Therapeutic Management of Immune Thrombocytopenia Case 2 - Episode 3
James B. Bussel, MD:Given all the drawbacks that there can be with ITP treatment, especially with prednisone, what would have happened if she had been left alone and not treated? Typically, even if it’s not well recognized even by the patient who thinks, “Oh yeah, I feel lousy every day but that’s just me,” or by the physician who doesn’t think of ITP as associated with impaired health-related quality of life, these effects can be important in an untreated patient, completely separately from any issues of what is the platelet count and what is the risk of bleeding.
Depending on a given count as to how much bleeding she has and what else is going on, it may make it socially difficult for her to go to work or see people outside the house if her menses are very heavy for the week or so that that may be occurring. If she takes, as many people would recommend, oral contraceptives, if she uses those that contain estrogen, there are women in whom that will make their ITP worse. And estrogen is well known to foster autoimmune disease. On the other hand, she could use just progesterone either with daily Provera (medroxyprogesterone acetate) or Depo-Provera shots.
Although these would work in general to stop her heavy menses, she may have mild intermittent bleeding, and many people do not like the effects of that, especially over time. So, this is also not an optimal approach. In that sense, increasing the platelet count will usually be the best way to reduce heavy menses if that’s a problem, which it sounds as if it may be in her. Other options such as using Amicar, or epsilon aminocaproic acid, or Cyklokapron, which inhibit fibrinolysis, may also lessen the periods. But ITP itself is a prothrombotic disease, at least mildly, so there is an extra risk of clotting when these are used, as there may be with oral contraceptive pills.
So, it gets to be a complicated issue. If the patient feels good, if the heavy mensesas in this case—are not severe, and if the patient prefers no treatment and is not otherwise having important bleeding and no risks of either her activities, her access to medical care, etc, then it may be OK to leave her without treatment for a while and see if she gets better on her own. But almost everybody with platelets less than 30,000, and especially less than 20,000, is going to require treatment usually starting at diagnosis.
Transcript edited for clarity.
Case: A 44-year-old woman presenting with reddish-purple rash on lower legs