Does treatment with intermittent infusions of intravenous anti-D allow a proportion of adults with recently diagnosed immune thrombocytopenic purpura to avoid splenectomy?

Abstract

This study explored whether repeated infusions of intravenous anti-D could allow adults with recently diagnosed immune thrombocytopenic purpura (ITP) who had failed an initial steroid course to postpone and ultimately avoid splenectomy. Twenty-eight Rh ؉ , nonsplenectomized adults with ITP diagnosed within 1 to 11 months and platelet counts 30 ؋ 10 9 / L (30 000/L) or below were enrolled. Anti-D was infused whenever the platelet count decreased to 30 ؋ 10 9 /L (30 000/ L) or below. "Response" was defined as a platelet increase of more than 20 ؋ 10 9 / L (20 000/L) to more than 30 ؋ 10 9 /L (30 000/L) within 7 days of treatment. Patients were a median 3.5 months from ITP diagnosis at enrollment and had received a median of 2 previous therapies, including prednisone in 26 of 28 cases. They were followed for a median 26 months. A total of 93% responded to their initial infusion of anti-D, and 68% repeatedly responded with counts maintained above 30 ؋ 10 9 /L (30 000/L) using anti-D alone. Currently, 12 (43%) of 28 patients have been off all treatment for more than 6 months without undergoing splenectomy, 6 maintaining counts above 100 ؋ 10 9 /L (100 000/L). Seven continue on treatment, 8 underwent splenectomy, and 1 was lost to follow-up at 10 months. One patient discontinued anti-D because of toxicity. Patients with platelet counts at least 14 ؋ 10 9 /L (14 000/L) at enrollment were more likely to discontinue treatment (P < .05). Anti-D was an effective maintenance treatment for two thirds of Rh ؉ , nonsplenectomized adults with ITP who had failed an initial steroid course. Intermittent infusions of intravenous anti-D allowed more than 40% of these adults to avoid splenectomy and to achieve stable platelet counts off all therapy, even after many months of treatment. Platelet count at study entry was the primary predictor of outcome. (Blood.

Efficacy of mycophenolate mofetil as single‐agent therapy for refractory immune thrombocytopenic purpura

“…Standard first-line treatments for ITP include prednisone [3][4][5][6][7], intravenous gamma globulin (IVIg) [6], and intravenous anti-D [8][9][10][11][12][13]. If ITP is persistent despite first-line therapies, then splenectomy is usually the second-line approach in adults.…”

Safety and tolerability of a novel chromatography‐based intravenous immunoglobulin when administered at a high infusion rate in patients with immune thrombocytopenic purpura

“…Childhood ITP is typically a disease of acute onset; more than 80% of children will have a spontaneous and permanent remission within 1 year of onset [2]. In contrast, adults tend to have more persistent ITP [3], although recent studies suggest that there is a tendency for certain patients to improve with time [3][4][5][6]. Rarely, life-threatening bleeding occurs, with intracranial hemorrhage being the principle cause of death [1,7].…”

ITP in the 21st Century

“…This approach is common for children, many of whom will remit over time, and one single-arm prospective trial suggested that 40% of adults who failed an initial course of steroids could avoid splenectomy by intermittent treatment with anti-D. 34 A multi-institutional, randomized trial was conducted to compare "standard management" (oral steroids followed by early splenectomy) to aggressive anti-D for adults with ITP. 35 In this trial, treatment with anti-D was able to delay, but not avoid, splenectomy.…”