High dose gammaglobulin therapy in adults with idiopathic thrombocytopenic purpura (ITP). Clinical effects

Remission of newly diagnosed immune thrombocytopenia after lung cancer resection

Secondary immune thrombocytopenia is a rare paraneoplastic syndrome of lung cancer. We report a case of pulmonary pleomorphic carcinoma with newly diagnosed secondary immune thrombocytopenia. On referral, the patient's complete blood cell count was normal; however, it showed marked thrombocytopenia after 1 month. Blood biochemistry and bone marrow puncture showed normal findings. We speculated that he had immune thrombocytopenia associated with the lung cancer and planned lung resection. Sleeve middle and lower lobectomy was successfully performed with preoperative intravenous immunoglobulin and intraoperative platelet transfusion. His platelet count was restored and maintained a normal level at 8 months after the operation.

[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.

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.

Immune thrombocytopenia: surgical therapy and predictors of response

We have reviewed 40 patients with immune thrombocytopenia purpura (ITP) to assess current methods of preparation for surgery and to evaluate perioperative complications and response to splenectomy. Twenty-one patients had chronic ITP (greater than 1 year duration) and 19 patients had severe acute thrombocytopenia (platelet counts less than 10,000). A progression of methods of pretreatment was seen in the 10-year period reviewed. Seventeen patients received no treatment before admission for surgery, and 10 of these received platelet transfusions. Seventeen patients received steroids immediately preceding surgery; 16 of these responded and 1 received a platelet transfusion. Recently, 5 patients received intravenous gamma globulin (IgG) preceding surgery with all patients responding and none receiving platelet transfusions. One patient received a combination of steroids and IgG with good response and did not require platelet transfusion. No major postoperative complications occurred (ie, pancreatitis, small bowel obstruction, or sepsis) except for one patient requiring a secondary exploration for an accessory spleen and recurrent thrombocytopenia. Eight patients (20%), 6 with severe ITP and 2 with chronic ITP (5 males and 3 females) developed recurrence of thrombocytopenia following surgery up to 1 1/2 years after splenectomy. These patients all required further medical therapy. Three additional patients (2 chronic and 1 severe) developed thrombocytopenia following viral illnesses, but required no further therapy. Of the 8 surgical failures, 4 failed to respond to prior treatment with steroids, 1 to IgG, and 2 failed to respond to combination therapy, while one surgical failure responded to both steroid and combination therapy. Of the responders to splenectomy (32 patients), only 3 failed to respond to prior treatment with steroids.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the efficacy of a two-day and a five-day schedule for infusing intravenous gamma globulin in the treatment of immune thrombocytopenic purpura in adults

The standard schedule for treating immune thrombocytopenia purpura in adults with intravenous immunoglobulin G infusion (IVIG), 400 mg/kg per day for five days, was compared with a shorter schedule using 1,000 mg/kg per day for two days. Both schedules were found to be effective in correcting thrombocytopenia. Eleven of the 17 patients treated with the five-day regimen and nine of 10 patients treated with the two-day regimen had significant responses. Patients with an initial platelet count of less than 20,000 platelets/mm3 or with an estimated in vivo platelet survival in excess of 90 hours were less likely to have a response than were other patients. There were no serious side effects in either group, but thrombophlebitis was observed in some patients receiving the five-day regimen when a single intravenous catheter was used for more than three days. Headaches and, less commonly, low-grade fever were noted in some patients receiving the two-day regimen when infusions were given at flow rates in excess of 0.04 ml/kg/minute. Since the two-day regimen requires shorter hospitalization and corrects thrombocytopenia slightly faster than the five-day course, it may be particularly useful in correcting thrombocytopenia in hospitalized patients requiring splenectomy or other surgery.

