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Upfront Use of Corticosteroids in ITP

Panelists: Ivy Altomare, MD, Duke University Medical Center; Terry Gernsheimer, MD, Fred Hutchingson Cancer Research Center; Keith R McCrae, MD, The Cleveland Clinic
Published: Tuesday, Jan 30, 2018



Transcript: 

Ivy Altomare, MD: For first-line therapy, I think we would all agree with the use of steroids. There are a few different flavors of steroids. Can you discuss your choice of upfront therapy once you’ve decided to treat a patient? What drug do you actually use? How you dose it, and what duration do you use?

Terry Gernsheimer, MD: There are some data that suggest that dexamethasone may be better at inducing a longer-term remission.

Ivy Altomare, MD: Versus?

Terry Gernsheimer, MD: Versus just using oral prednisone. I tend to go with oral prednisone because I’m not entirely convinced that we really put people into longer-term remissions with dexamethasone. And I think dexamethasone is often poorly tolerated. All corticosteroids are poorly tolerated. Dexamethasone is particularly poorly tolerated in older individuals, so I almost never use it in patients over the age of 60.

Ivy Altomare, MD: And you give prednisone at what dose?

Terry Gernsheimer, MD: Usually I start at somewhere around 1 mg/kg. That’s going to depend somewhat on the size of the patient. If I’ve got a very large patient, I’m not going to go that high. But I usually start with 1 mg/kg, and I pretty rapidly taper that prednisone down.

Ivy Altomare, MD: How rapidly?

Terry Gernsheimer, MD: It usually depends on how they’ve responded. I’m usually looking for a response. And when I say a response, I usually like to see them over 100,000, and then I begin to taper. And when I say rapidly‒let’s say I’m at 100 mg‒I will very quickly go to 80 mg, 60 mg, 40 mg, and then maybe get a little bit slower. People declare themselves somewhere in there.

Ivy Altomare, MD: When you start the prednisone, 1 mg/kg, are you checking counts weekly?

Terry Gernsheimer, MD: Absolutely. If they’re very low, I might check them in just a few days. If they’re very low, especially if they have symptoms of bleeding, I’ll usually add IVIG (intravenous immunoglobulin).

Ivy Altomare, MD: Sure.

Terry Gernsheimer, MD: Then you see a more rapid response.

Ivy Altomare, MD: I am asking this in the outpatient setting. I do believe that if patients are hemorrhaging, we would use IVIG in an inpatient setting?

Terry Gernsheimer, MD: Yes. But even without hemorrhage, if I’m meeting them for the first time and they’ve got a very low count, they’re in the single digits, I will frequently add IVIG just to get them to move in the first place. And then that’ll last a little while. We know it’s going to ultimately come down. In the meantime, we can start to taper steroids because I’m going to start them together.

Ivy Altomare, MD: So, you’re tapering and knowing that this is very individualized. Your tapering, in general, lasts for what, 4 weeks, 6 weeks?

Terry Gernsheimer, MD: Four to 6 weeks. I would hope that I’d be pretty close to getting them off the drug somewhere in there. Or at that point, I’d be seeing that they’re not going to tolerate a further taper.

Ivy Altomare, MD: And you taper completely to off?

Terry Gernsheimer, MD: I try.

Ivy Altomare, MD: All right. Dr. McCrae, how do you use steroids in the frontline setting?

Keith R. McCrae, MD: My approach is pretty similar. I’ve used prednisone over the years. As I see more and more dexamethasone, although papers suggest that it might be a little better, I’m not entirely convinced. I probably use it a little more often, but I would have the same general approach. When I do use dexamethasone, it’s mostly in younger patients. In a lot of these reports that you read, it says that there is no more toxicity with dexamethasone as compared to prednisone. That’s certainly not my experience, especially in older patients who are glucose intolerant or have a metabolic syndrome or other things. So, when I use prednisone, I usually start at a flat 60 mg. And then, once they respond, I taper it by about 10 mg per week. So, it’s about the same duration of taper. I just don’t go quite as high, perhaps, as Dr. Gernsheimer, initially.

Ivy Altomare, MD: And when you give the dexamethasone, what is your dose and what is your schedule?

Keith R. McCrae, MD: It’s the 40-mg/day dose for 4 days. If they haven’t had a strong response within 10 to 14 days, I’ll repeat that and just hope for the best. And then, if that doesn’t work, we go to plan B very quickly.

