Пульс-терапия дексаметазоном для лечения иммунной тромбоцитопении (ИТП)

[Dr.Vad]

В сегодняшнем номере NEJM опубликованы данные на основе 125 пациентов, что 4-х дневный прием дексаметазона в дозе 40 мг внутрь у 85% (106) пациентов вызвал положительный эффект в виде подьема тромбоцитов с 12 до не менее 20 тыс. на третий и до 101+/-53 тыс. к 7 дню лечения. Из них у половины (53) ремиссия отмечалась более 6 мес, в то время как у другой половины рецидив произошел преимущественно в первые 3 мес., повышение тромбоцитов менее 90 000 на 10-j день указывало на высокий риск раннего рецидива.

Более подробно здесь:

N Eng J Med 2003;349:831-6.
Initial Treatment of Immune Thrombocytopenic Purpura with High-Dose Dexamethasone
Yunfeng Cheng, M.D., Raymond S.M. Wong, M.B., Ch.B., Yannie O.Y. Soo, M.B., Ch.B., Chung Hin Chui, Ph.D., Fung Yi Lau, Ph.D., Natalie P.H. Chan, M.B., Ch.B., Wai Shan Wong, M.B., Ch.B., and Gregory Cheng, M.D., Ph.D.

More than 40% of the adult patients treated with a single course of high-dose oral dexamethasone for immune thrombocytopenic purpurea achieved long-term remission according to research conducted in Hong Kong.
A good initial response was achieved in 85% of the patients treated reports Gregory Cheng, MD, PhD, of Chinese University of Hong Kong and colleagues. "This response rate is similar to the rate reported with conventional corticosteroid therapy," the authors note.
Dr. Cheng's group treated 85 female and 40 male patients, ranging in age from 17 to 84 years, with newly diagnosed immune thrombocytopenic purpurea with 40 mg per day oral dexamethasone for 4 consecutive days. Prior to treatment the mean platelet count in the 125 patients was 12,200 per cubic millimetre. The median follow up was 30.5 months.
A good initial response -- defined as a platelet count increase of at least 30,000 per cubic millimetre, cessation of bleeding, and a platelet count of more than 50,000 per cubic millimetre by the 10th day after initiation of treatment -- was achieved in 106 (85%) of the patients. Among these, 53 patients (50%) had a sustained platelet count higher than 50,000 per cubic millimetre after a single course of dexamethasone and, during 2 to 5 years of follow up, required no further treatment. Of the other patients, 50 had a relapse within 3 months and 3 relapsed within 6 months, but all had a platelet count of more than 50,000 per cubic millimetre within 1 week after a second course of high-dose dexamethasone. Relapsed patients received maintenance therapy of daily prednisone to maintain platelet counts higher than 50,000 per cubic millimetre.
The researchers found that a platelet count of less than 90,000 per cubic millimetre 10 days after initiation of treatment was associated with a relapse rate of 70%. Conversely, patients with a platelet count of more than 120,000 per cubic millimetre at day 10 had a 20% risk of relapse.
Overall, 45 patients - 19 who did not have an initial response and 26 who had a relapse - required splenectomy, intravenous immune globulin, anti-D immune globulin, danazol, vinca alkaloids, alkylating agents, or cyclosporine. No patients reported side effects severe enough to cease dexamethasone treatment.
Treatment with various corticosteroid regimens may result in a sustained response in about 30% to 40% of adults with immune thrombocytopenic purpurea, the researchers note. The use of high-dose dexamethasone "may identify this group of patients who are likely to have a response and expose them to only a short course of corticosteroid therapy," Dr. Cheng and colleagues conclude.