Intravenous treatment with gammaglobulin in adults with immune thrombocytopenic purpura: review of the literature

The results of high-dose intravenous gammaglobulin therapy (IVGG) of adults with immune thrombocytopenic purpura (ITP) were reviewed in 28 published reports which included 282 patients. Overall, 64% of the patients responded to IVGG with a peak platelet count greater than 100,000/mm3; 83% had peak platelet counts greater than 50,000/mm3. Unmodified immunoglobulin was superior to modified immunoglobulin; 70% of the patients treated with the former having platelet increases to greater than 100,000/mm3 compared to only 49% of those treated with the latter. More patients were refractory among those who had had ITP for at least 3 years. A higher peak platelet count immediately after IVGG administration was correlated with a longer duration of the platelet response. Patients above the age of 60 tended to have a weaker response to IVGG than did younger patients, and females tended to respond better than males. A pre-IVGG platelet count of less than 10,000/mm3 was not associated with a poor response to IVGG. While there is still no way to reliably predict response prior to therapy in an individual patient, the above information may help in the decision of whether or not treatment with IVGG is likely to be successful. It also suggests that inhibition of antiplatelet antibody production is an important mechanism of IVGG effect at least in some patients.

Reticuloendothelial system Fc-receptor function in patients with immune thrombocytopenia after treatment with high dose intravenous immunoglobulin

Reticuloendothelial system Fc-receptor (FcR) function was measured in 4 healthy controls and 9 patients with immune thrombocytopenia before and after therapy with high dose i.v. gammaglobulin (HDIg). Idiopathic thrombocytopenic purpura (ITP) was diagnosed in 5 patients. 2 patients with hemophilia A, 1 with acute tuberculosis and 1 with psoriasis vulgaris had thrombocytopenia that clinically resembled ITP. 4 out of 9 patients received prednisone prior to or during the study. FcR blockade was observed only in patients with ITP not receiving prednisone. In all other patients, HDIg did not induce a measurable FcR blockade. However, all except 1 patient (with acute tuberculosis) showed a marked rise in platelet counts for 2 to 12 wk. This is consistent with therapeutic efficacy of HDIg in various clinical settings of immune thrombocytopenia. All platelets were fully hemostatic and clinically no difference could be observed. This indicates that the effect of HDIg cannot be due to FcR blockade alone.

Improvement of post platelet transfusion increments following intravenous immunoglobulin therapy for leukaemic HLA-immunized patients

3 patients with acute leukaemia, HLA antibodies and thrombocytopenia refractory to random donor platelet transfusions were treated with high-dose i.v. immunoglobulin. All 3 patients responded favourably with improved post-transfusion recovery of random platelets. In 1 patient, the recovery of transfused histocompatible platelets was also enhanced. Treatment was followed by reduction in the total lymphocyte count and marked changes in lymphocyte subsets in 1 patient.

Transient deficiency of peripheral blood accessory cells in supporting T cell mitogenesis in patients suffering from chronic idiopathic thrombocytopenic purpura after intravenous gammaglobulin treatment

Mitogenic response of blood lymphocytes to phytohemagglutinin (PHA) and to OKT3 monoclonal antibodies was investigated in 7 patients suffering from chronic idiopathic thrombocytopenic purpura (ITP) before, during and after high-dose intravenous (i.v.) immunogammaglobulin (IgG) infusion. The platelet count rose above the pre-treatment values during infusion therapy in all patients but one. Five out of seven patients presented elevated platelet-associated IgG (PA-IgG) levels at the time of the first infusion; four of these showed an increase in platelet count and a transient reduction or normalization of PA-IgG after IgG infusion. Five out of seven patients showed an impairment of T lymphocyte mitogenic response to PHA and OKT3 before therapy. All patients responded to IgG therapy with a transient deficiency of FcR mediated monocytes (Mo) in supporting T cell mitogenesis induced by both mitogens during and after IgG infusion. This reduced cooperative capability of Mo disappeared at various times after the end of therapy (range 3-12 days). The transient alteration of Mo function, possibly due to a modification in the surface number or in the affinity of Fc-receptors, can explain in part, the increase in platelet count during and after IgSRK infusion.