Safety and Efficacy of Azathioprine as a Second Line Therapy for Primary Immune Thrombocytopenic Purpura

Abstract

Introduction: Immune thrombocytopenic purpura remains common blood disease in Nepal. Azathioprine is an oral immunosupressive medicine which has been used widely in various autoimmune disease and solid organ transplant patients. It is inexpensive, easily available and well tolerated medicine. This study was carried out to evaluate efficacy and safety of azathioprine as a second line medicine for primary ITP patients who were refractory to steroid therapy.Methods: The observational, pre-post study was conducted at Government of Nepal Civil Service Hospital, Kathmandu from January to October 2014. Twenty four primary ITP patients who were steroid refractory were treated with Azathioprine. Patients were termed steroid refractory if platelet counts were less than 30,000/ul on day 21st of steroid therapy. From day 22 onwards oral azathioprine 2mg/kg was started and steroids were tapered 10mg/week and stopped. Platelet counts of more than 30000/ul after one month of stopping steroid, while still on azathioprine, were termed response to azathioprine. Platelet count of more than 100,000/ul was termed complete response. The associations among age, gender, duration and platelets counts were analyzed by chi square test and Fisher's exact test (when individual cell frequency was less than 5). The comparison of platelets counts among the start and day 90 of Azathioprine therapy was performed by the paired t-test. Results: The study showed that there was not significant association among age and gender of the patients and their platelets count on the start of Azathioprine therapy (p value 0.354 and 0.725 respectively) and on day 90 of Azathioprine therapy (p value 0.082 and 0.762 respectively). The duration-wise comparisons of platelets count on both the start and day 90 of Azathioprine therapy were significant (p values 0.029 and 0.008 respectively). The paired comparison among platelets count on the start and day 90 of Azathioprine therapy was highly significant (p value 0.000).Conclusions: The study showed the therapeutic implication of azathioprine in ITP patients. It also showed that efficacy of azathioprine was comparable with other modes of treatment. In low income countries like Nepal azathioprine can be considered as second line treatment for steroid refractory ITP patients.Keywords: Immune thrombocytopenic purpura; autoimmune disease; steroids; azathioprine; Nepal. | PubMed

Immune thrombocytopenia: Effectiveness of frontline steroids and comparison of azathioprine, splenectomy, and rituximab as second‐line treatment

“…Nevertheless, both splenectomy and azathioprine are associated with relatively good response rates and minimal toxicities. Azathioprine has been shown to be a cost‐effective treatment . Splenectomy provides possibilities of long‐term durable responses, with no additional immunosuppressants.…”

“…Azathioprine has been shown to be a cost-effective treatment. 37 Splenectomy provides possibilities of long-term durable responses, with no additional immunosuppressants. Such a curative potential is consistent with those described in literature.…”

Danazol as a second‐line treatment for immune thrombocytopenic purpura

“…3 However, there are some reports about its efficiency in the literature. 4,5 The authors obtain a surprisingly high rate of success and explain the discrepancy with former studies with "difference in case enrollment and definition of response". 1 The outcome of a high number of ITP cases has improved since the addition of rituximab and thrombopoietin receptor agonists to the therapeutic arsenal.…”

Challenges and Results of Laparoscopic Splenectomy for Hematological Diseases in a Developing Country

“…Though, in our series, hereditary spherocytosis is the most common cause of anemia for which splenectomy was done. Other than hemoglobinopathies, ITP is also a common blood disorder in Nepalese population and is frequently seen in young women [ 27 ]. Poudyal et al have studied azathioprine as second-line modality for ITP patients; we have studied in those patients who were both azathioprine and steroid refractory/dependent [ 27 ].…”

“…Other than hemoglobinopathies, ITP is also a common blood disorder in Nepalese population and is frequently seen in young women [ 27 ]. Poudyal et al have studied azathioprine as second-line modality for ITP patients; we have studied in those patients who were both azathioprine and steroid refractory/dependent [ 27 ]. Shrestha et al have established open splenectomy to have significant response for these patients before; we have ventured via minimally invasive approach [ 28 ].…”