greater than 30,000 to 50,000/microL. The risk for major bleeding seems great only when the platelet count is less than 10,000/microL. Treatment of patients with moderate thrombocytopenia and no clinically important bleeding symptoms should be avoided. There is no accepted algorithm for management of patients with chronic refractory ITP. Observation without specific treatment must be considered a cornerstone of management. Combination regimens of Immunosuppressive agents may be required for patients with severe and symptomatic thrombocytopenia. Additional supportive care measures are also important.

Approach to the investigation and management of immune thrombocytopenic purpura in children

Childhood immune thrombocytopenic purpura (ITP) is typically a benign, self-limiting disorder occurring in young (<10 years of age) previously healthy children. More than 80% of such children enter a complete sustained remission within a few weeks to a few months of initial presentation, irrespective of any therapy given. The major concern is the small but finite (0.1 to 0.9%) risk of intracranial hemorrhage, which occurs in children with very low platelet counts (<20 x 10(9)/L), and is the justification for treatment to increase the circulating platelet count. Effective treatment strategies are single-dose intravenous immunoglobulin G (IVIgG; approximately 1 g/kg) and medium to high-dose corticosteroids, administered orally or parenterally. The necessity for initial bone marrow aspiration and hospitalization continues to be debated. In children with chronic ITP, defined by persistence of thrombocytopenia for > or =6 months, splenectomy should be considered for the relatively small subgroup with symptomatic, severe thrombocytopenia who have either failed an adequate trial (> or = 12 months) of primary therapy (IVIgG, intravenous anti-D, corticosteroids) or are intolerant of such therapy. Laparoscopic splenectomy is preferred over open splenectomy. Children who fail to respond to splenectomy ( < or = 20% of cases) should be evaluated for the presence of accessory spleens; their management is often difficult and must be individualized. In severe refractory cases, second-line therapies (such as azathioprine or vinca alkaloids) need to be considered. Secondary ITP in children is relatively rare and is sometimes associated with other autoimmune cytopenias (Evan's syndrome, ITP with autoimmune neutropenia). These cases often respond poorly to conventional medical therapies and response rates to splenectomy are considerably lower than in children with primary chronic ITP.

[Chronic idiopathic thrombocytopenic purpura. Current therapy concept and introduction to pathophysiologic, clinical and diagnostic aspects]

PATHOPHYSIOLOGY

Chronic idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by platelet destruction due to an antiplatelet autoantibody, usually of the IgG class, which coats autologue platelets and leads to their elimination by the reticuloendothelial system (RES). While in childhood ITP is more usually an acute and self-limiting problem which needs no drug treatment, adult ITP is a relatively common chronic hematological disease.

TREATMENT

Treatment aimes at inhibition of antibody-production and binding on thrombocytes and thrombocyte phagocytosis by the RES. Therapy should result in a platelet count of > 100,000/microliter or at least in stabilization of the platelet count without bleeding. Therapeutic approaches were divided into emergency and long-term treatment. In patients who require non-emergency treatment conventional-dose corticoids (1 to 2 mg/kg/d prednisone) are recommended as initial treatment, whereas pulsed high-dose dexamethason is recently reported to be effective in refractory ITP. After unsuccessful splenectomy or if treatment with gammaglobulins fails alternative and partly experimental therapies may have to be used.

CONCLUSION

Treatment of adult ITP includes established medical, immunological and surgical measurements. Their application depends on diseases progression as well as imminent or manifest complications. Remission is achieved in up to 75% of all patients. Alternative treatments remain for refractory cases.

High-dose dexamethasone therapy for a 14-month-old boy with refractory idiopathic thrombocytopenic purpura

A 14-month-old boy with refractory idiopathic thrombocytopenic purpura (ITP), who was successfully treated with pulsed high-dose oral dexamethasone therapy is reported. The platelet count increased after six scheduled courses of treatment (10 mg/day x 4 days, six courses). Twenty-four months later, the platelet count remained over 10.0 x 10(4)/microL. No obvious side effects were observed during or after the therapy. This treatment could be taken into consideration not only for adults but also for young children with refractory ITP. It is effective, safe, easy to administer, patient comfort is taken into consideration, and hospitalization duration and costs are minimized.

Canine idiopathic thrombocytopenic purpura

Canine idiopathic thrombocytopenic purpura (ITP) is a disease in which antibodies bound to the surface of platelets mediate premature platelet destruction by macrophages. ITP in dogs and chronic ITP in humans are analogous diseases. This article draws on information from the literature on ITP in dogs and in humans, and reviews the pathogenesis, diagnosis, and treatment of ITP in dogs.

