Optimizing first-line therapy in ITP: selection and treatment goals


Morey Blinder, MD: Let’s think about the goals of first-line treatment of ITP. What factors go into the choice of treatment? What are your definitions of remission and disease control, and what discussions do you have about what to expect before initiating first-line therapy? Danny, do you want to start?

Daniel Landau, MD: Sure. Thanks. I think a lot of my conversations with patients will have to do with the severity of their presentation, whether they have extensive purpura, bleeding events, or whether it’s a potentially milder lab abnormality with no other manifestations. . One thing that I’ve noticed, and has been described in a few articles, is that a number of people who have very active ITP don’t feel well in general. This manifested itself in days of school missed, days of work missed, either because of the disease itself or a complication of it. There are going to be patient-dependent factors that go into treatment decisions. In many articles, especially with TPO doctors, success was defined as a platelet count above 50. It was relatively long-lasting. That’s one of the goals, to increase platelets, but especially with first-line therapy, I think most of us expect platelets to normalize and hopefully stay normal for some time. Unfortunately, some of these first-line therapies, in general, are very steroid-intensive. I can tell you that my patients are very angry with me when I have to undergo very intensive steroid therapy. There’s a lot of explanations for why I give them insomnia and weight gain and everything that goes with it.

Morey Blinder, MD: I think steroids are really part of the first line treatment for the majority of patients. Do any of you 3 use a lot of anti-D therapy in the initial management of ITP?

Daniel Landau, MD: Not recently.

Cindy Neunert, MD: We probably outnumber our use in the pediatric population. We use anti-D in the pediatric population. There were concerns about adverse effects, especially with the FDA black box warning and associated DIC [disseminated intravascular coagulation]. It becomes difficult because the children for whom you want a rapid anti-D immunoglobulin platelet count response are the same children who come in and have heavy bleeding, who often already have low hemoglobin and you really don’t want to risk another 2 gram decline. We will use anti-D in the right context in an Rh positive patient with a spleen.

Transcript edited for clarity.

Martin E. Berry