Therapeutic Management of Immune Thrombocytopenia Case 1 - Episode 4
James B. Bussel, MD:It’s a very complicated issue about how long to go with first-line treatment. If, for example, you use high-dose dexamethasone, then you can give 4-day cycles 3 or 4 times even. But if that’s not working, then most people would change to something else after that, and depending how long each cycle induces the platelet count to be good, that could be 2 months or 6 months or 12 months. If one is using prednisone, that’s a little more complicated. On the one hand, when you use prednisone, pretty much everybody knows by now that continuing a significant dose of prednisone, which might be considered to be 10 mg a day or more, is not optimal for general health. There are certainly more different side effects of prednisone that are pretty well known than I could name using one of my fingers for each one, and my hands at least in terms of numbers of fingers are anatomically normal.
But if it would turn out that what might happen is prednisone is given at a high dose, as it was in this woman, she takes a milligram per kilogram for 2 to 4 weeks, her platelets hypothetically go up nicely, then she is tapered off and either manages to get off prednisone or gets to a very low dose and her platelets crash. If whoever is managing her does not want to admit her to the hospital and/or wants to admit her to the hospital but only for a day or two and maybe gives her IVIg then, it is very hard to get rapid approval for other agents such as rituximab or a thrombopoietin receptor agonist. So, there’s a certain amount again in the United States of an insurance trap whereby it’s a lot easier to continue the prednisone.
And even if you try to plan ahead and say, “Well, if and when the count falls again, I’ll be set to go with whatever other treatment I want,” that may not work with insurance. If she’s getting a first or second course of prednisone, the count may be good, and then the insurance company may not agree to use rituximab or a TPO receptor agonist because they’ll say, “Well, it’s not justified. The platelets are 60,000,” and then there’s sort of a catch-22 that’s involved. In principle, you wouldn’t give more than 1 course of prednisone, especially since the chances that that will result in a long-term remission are well under 10%, so the side effects seem to outweigh the benefit there given that there are other treatments available. But insurance may make that more difficult than one would anticipate.
Transcript edited for clarity.
Case: A 48-year-old woman presenting with unusual bruising