Pulsed high-dose dexamethasone in refractory chronic idiopathic thrombocytopenic purpura: a report on 10 cases

We treated 10 patients who had chronic refractory idiopathic thrombocytopenic purpura (ITP) with high-dose dexamethasone (DXM, 40 mg/d for 4 sequential days every month). The interval from diagnosis ranged from 49 to 300 months, and patients had previously received a median of 5.5 treatments (including splenectomy in nine cases). Median platelet count was 14 x 10(9)l (range 6-26 x 10(9)/l) at the onset of DXM and eight patients had bleeding symptoms. Eight patients received at least three cycles of DXM. Five patients had a response (i.e. platelet count at least doubled and increased by > 20 x 10(9)/l), including one almost complete remission and four minor responses (MR). Of the MR, one was probably due to concurrent IVIg administration, and all four MR were transient, in spite of further cycles of DXM. In three patients DXM was a failure after three or four cycles. In two patients DXM had to be stopped after one course because of major side-effects (systemic hypertension with stroke and insulin-dependent diabetes, respectively). In our experience, high-dose DXM had a relatively limited effect in chronic refractory ITP and was associated with severe side-effects in some cases.

Splenic irradiation for chronic autoimmune thrombocytopenic purpura in patients with contra-indications to splenectomy

We treated by splenic irradiation eight patients with chronic idiopathic thrombocytopenic purpura (ITP, seven cases) or secondary autoimmune thrombocytopenic purpura (one case) who had contra-indications to splenectomy. A total dose of 15 Gy was delivered to the spleen, with left kidney protection. One patient had a good durable response (> 1 year); two patients had a good transient response (of 3 months duration) but they responded again to a second course of irradiation; two patients had only partial response, but have required no other treatments for 2 years; the three remaining patients had no response. Side-effects were minor. Therefore splenic irradiation appears to be a therapeutic option in patients with chronic ITP who have contra-indications to splenectomy.

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.

A randomized trial comparing vinblastine in slow infusion and by bolus i.v. injection in idiopathic thrombocytopenic purpura: a report on 42 patients

Forty-two patients with ITP were randomly allocated to vinblastine slow infusion or bolus injection. 16/21 patients (76%) receiving slow infusion of vinblastine and 14/21 patients (67%) receiving a bolus injection of vinblastine had a response. There was no superiority of slow infusions of vinblastine over intravenous bolus injections, either when recently diagnosed and chronic ITP were analysed together or separately. In our opinion, intravenous bolus injections of vinblastine might be preferred, because they are easier to perform and have a better local tolerance.

Accessory spleen in recurrent chronic immune thrombocytopenic purpura

From 1969 to 1985 we discovered accessory spleens in 8 patients with chronic immune thrombocytopenic purpura (ITP) who relapsed or failed after splenectomy. Imaging of accessory spleen used a liver spleen scintigraphy with heat-treated RBC labeled with Tc-99m. Platelet kinetic studies with 51Cr or 111In, including sequestration index, were performed. Five patients had accessory splenectomy. Disappearance of bleeding symptoms was achieved in the 5 splenectomized patients but with only partial response of platelet counts. These results are discussed in the context of diagnosis and therapeutic management of accessory spleens in patients with chronic immune thrombocytopenic purpura who relapsed or failed after splenectomy.

Targeted-immunosuppression with vincristine infusion in the treatment of immune thrombocytopenia

Twenty-four patients with immune thrombocytopenia (ITP) were treated with vincristine (VCR) 1.0-2.0mg given as 4-hr I.V. infusions at weekly intervals for four-six weeks; four patients received further infusions, as maintenance therapy, at increasing intervals for up to 12 months. Eight of ten patients with recent-onset (less than 6 months) ITP showed an excellent and sustained response, 7/8 without maintenance therapy. Among the 14 patients with ITP of greater than or equal to 6 months' duration, seven showed a good or excellent but only transient response; sustained responses (two good, one partial) were seen only in the three patients who received maintenance therapy. The collective global experience with this novel therapeutic approach of targeted-immunosuppression for ITP is still small, but results to date suggest a promising role for this approach, especially in patients with recent-onset ITP.

