Triple Immunosuppressive Therapy in Patients with Chronic Resistant Immune Thrombocytopenic Purpura; a Case Series of 11 Patients.
Notice bibliographique
Résumé
Introduction: Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by destruction of opsonized platelets. The first-line therapy for adult patients with chronic ITP includes steroid, IVIG and anti-D. Splenectomy is reserved for patients not responding to the first-line therapy. However, approximately 20–30% of patients are resistant or relapsed after splenectomy. In this subgroup of patients, more aggressive immunosuppressive therapy is indicated. Methods: This is a case series of patients with chronic resistant ITP receiving multiple immunosuppressive treatments in a tertiary medical referral center. The diagnosis of ITP was established by excluding other thrombocytopenic diseases. Adult patients with chronic resistant ITP presenting with life threatening thrombocytopenia were selected for a therapeutic trial of immunosuppressive therapy. The therapy included azathioprine 100–200 mg daily; cyclosporine 100–200 mg daily; and mycophenolate 1–2 gm daily (triple immunosuppressive therapy). All of these patients failed 1st line therapy; splenectomy; and other immunosuppressive treatments. Patients with uncontrolled hypertension; impaired liver functions; impaired renal functions; and those who have not completed family were excluded from triple immunosuppressive therapy. A response to the therapy was defined as persistent platelet count above 30 without other concurrent treatments. When patients responded to the triple immunosuppressive therapy, the doses of the medications were gradually tapered to minimize the long-term side effects. Results: Since July of 2000, 11 patients with chronic resistant ITP have received triple immunosuppressive therapy for a variable duration (table 1). Five out of these 11 patients (45.5%) achieved a response within 4 to 6 weeks after the initiation of the treatments. One of the five patients eventually had a break-through during the tapering of triple immunosuppressive therapy. This patient was stabilized by further doses of IVIG and prednisone. The treatments were well tolerated. The most common side effects were mildly elevated blood pressure; and mildly impaired liver function tests. None of the patients suffered from serious side effects that resulted in termination of the treatments. Conclusion: Combining low-dose azathioprine, cyclosporin and mycophenolate can induce long-term remission in patients with chronic ITP resistant to steroid, IVIG, splenectomy and other immunosuppressive agents. This combination regimen is safe and well-tolerated. In adult patients with chronic resistant ITP, the immune dysfunction may need multiple immune blockades. Summary of Treatments ID Rx Prior to Triple Rx Concurrent Rx with Triple Rx Mean (mg OD) Mean (mg OD) Mean (gm OD) Response Duration of Triple Rx Triple Rx:Triple Immunosuppressive Therapy; PRD:Prednisone; DAN:Danazol; AnD:Anti-D; SPN:Splenectomy; VCR:Vincristine; CTX:Cyclophosphamide; LUF:Luflunomide 1 PRD, IVIG, DAN, SPN PRD, IVIG 66.7 63.8 1 No 77 2 PRD, IVIG, DAN, SPN, VCR 75 25 0.8 No 20 3 PRD, AnD, SPN, CTX PRD (taper) 75 50 0.9 Yes 91 4 PRD, SPN, DAN, CTX, LUF 100 100 2 No 106 5 PRD, IVIG, SPN, DAN PRD, IVIG 144.2 236.1 1.9 No 217 6 PRD, IVIG, SPN, DAN, VCR IVIG 91.7 120.5 1.4 No 406 7 PRD, IVIG, DAN, SPN, VCR PRD (taper) 140.9 156.6 1.6 Yes 296 8 PRD, IVIG, SPN, DAN, VCR DAN (taper) 150 100 2 Yes 1351 9 PRD, DAN, SPN, AnD, CTX IVIG 100 150 2 No 130 10 PRD, IVIG, SPN, VCR, CTX PRD (taper) 85.6 121.1 1.4 Yes 1456 11 PRD, DAN, IVIG, SPN, AnD IVIG, PRD (taper) 125.6 225 1.9 Yes 875
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,000 | 0,001 |
| Méta-épidémiologie (sens strict) | 0,002 | 0,001 |
| Méta-épidémiologie (sens large) | 0,001 | 0,001 |
| Bibliométrie | 0,002 | 0,001 |
| Études des sciences et des technologies | 0,002 | 0,001 |
| Communication savante | 0,001 | 0,001 |
| Science ouverte | 0,001 | 0,001 |
| Intégrité de la recherche | 0,002 | 0,001 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,003 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».