Management of major bleeds in patients with immune thrombocytopenia.

BACKGROUND: A standard approach to the recognition and management of major bleeding in immune thrombocytopenia (ITP) is lacking. METHODS: Retrospective cohort study of ITP patients presenting to the emergency department (ED) with severe thrombocytopenia (platelet count <20 × 109 /L) and bleeding in four academic hospitals from 2008 to 2016. We defined a major ITP bleed as a bleed at a critical site or causing hemodynamic instability. RESULTS: We identified 112 ITP patients (n = 141 visits) who presented to the ED with platelets <20 × 109 /L and bleeding. Twenty--nine patients (26%) had 32 ED visits with major bleeds. Risk factors for major bleeds were older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.06), male sex (OR 3.25, 95% CI 1.22-9.32), and more prior ITP therapies (OR 1.42, 95% CI 1.10-1.87). Acute treatment of major bleeds required a median of three treatments (interquartile range [IQR] 2--4), which included intravenous immune globulin (91% of visits), corticosteroids (78% of visits), and platelet transfusions (75% of visits). Three patients (10%) died, nine (31%) developed recurrent bleeds, one (3%) developed arterial thrombosis, and one (3%) had permanent neurological disability. Six patients presented with minor bleeding and subsequently developed a major bleed after a median of 2 days (IQR 1-3). All six patients had oral purpura and four of six had gross hematuria preceding the major bleed. CONCLUSIONS: Major ITP bleeds are associated with significant morbidity and mortality. Oral purpura and hematuria often preceded major bleeds. Further research is needed to refine the definition of a major ITP bleed and develop evidence-based treatment strategies.

Clinical Observation of Therapy of Soothing Liver and Clearing Heat for Treatment of Glucocorticoid-dependent Adult Chronic Idiopathic Thrombocytopenic Purpura / 广州中医药大学学报

Objective To observe the clinical efficacy of therapy of soothing liver and clearing heat for the treatment of glucocorticoid-dependent adult chronic idiopathic thrombocytopenic purpura ( CITP) . Methods Thirty-two qualified glucocorticoid-dependent adult CITP patients with the syndrome of interior heat due to liver stagnation and liver failing in storing blood were enrolled into the study. Based on the primary regimen, the patients were additionally given Shugan Qingre Recipe ( mainly composed of Rhizoma Dioscoreae, Radix Bupleuri, Radix Paeoniae Alba, Radix Rehmanniae, Cortex Moutan, Herba Artemisiae Scopariae, Poria, Fructus Corni, Fructus Lycii, Herba Agrimoniae , Radix Rubiae, Radix Glycyrrhizae) for 3 months (12 weeks), 2 doses a day, decocting with water for oral use. Before and after treatment, the changes of Chinese medical syndrome scores and the laboratory indexes were investigated. Results (1) After treatment for 12 weeks, 10 cases were markedly effective, 16 effective , 5 improved, one ineffective, and the total effective rate arrived to 81.25%. ( 2) After treatment for one month, the scores of traditional Chinese medical syndrome were not improved ( P>0.05 compared with those before treatment) . At the end of 2-month and 3-month treatment course, the scores were improved obviously compared with those before treatment, the difference being significant (P<0.05 or P<0.01) . (3) Platelet count rose up from the fourth week of treatment, and the difference was significant compared with that before treatment ( P<0.01) . Conclusion Therapy of soothing liver and clearing heat shows certain ef fect for the treatment of glucocorticoid-dependent adult chronic CITP, and has satisfactory clinical prospect.

Rituximab treatment for adults with steroid-resistant idiopathic thrombocytopenic purpura / 中华内科杂志

Objective To investigate the efficacy and safety as well as the effects of rituximab on B-lymphocytes and anti-platelet glycoprotein-specific antibodies,in patients with steroid-resistant idiopathic thrombocytopenic purpura(ITP).Methods Twelve steroid-resistant ITP patients,16 to 54 years old,received intravenous rituximab at the dose of 375 mg/m2 once-weekly for 4 weeks.Lab studies included CBC,serum concentrations of IgG,IgM and IgA.CD+3,CD+4,CD+8,CD+19,CD+20 cell numbers were assayed by flow cytometry and anti-platelet glycoprotein-specific antibodies(GP Ⅱ b/Ⅲ a,GP Ⅰ b/Ⅸ)were assayed by monoclonal antibody-specific immobilisation of platelet antigens prior to and following rituximab therapy.Results A complete response(platelet counts ≥100×109/L)was observed in 4 cases,a partial response (platelet counts between 50 and 100×109/L)in 3 cases,a minor response(platelet counts between 30 and 50×109/L)in 2 cases,and non response(platelet counts＜30×109/L)in 3 cases.Responses were sustained 0.5 to 12 months(median 5 months).After 4 weeks of rituximab therapy,anti-platelet glycoprotein-specific antibodies(GP Ⅱ b/Ⅲ a,GP Ⅰ b/Ⅸ)disappeared except one NR patient and CD+19/CD+20 cells were almost depleted in all patients(295.0±86.4)×106/L vs(4.1±2.2)×106/L(P＜0.01).As expected,the T cell counts,and the serum concentrations of IgG,IgM and IgA were not changed after therapy.No severe side effects were observed.Conclusion Rituximab may be an effective and safe treatment for adults with steroid-resistant ITP.