Transcript Edited for Clarity 

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Transcript: 

Ivy Altomare, MD: For first-line therapy, I think we would all agree with the use of steroids. There are a few different flavors of steroids. Can you discuss your choice of upfront therapy once you’ve decided to treat a patient? What drug do you actually use? How you dose it, and what duration do you use?

Terry Gernsheimer, MD: There are some data that suggest that dexamethasone may be better at inducing a longer-term remission.

Ivy Altomare, MD: Versus?

Terry Gernsheimer, MD: Versus just using oral prednisone. I tend to go with oral prednisone because I’m not entirely convinced that we really put people into longer-term remissions with dexamethasone. And I think dexamethasone is often poorly tolerated. All corticosteroids are poorly tolerated. Dexamethasone is particularly poorly tolerated in older individuals, so I almost never use it in patients over the age of 60.

Ivy Altomare, MD: And you give prednisone at what dose?

Terry Gernsheimer, MD: Usually I start at somewhere around 1 mg/kg. That’s going to depend somewhat on the size of the patient. If I’ve got a very large patient, I’m not going to go that high. But I usually start with 1 mg/kg, and I pretty rapidly taper that prednisone down.

Ivy Altomare, MD: How rapidly?

Terry Gernsheimer, MD: It usually depends on how they’ve responded. I’m usually looking for a response. And when I say a response, I usually like to see them over 100,000, and then I begin to taper. And when I say rapidly‒let’s say I’m at 100 mg‒I will very quickly go to 80 mg, 60 mg, 40 mg, and then maybe get a little bit slower. People declare themselves somewhere in there.

Ivy Altomare, MD: When you start the prednisone, 1 mg/kg, are you checking counts weekly?

Terry Gernsheimer, MD: Absolutely. If they’re very low, I might check them in just a few days. If they’re very low, especially if they have symptoms of bleeding, I’ll usually add IVIG (intravenous immunoglobulin).

Ivy Altomare, MD: Sure.

Terry Gernsheimer, MD: Then you see a more rapid response.

Ivy Altomare, MD: I am asking this in the outpatient setting. I do believe that if patients are hemorrhaging, we would use IVIG in an inpatient setting?

Terry Gernsheimer, MD: Yes. But even without hemorrhage, if I’m meeting them for the first time and they’ve got a very low count, they’re in the single digits, I will frequently add IVIG just to get them to move in the first place. And then that’ll last a little while. We know it’s going to ultimately come down. In the meantime, we can start to taper steroids because I’m going to start them together.

Ivy Altomare, MD: So, you’re tapering and knowing that this is very individualized. Your tapering, in general, lasts for what, 4 weeks, 6 weeks?

Terry Gernsheimer, MD: Four to 6 weeks. I would hope that I’d be pretty close to getting them off the drug somewhere in there. Or at that point, I’d be seeing that they’re not going to tolerate a further taper.

Ivy Altomare, MD: And you taper completely to off?

Terry Gernsheimer, MD: I try.

Ivy Altomare, MD: All right. Dr. McCrae, how do you use steroids in the frontline setting?

Keith R. McCrae, MD: My approach is pretty similar. I’ve used prednisone over the years. As I see more and more dexamethasone, although papers suggest that it might be a little better, I’m not entirely convinced. I probably use it a little more often, but I would have the same general approach. When I do use dexamethasone, it’s mostly in younger patients. In a lot of these reports that you read, it says that there is no more toxicity with dexamethasone as compared to prednisone. That’s certainly not my experience, especially in older patients who are glucose intolerant or have a metabolic syndrome or other things. So, when I use prednisone, I usually start at a flat 60 mg. And then, once they respond, I taper it by about 10 mg per week. So, it’s about the same duration of taper. I just don’t go quite as high, perhaps, as Dr. Gernsheimer, initially.

Ivy Altomare, MD: And when you give the dexamethasone, what is your dose and what is your schedule?

Keith R. McCrae, MD: It’s the 40-mg/day dose for 4 days. If they haven’t had a strong response within 10 to 14 days, I’ll repeat that and just hope for the best. And then, if that doesn’t work, we go to plan B very quickly.

Transcript Edited for Clarity 
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