2. Patient name : Mr.SG
Age : 42 years
Gender : Male
IP No: 282799
DOD:24/9/18
DOD:29/9/18
3. SUBJECTIVE
Chief complaints:
Accidentally detected as thrombocytopenia(3000 platelets only)
on routine blood check for diabetes screening.
No H/o fever , weakness , bleeding tendencies.
H/o dry cough on and off since 3 days , and no history of chest
pain, pain in abdomen.
Past Illness History:
Known case Hbs Ag +Ve detected in month of July 2018.
Not on medication, admitted for further management.
6. DRUG CHART
DRUG GENERIC DOSE ROA FREQ CATEGORY INDICATION
IV fluids
Normal
saline
NaCl 0.9% 75ml/hr IV STAT Electrolyte Fluid management
Tab. Azithral Azithromycine 500 mg PO OD for
5 days
Antibiotic Infection prophylaxis
Tab.Pantodac Pantoprazole 40 mg PO OD PPI Ulcer prophylaxis
Syp.Deletus
D
Dextro-
methorphan
Chlorphenir-
amine maleate
10 ml PO TID Cough
suppressant
Cough(dry)
Tab.Hepbest Tenofovir
alafenamide
25 mg PO OD Nucleotide
reverse
transcriptase
inhibitor
Hepatitis B
7. CHEMOTHERAPY DRUG CHART
Pre medications:
Inj. ZOFER 16 mg IV NS 100 ml over 1 hr
Inj. RANTAC 50 mg IV STAT
Inj. AVIL 1amp IV STAT
Chemo drugs:
Inj. RITUXIMAB 100 mg IV NS in 100 ml over 1 hour
5 drops -10 mins, 10 drops-10 mins,30 drops-10 mins,50
drops-10 mins,60 drops-10 mins
Inj. RITUXIMAB 500 mg IV in NS 500 ml over 3 hours
Post medication:
Inj. ZOFER 8 mg IV NS in 100 ml over 1 hour
8. GOALS OF THE THERAPY:
To increase the platelet levels
To prevent the activation of HBs Ag
To prevent further complications like bleeding
To improve the quality of life
9. ASSESSMENT
Day-1(25/9/18)
Mr.SG a 42YOM, known case of HBsAg +ve(inactive
carrier)admitted with thrombocytopenia(platelets of 3000 only),came
here for further management.
Ultrasound abdomen shows no significant abnormality detected.
On evaluation his labs showed platelets of 6000.
All other blood parameters within normal limits.
Initially supportive and symptomatic treatment was given.
IV Fluids NS 75ml/hr IV on flow was administered for fluid
management.
T.AZITHRAL 500 mg PO OD was given as antibiotic for infection
prophylaxis.
T.PANTODEC 40 mg PO OD was given for ulcer prophylaxis.
Syp.DELETUS-D 10 ml TID was given for dry cough.
10. 3 units of RDP transfused uneventfully@6 Pm.
This treatment is reserved for patients with very low platelet
counts and life or organ-, threatening bleeding.
Nil reaction(No bleeding tendencies, heamaturia and rashes)
Post transfusion vitals were stable.
DAY-2(26/9/18)
Platelet count reached 7000.
No fresh complaints.
Patient was feeling better.
Same drugs were continued.
11. DAY-3(27/9/18)
Patient was stable.
No bleeding tendency.
Platelet count 7000.
Patient was conscious and coherent.
Same drugs were continued.
3 more units of RDP was transfused.
(total 6 units of RDP).
12. DAY-4(28/9/18)
Patient family was clearly explained about the clinical
condition of the patient, disease of the patient (ITP).
And discussed about further plan of treatment with IV
steroids, its side effects(DM,Wt.gain) and IV
immunoglobulins and weekly once IV RITUXIMAB (4
doses). and if required splenectomy and also explained that
no treatment is guaranteeing a result.
Patient opted for weekly monoclonal antibodies
(RITUXIMAB, once a week for four weeks) as a
treatment option for ITP.`
Patient received 1st week 1 RITUXIMAB on 28/9/28 which
was tolerated well and uneventful.