Slow infusions of vinblastine in the treatment of adult idiopathic thrombocytopenic purpura: a report on 43 cases

Forty-three adult patients with idiopathic thrombocytopenic purpura (ITP) were treated by slow intravenous infusions of vinblastine. Nineteen had ITP of recent onset (i.e. of less than 6 months duration) and had contraindication to steroids (3 patients), refractoriness to steroids (6 patients) or to steroids and high dose intravenous immunoglobulins (IVIg, 10 patients). Of the 19 patients, 10 achieved complete response (CR), 2 achieved partial response (PR), 2 had minor response (MR) and the remaining 5 patients had no response (NR). Six of the complete responders remained in CR after 12 to 48 months, whereas all other responders relapsed within 3 months, in spite of maintenance therapy. Twenty-four patients had chronic ITP (i.e. of 6 months duration or more) and had showed no or only transient response to steroids and/or splenectomy, and in many of them, to other therapeutic approaches. Four achieved CR, 4 PR, 6 MR and 10 NR. All but 3 responses were shorter than 3 months, in spite of maintenance therapy. Most responses to slow infusions of vinblastine began after the first infusion. Main side effects included leukopenia in 9 patients (but with absolute neutropenia in only one) and peripheral neuropathy in 2 patients. Interval from diagnosis was the only prognostic factor of response to treatment. We conclude that slow infusions of vinblastine may be a useful approach in ITP of recent onset, when contraindication or refractoriness to steroids and/or IVIg exists. In our experience, this treatment has limited benefit in chronic ITP. In addition, it remains to be demonstrated that slow infusions of vinca alkaloids have any superiority over intravenous bolus injections of the same drugs.

Re-evaluation of the role of azathioprine in the treatment of adult chronic idiopathic thrombocytopenic purpura: a report on 53 cases

We treated 53 adults (mean age 54 years, range 17-89; 37 females and 16 males) with chronic idiopathic thrombocytopenic purpura (ITP) by azathioprine. All patients had received at least one form of therapy (including splenectomy in 40 patients) and had less than 50 x 10(9)/1 platelets. The duration of ITP before azathioprine was started ranged from 6 to 350 months (median 19). All patients initially received 150 mg/d of azathioprine. This was associated with a short initial course of prednisone (0.3-0.5 mg/kg d) in 10 of them, who were refractory to prednisone alone. 34 (64%) patients responded, including 24 (45%) complete remissions (CR), three (6%) partial remissions (PR) and seven (13%) minor responses (MR). Median time to achieve response was 4 months. 17 of the CR persisted after 7-182 months, 10 of them after discontinuation of azathioprine. Seven patients relapsed after 4-26 months, five of them after azathioprine was stopped or its dose was reduced. PR were short and the median duration of MR was 8 months. Overall, 21 patients (40%) had responses lasting 1 year or more and 17 (32%) lasting 2 years or more. Median duration of treatment was 18 months (range 3-84). Five patients died of bleeding while on treatment. No prognostic factors for response to azathioprine were found. Mild leucopenia was seen in seven patients and a moderate (x3) increase in transaminases in two patients. No opportunistic infections were seen and no malignancy has occurred since the onset of azathioprine. We conclude that azathioprine gives a relatively high incidence of durable responses and very limited side effects in chronic ITP, when splenectomy has failed or is contraindicated. This efficacy, in our experience, is superior to that obtained with other therapeutic approaches. As responses may be delayed, a course of azathioprine of 4 months is required before one can infer a failure to respond. In responding patients, however, the optimum duration of treatment remains to be established.

Epstein-Barr virus induced thrombocytopenia treated with intravenous acyclovir and immunoglobulin

We report infectious mononucleosis in a 15-year-old girl with severe thrombocytopenia (2 x 10(9)/l). Intravenous hydrocortisone in high doses for 4 days had no effect. When intravenous immunoglobulin and acyclovir were added an immediate response was noted with normalization of the thrombocyte count within 3 days.

Treatment of idiopathic thrombocytopenic purpura with ascorbate

The treatment of idiopathic thrombocytopenic purpura (ITP) includes corticosteroids, danazol, splenectomy and various immunosuppressives. Treatment can be difficult for those patients refractory to these modalities and/or those patients intolerant of the secondary effects. In this paper we report on the use of ascorbate in the treatment of ITP and its successful use in seven of 11 patients studied. We found that therapy with ascorbate appeared to improve the platelet count and the intravascular survival of platelets. Because of excellent patient compliance and its lack of toxicity, it may be an alternative for the treatment of ITP. The exact role of ascorbate in the treatment of ITP, as well as its mechanism of action, await further study.

Management of refractory idiopathic thrombocytopenia

In refractory thrombocytopenia one should first evaluate whether the therapeutic approach has more risks to the patient than no treatment at all. The patient may remain relatively asymptomatic and the only incommoding circumstances be cosmetic. Coincidental medical problems such as hypertension and peptic ulceration are particularly worrying in the patient with ITP. Very occasionally a cerebral haemorrhage may occur without any obvious predisposing cause. In most instances, however, refractory thrombocytopenia is a benign condition which rarely directly causes the death of the patient. Since many of the remedies advocated for this problem have significant side effects these must always be carefully balanced and fully discussed with the patient before their introduction.

