Most patients with immune thrombocytopenia (ITP) respond to first line therapy. Rarely there are patients who remain with very low platelet counts despite administration of intravenous immune globulin (IVIG). A protocol at our institution (colloquially known as the "platelet boilermaker") for these refractory patients is to give 1 gram/kg of IVIG continuously over 24 hours concurrent with one unit of plateletpheresis product given over 6 hours repeated times 4. We examined the charts of 10 patients in the past 6 years who have received combined therapy. 70% were male; all were refractory to steroids and IVIG. Results are in table:

Abstract 5023. Table
AgeGenderDiseaseBleedingPlts PreDay +1Day+2Day+3Results
65 M Evans GIB 1 110 5 10 Stopped bleeding 
59 M ITP, CLL Bruising 3 6 5 6 No response 
34 F ITP Pregnancy 25 83 175 150 Delivered 
81 F ITP Epistaxis 15 38 41 67 Splenectomy day +1 
23 F ITP Epistaxis 5 52 165  Splenectomy day +1 
64 M DITP Epistaxis, ruising 2 52 42 7 Stopped bleeding 
89 M ITP Epistaxis 4 65 50 46 Splenectomy day +1 
57 M ITP Bruising 9 58 69 46 Splenectomy day +1 
28 M ITP ICH 14 133 325 326 No extension 
78 M ITP GIB 27 35 44 98 Splenectomy day +1 
AgeGenderDiseaseBleedingPlts PreDay +1Day+2Day+3Results
65 M Evans GIB 1 110 5 10 Stopped bleeding 
59 M ITP, CLL Bruising 3 6 5 6 No response 
34 F ITP Pregnancy 25 83 175 150 Delivered 
81 F ITP Epistaxis 15 38 41 67 Splenectomy day +1 
23 F ITP Epistaxis 5 52 165  Splenectomy day +1 
64 M DITP Epistaxis, ruising 2 52 42 7 Stopped bleeding 
89 M ITP Epistaxis 4 65 50 46 Splenectomy day +1 
57 M ITP Bruising 9 58 69 46 Splenectomy day +1 
28 M ITP ICH 14 133 325 326 No extension 
78 M ITP GIB 27 35 44 98 Splenectomy day +1 
View Large

Plt = platelet count x 109/L

DITP = drug induced ITP, ICH - intracranial hemorrhage. GIB - gastrointestinal bleeding

9/10 patients had at least a transient rise in platelets greater than 30x109/L - 5 patients underwent emergent splenectomy with no bleeding complications. The patient with ICH had no extension and while the other patients who responded had cessation of bleeding. In summary for patients with IVIG refractory ITP who either have bleeding or need urgent splenectomy combined continuous platelets/IVIG is a therapeutic option.

Disclosures

Off Label Use: profilnine - warfarin reversal rVIIa - warfarin reversal.

Topics:
blood platelets, immunoglobulins, intravenous, inosine triphosphate, platelet count measurement, purpura, thrombocytopenic, idiopathic, splenectomy, hemorrhage, epistaxis, contusions, warfarin

Author notes

*

Asterisk with author names denotes non-ASH members.

© 2014 by The American Society of Hematology
2014
Sign in via your Institution