Patient was stable and no new issues.
13. Rituximab is a chimeric monoclonal antibody which
effectively depletes B-lymphocytes after intravenous infusion
and has been used in the treatment of B-cell malignancies.
In the recent years, it has been used in the treatment of ITP
patients. Rituximab at a standard dose of 375 mg/m2 per
week for 4 weeks appears to be safe and effective, allowing
nearly 40% of patients with ITP to achieve a long-term
response and splenectomy-sparing effect.
The response to rituximab can be immediate or delayed.
Immediate responses can occur within 1-2 weeks after the
start of treatment, whereas delayed responses can occur up to
3 months later.
14. Patient is a known case of inactive HBsAg carrier state so
there is a chance of HBV reactivation with the use of
immunosuppressing agent RITUXIMAB because immune
system is essential in suppressing HBV viral replication.
Reactivation of hepatitis B is defined as an abrupt increase in
the pace of HBV replication, marked by a rise in HBV DNA
levels, in a person with previously stable or undetectable
levels; this is usually accompanied by liver injury (a
"hepatitis flare"), as shown by elevations in serum alanine
aminotransferase (ALT) levels.
In 2013, the US Food and Drug Administration (FDA) issued
a Drug Safety Communication titled, "Boxed Warning and
New Recommendations to Decrease Risk of Hepatitis B
Reactivation With the Immune-Suppressing and Anti-
cancer Drugs Ofatumumab and Rituximab.”
15. Reports of rituximab-associated HBV reactivation led to the
expanded box warning by the FDA, which strongly
recommended that all patients about to undergo B-cell–
depletion therapy be screened for HBV and that those
candidates who are found to be positive should be
considered for antiviral prophylaxis.
T.HEPBEST 25mg PO OD was started as antiviral
prophylaxis to reduce the chance of HBV reactivation.
The rate of HBV reactivation was lower in patients who
received antiviral prophylaxis than in those who did not (2%
vs 15%).
The appropriate duration of antiviral prophylaxis has not
been established. Extension of antiviral administration to 6-
12 months following completion of chemotherapy has been
suggested as a reasonable empiric strategy.
16. PLAN
DISEASE MONITORING:
Monitor platelet count(ITP)
Watch for bleeding tendencies.
Maintain MAP > 65mm Hg
HBV DNA levels
LFT’s
DRUG MONITORING :
RITUXIMAB:
High chances of reactivation of HBV during treatment with
RITUXIMAB.
So, start HEPBEST 25mg before starting RITUXIMAB to
prevent flare. Continue HEPBEST at-least 6 months after the
completion of RITUXIMAB course.
17. PATIENT COUNSELLING
Platelets are small cells in the blood that help it to clot, which
helps stop bleeding.
ITP is an autoimmune disease that attacks the body's own
platelets.
Platelet destruction in ITP causes normal platelet count to
drop below what it should be. If platelet count is too low,
bruising and severe bleeding may occur.
18. Symptoms may include:
Skin that bruises very easily
A skin rash of small red dots (petechiae)
Bleeding from any area of the body
Bleeding from the gums
Frequent nose bleeds that take a long time to stop
Internal bleeding
19. DISCHARGE MEDICATIONS
Tab.PAN 40 mg 1 tab to be taken orally before breakfast till
review, given for APD
Cap.BECOSULES 1cap to be taken orally after food till
review, given as MVT
T.HEPBEST(tafnat)25 mg 1tab to be taken orally after food
once daily a to continue,given for HBV
T.ZOFER 8 mg to be taken orally before food as and when
required , given for vomiting.
20. LIFE STYLE MODIFICATIONS
Avoid activities that could cause injury.
Eat a healthy diet with lots of fruits and vegetables,
especially leafy greens, to give your body the nutrients it
needs.
Use caution with over-the-counter medications. Non
prescription drugs such as aspirin and ibuprofen that can
impair platelet function.