[Value of preoperative thrombocyte marking in patients with idiopathic thrombocytopenic purpura]

51Cr-platelet kinetic studies were performed in 77 patients with idiopathic thrombocytopenic purpura. The sequestration site was splenic for 63, splenic/hepatic for 7 or hepatic for remaining 7 patients. In 20 patients platelet survival was extremely shortened to 0-3 h, whereas only 26 patients had a survival time of more than 24 h. Those patients with low platelet counts also had a very short platelet survival time, whereas patients with higher platelet counts (greater than 50 x 10(9)/l) had longer platelet survival times. 51 patients (66%) were splenectomized following the kinetic studies. 25 patients who had a splenic sequestration site had normalized platelet counts and 6 patients had platelet counts between 80-149 x 10(9)/l 12 months after splenectomy (i.e. in 92% of cases with splenic sequestration site a full or partial remission). Of the 11 patients with a hepatic or splenic/hepatic sequestration site, 2 patients had full remission, 1 partial remission, 3 patients had minimal improvement and 5 other patients were treatment failures in respect to the splenectomy.

Use of intravenous gamma globulin in children and adolescents with idiopathic thrombocytopenic purpura and other immune thrombocytopenias

Approximately 85 to 90 percent of cases of idiopathic thrombocytopenic purpura (ITP) in children are of the acute, self-limited variety that generally occurs after a viral infection. The remaining 10 to 15 percent of children with this disorder have the chronic (autoimmune) type of ITP. For these patients, splenectomy is often the recommended treatment if severe bleeding occurs and platelet counts remain below 40,000/mm3. However, splenectomy has associated risks and the response to this surgery cannot always be predicted. Intravenous gamma globulin (IVIG) has proven useful as an alternative to splenectomy, especially in children who are considered too young for splenectomy or in those in whom there is no response to splenectomy. It should be noted that booster shots are frequently required and the patient's ITP may become refractory. IVIG may also be useful in preparing a child with ITP for splenectomy and in treating children or adolescents with ITP who have central nervous system or other serious hemorrhages. Although IVIG is not always effective in raising the platelet count, it does provide a very useful alternative method of treating this disorder.

The treatment of adult idiopathic thrombocytopenic purpura. Infusion of vinblastine in ITP

16 adult idiopathic thrombocytopenic purpura (ITP) patients, with mean age 51 years, were treated by 5 weekly slow intravenous infusions of vinblastine (0.1 mg/kg). When a complete or partial response (CR or PR) was obtained, slow infusions were repeated at 2-weekly then monthly intervals, as maintenance therapy. In 4 cases with ITP of recent onset, but presenting contraindication or failure to prednisone and high dose intravenous immunoglobulins, CR was obtained in all patients after 4 to 15 days (mean 9.5). Only one of these patients relapsed. In 12 cases of refractory chronic ITP (of whom 10 had been splenectomized), there were 2 CR, 6 PR and 4 failures. The 8 responding patients had a mean interval to response of 20 days. The 6 PR were short and did not exceed 15 days. Our results do not support a superiority of this treatment compared to other modes of administration of vinca alkaloids in ITP (intravenous bolus, vinca loaded platelets).

Therapeutic considerations in childhood idiopathic thrombocytopenic purpura

This monograph reviews the literature regarding therapy for childhood idiopathic thrombocytopenic purpura (ITP). The role and mechanism of action are discussed for corticosteroids, splenectomy, and intravenous gamma globulin. Alternative therapies with potent immunosuppressive agents are also mentioned. Guidelines for the management of children with ITP are presented.

Hematologic disorders

A distinction is made between postinfection thrombocytopenia of childhood and idiopathic thrombocytopenia (ITP) of adulthood. Relative advantages of treatment modalities, including splenectomy, are weighed, with an emphasis on the administration of intravenous immunoglobulin (IVIG) as an emergency measure in the adult patient with ITP. Management of thrombotic thrombocytopenic purpura (TTP) is also discussed, as is the case of a patient who became alloimmunized after 2 years of multiple transfusions used to treat an arteriovenous malformation of the small bowel.

Slow infusion of vincristine in the treatment of idiopathic thrombocytopenic purpura

Ten patients with idiopathic thrombocytopenic purpura (ITP) were treated with vincristine (VCR), given as a slow infusion over a 4-hr period, at weekly intervals for 4 weeks. The VCR therapy achieved a sustained recovery of platelet count in five patients with ITP of 2 weeks to 5 months duration; a transient recovery was observed in four patients with ITP of 6 months to 5 years duration. Therapy had no effect at all in one patient who had ITP of 10 years duration. Vincristine therapy appears to be therapeutically more beneficial when given as a slow infusion and can achieve sustained recovery of platelet count in patients with ITP of less than six months duration.