Therapeutic Management of Immune Thrombocytopenia Case 2 - Episode 6
James B. Bussel, MD:The primary second-line treatments in use in the United States, western Europe, and other parts of the world, including Japan, are a thrombopoietin receptor agonist, or a TPO receptor agonist, and rituximab-based therapy. In regard to a rituximab-based therapy, we would be particularly likely to use it, and this is my experience, though we have published data inHaematologica and theAmerican Journal of Hematologyin the past 5 years substantiating that. One person we would use it in, which is experiential and not data driven, is somebody who may be at risk for having additional autoimmune disease. For example, if there’s a patient with ITP who has a high ANA (antinuclear antibody), then that might be somebody you’d be a little more inclined to use a treatment that has a general immunosuppressive mechanism rather than one that just works on the platelets.
We believe, based on published data, that using rituximab plus 3 cycles of dexamethasone would be particularly effective if used in this woman when she’s less than 1 year from diagnosis. However, if she has already received 3 courses of prednisone, unless she’s responding very well to them, she’s likely not to want to now additionally take 3 cycles of dexamethasone. Even if she agrees to do that with the idea that she’s hoping for cure, as are all patients, it would likely be that she would hate the first cycle of dexamethasone so much that she might not want to persist. Whether other treatments could be substituted for dexamethasone is a subject of ongoing investigation. The idea of combining dexamethasone with rituximab is to attack the plasma cells as well as the B cells, which rituximab attacks.
Transcript edited for clarity.
Case: A 44-year-old woman presenting with reddish-purple rash on lower legs