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Clinical Management 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: Friday, Feb 09, 2018



Transcript: 

Ivy Altomare, MD: What is the expected response rate to upfront steroids in general?

Keith R. McCrae, MD: It’s probably 70% to 80%, somewhere in that range.

Ivy Altomare, MD: And the duration of response would be?

Keith R. McCrae, MD: Well the duration for standard prednisone is for as long as they continue prednisone. Classically, in adult idiopathic thrombocytopenia purpura, when you taper, as you taper, you’re going to start to see a fall in the platelet count in most cases. Occasionally not. But I’d say more often than not, you do. By the time you’re out to 2.5, 3 months, and getting off that taper, you see this seesaw pattern. I see this with a lot of patients referred. They fall. They go back on high-dose prednisone again. They taper. They fall. I don’t like the seesaw. I don’t like chronic steroid exposure. I don’t know how many patients I’ve seen referred to me who have come in and they’ve gained 30 pounds, 40 pounds, over the previous 4 months because they’ve been on steroids almost continuously. I really like to avoid that.

Ivy Altomare, MD: And diabetes. I’ve seen people get divorced and it was attributed to steroids.

Terry Gernsheimer, MD: I was just going to bring this up. I hope that they’ve brought in their spouse with them, because I will turn to their spouse or their partner and I’ll say, “Listen, it’s going to be the drug talking. Remember that.” People seem to become more of whatever they are. More inflammatory. More reactive. It’s really important to tell everybody around them that this could be a tough haul. I had one patient who, whenever he had to, when he got IVIG (intravenous immunoglobulin)—which was the only thing years, ago at that point, that was working—we had to give him steroids along with it. His family literally would put him on the other end of the house for the few days following those steroids, because it was really so difficult. So, I think it’s really important to remember that you’ve got to talk to the whole family because the whole family is going to be experiencing that.

Ivy Altomare, MD: Yes. When you use prednisone up-front—because dexamethasone is a pulse that stops—is your intent to get them completely off prednisone? Or do you continue a low dose?

Keith R. McCrae, MD: Absolutely. I mean, is there any such thing as an acceptable dose of long-term steroid? That’s a good question, and I don’t really know.

Ivy Altomare, MD: In ITP.

Keith R. McCrae, MD: In ITP or in anything really. I think maybe 2.5 mg a day? But maybe even that’s too much. I would not consider anything more than that.

Terry Gernsheimer, MD: I will, sometimes, in a very refractory patient who—for whatever reason seems to be under control at 5 mg—allow that. They say it’s a physiologic dose these days. But it’s not without side effects. The patients will tell you, “I do feel differently.” But it’s usually tolerable. I’m not happy about it, but there are patients. Rather than go to something that’s very immunosuppressive, or that’s going to be something that we don’t know what the long-term effects may be, or that I think is not going to last, if I know they’re responding…
It’s interesting. You can sometimes see these patients who are fine at 5 mg. You try and take them down to 4 mg and boom, they relapse. Patients sometimes get very, very sensitive to these small changes in dose.

Ivy Altomare, MD: Then you have to go back and do the whole thing, or switch to another therapy.

Terry Gernsheimer, MD: Or at least come up a little bit. That’s that seesaw that we’re always trying to avoid because it’s so hard on the patient.

Ivy Altomare, MD: Absolutely.

Transcript Edited for Clarity 

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Transcript: 

Ivy Altomare, MD: What is the expected response rate to upfront steroids in general?

Keith R. McCrae, MD: It’s probably 70% to 80%, somewhere in that range.

Ivy Altomare, MD: And the duration of response would be?

Keith R. McCrae, MD: Well the duration for standard prednisone is for as long as they continue prednisone. Classically, in adult idiopathic thrombocytopenia purpura, when you taper, as you taper, you’re going to start to see a fall in the platelet count in most cases. Occasionally not. But I’d say more often than not, you do. By the time you’re out to 2.5, 3 months, and getting off that taper, you see this seesaw pattern. I see this with a lot of patients referred. They fall. They go back on high-dose prednisone again. They taper. They fall. I don’t like the seesaw. I don’t like chronic steroid exposure. I don’t know how many patients I’ve seen referred to me who have come in and they’ve gained 30 pounds, 40 pounds, over the previous 4 months because they’ve been on steroids almost continuously. I really like to avoid that.

Ivy Altomare, MD: And diabetes. I’ve seen people get divorced and it was attributed to steroids.

Terry Gernsheimer, MD: I was just going to bring this up. I hope that they’ve brought in their spouse with them, because I will turn to their spouse or their partner and I’ll say, “Listen, it’s going to be the drug talking. Remember that.” People seem to become more of whatever they are. More inflammatory. More reactive. It’s really important to tell everybody around them that this could be a tough haul. I had one patient who, whenever he had to, when he got IVIG (intravenous immunoglobulin)—which was the only thing years, ago at that point, that was working—we had to give him steroids along with it. His family literally would put him on the other end of the house for the few days following those steroids, because it was really so difficult. So, I think it’s really important to remember that you’ve got to talk to the whole family because the whole family is going to be experiencing that.

Ivy Altomare, MD: Yes. When you use prednisone up-front—because dexamethasone is a pulse that stops—is your intent to get them completely off prednisone? Or do you continue a low dose?

Keith R. McCrae, MD: Absolutely. I mean, is there any such thing as an acceptable dose of long-term steroid? That’s a good question, and I don’t really know.

Ivy Altomare, MD: In ITP.

Keith R. McCrae, MD: In ITP or in anything really. I think maybe 2.5 mg a day? But maybe even that’s too much. I would not consider anything more than that.

Terry Gernsheimer, MD: I will, sometimes, in a very refractory patient who—for whatever reason seems to be under control at 5 mg—allow that. They say it’s a physiologic dose these days. But it’s not without side effects. The patients will tell you, “I do feel differently.” But it’s usually tolerable. I’m not happy about it, but there are patients. Rather than go to something that’s very immunosuppressive, or that’s going to be something that we don’t know what the long-term effects may be, or that I think is not going to last, if I know they’re responding…
It’s interesting. You can sometimes see these patients who are fine at 5 mg. You try and take them down to 4 mg and boom, they relapse. Patients sometimes get very, very sensitive to these small changes in dose.

Ivy Altomare, MD: Then you have to go back and do the whole thing, or switch to another therapy.

Terry Gernsheimer, MD: Or at least come up a little bit. That’s that seesaw that we’re always trying to avoid because it’s so hard on the patient.

Ivy Altomare, MD: Absolutely.

Transcript Edited for Clarity 
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