Comparison of conventional dose steroid treatment and high dose steroid treatment as run-in regime for splenectomy in immune thrombocytopenic purpura (ITP)

Updated international consensus report on the investigation and management of primary immune thrombocytopenia

“…There are multiple small trials on prednisone and dexamethasone with various outcomes. [63][64][65][66][67][68][69] In a meta-analysis of high-dose dexamethasone vs prednisone, there was no difference in platelet count response at 6 months; however, high-dose dexamethasone led to faster responses without additional toxicity. 70 Acyclovir may be given with dexamethasone to minimize the potential for herpes virus reactivation (evidence level IV).…”

“…65,66 Romiplostim and eltrombopag are approved by the US Food and Drug Administration (FDA) and the European Medicines Agency for the treatment of adults (and children, see below) with chronic ITP who have had an insufficient response to corticosteroids, Igs, or splenectomy. [65][66][67][68] Avatrombopag has only recently (27 June 2019) been approved by the FDA for adult patients with chronic ITP who have had an insufficient response to a previous treatment. 118 Romiplostim is administered at an initial dose of 1 mg/kg per week subcutaneously, with dose adjustments up to 10 mg/kg per week according to platelet response.…”

“…65,67 Eltrombopag is administered at an initial dose of 25 or 50 mg/d, depending on patient age, Asian ancestry, and presence of hepatic impairment, up to a maximum of 75 mg/d. 66,68 Avatrombopag is administered initially as 1 20-mg pill daily with dose increases up to 40 mg/d, depending on subsequent platelet counts. 118 Due to their mechanism of action, TPO-RAs are considered a maintenance therapy.…”

“…191 Ideally, platelet counts should be increased if possible to .50 3 10 9 /L prior to the procedure to reduce postsurgical complications (evidence level IV). Steroids, IVIg, TPO-RAs, 66,192 or other effective therapy may be used to increase platelet counts prior to splenectomy.…”

Guideline on immune thrombocytopenia in adults: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. Project guidelines: Associação Médica Brasileira – 2018

“…In a prospective study involving 30 patients, a platelet count >50 × 10 9 /L was achieved in 27% of adult patients with ITP in response to high doses of methylprednisolone (30 mg/kg/day orally for seven days); 90% of these patients presented an increase in the platelet count >50 × 10 9 /L for two to seven days with peak response (90%) on the seventh day 38 (C). In a retrospective case analysis of patients who received corticosteroids before splenectomy, the rates of increase in platelet counts evaluated on Days 3, 5, and 7 after treatment were significantly higher with the use of high-dose corticosteroids (30 mg/kg/day of methylprednisolone) when compared to those taking conventional doses (1 mg/kg/day methylprednisolone; p -value < 0.05), although platelet counts had been similar in both groups 39 (C). In an open-label study, 80% of adult patients with ITP responded to the use of high doses of methylprednisolone (30 mg/kg/day orally) compared to 53% in patients treated with conventional doses (1 mg/kg/day of prednisolone).…”