Refractory ITP

PONLAPAT ROJNUCKARIN, M.D. PH.D. CHULALONGKORN UNIVERSITY How do I treat refractory ITP

Time to responses to initial treatments Blood. 2009;113:2386

Definition of Refractory ITP BJH 2008; 143, 16

Conditions to be excluded ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],BJH 2008; 143, 16

Aim of therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Initial treatment ,[object Object],[object Object],[object Object],[object Object],[object Object]

P=.016 P=.046 Praituan, JTH 2009; 7: 1036

Prednisolone tapering ,[object Object],[object Object],[object Object],[object Object]

Splenectomy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Kojouri K et al, Blood 2004

Splenectomy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Kojouri K et al, Blood 2004

Refractory ITP denied splenectomy. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],McMillan

Pulse Dexamethasone ,[object Object],[object Object],[object Object],[object Object],N Engl J Med 1994 ;330:1560-4

Dapsone ,[object Object],[object Object],[object Object],[object Object],[object Object],Br J Haematol. 1997;97:336-9.

Colchicine ,[object Object],[object Object],[object Object],[object Object],Arch Intern Med. 1984; 144:2198

Danazol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ahn YS. Acta Haematol. 1990;84: 122-9 Maloisel F. Am J Med. 2004; 116: 590-4

Rituximab ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Br J Haematol. 2004 Apr;125(2):232-9.

Outcomes of Rituximab Blood. 2008;112:999

Immunosuppressive agents ,[object Object],[object Object],[object Object],[object Object],[object Object],Ann Intern Med. 2004; 140: 112-20

Cyclophosphamide ,[object Object],[object Object],[object Object],[object Object],[object Object]

Azathioprine ,[object Object],[object Object],[object Object],[object Object],*Br J Clin Pharm 2004; 58: 66

Combination chemotherapy ,[object Object],[object Object],[object Object],[object Object],[object Object],N Engl J Med 1993;328:1226-9

Steroid refractory or dependence ITP Alternatives with Low side effect Pulse Dexamethasone Colchicine, Dapsone, Danazol, Rituximab, Combinations Splenectomy Second line: Cyclophosphamide, Azathioprine, MMF, CSP Third line: Combination chemotherapy, BMT, Experimental Rx

Control of TPO Levels NEJM 1998; 339: 746

Eltrombopag vs. placebo Lancet 2009; 373: 641

Romiplostim: Long-term response Blood 2009; 113: 2161

Thrombopoietic agents ,[object Object],[object Object],[object Object],[object Object]

Patients with major bleeding ,[object Object],[object Object],[object Object],[object Object]

Massive platelet transfusion (N=10) 3-7 Apheresis units Thromb Haemost 2008; 100: 762

Take home message ,[object Object],[object Object],[object Object]

Refractory ITP

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