Treating Refractory Idiopathic Thrombocytopenic Purpura

For High-Definition, Click

In chronic refractory idiopathic thrombocytopenic purpura (ITP), Howard A. Liebman, MD, pursues strategies that minimize the use of long-term immunosuppressant agents. Keith McCrae, MD, considers thrombopoietin receptor agonists in combination with cyclosporine, dapsone, or steroids in individuals with refractory ITP.

Liebman states that he may try anti-CD20 therapy, such as rituximab, in younger individuals with refractory disease. He explains to patients that while approximately 60% will respond to anti-CD20 therapies, only half of those respondents will have normal platelet counts. Newer treatment strategies combine anti-CD20 therapy with pulses of dexamethasone. While this combination increases toxicity and risk of infection, 50% to 60% of individuals have a normal platelet count at 1 year, notes Liebman.

There is little follow up on this approach, Liebman notes, but it may help some patients avoid splenectomy. Liebman never considers using splenectomy in patients receiving anti-CD20 therapy until a year after stopping agents, since he cannot administer necessary immunizations until that time. As a result of this restriction, he sometimes recommends immunizations prior to initiating an anti-CD20 therapy.