Use of Single- or Two-dose Pulse Methylprednisolone in the Treatment of Acute Immune Thrombocytopenic Purpura

Objectives: In immune thrombocytopenic purpura (ITP) treatment, the main goal is achieving the platelet level most rapidly for hemostasis. Pulse steroid therapy is common due to the rapid increase in the platelet count within the first 48 hours. Intravenous (IV) pulse steroid therapy is usually administered as a single methylprednisolone dose in the morning. Oral methylprednisolone is generally used as two divided doses due to its half-life, but there is no efficacy study for the use of pulse methylprednisolone therapy in two doses. In this study, we aimed to investigate whether the administration of single or double doses of pulse steroid treatment, which is the cheapest and most economical way to treat patients, differ in terms of platelet count increase rate.
Methods: The diagnosis of acute ITP was made based on the appropriate clinical, laboratory, and bone marrow findings and platelet count <100.000/mm3. All the patients were diagnosed with bone marrow aspiration, and they were admitted to the hospital. All patients with platelet counts below 20000/mm3 and those who had wet purpura or active bleeding were treated. Patients in need of treatment were randomly divided into two treatment groups with closed envelope method. The first group was given IV pulse methylprednisolone (30 mg/kg/day for three days and 20 mg/kg/day for four days) in the early morning hours. The second group received the same daily dosages in two divided doses. Hemoglobin, white blood cell, and platelet counts were evaluated before and on the first, second, third, fifth, and seventh days of treatment. To evaluate the rate of treatment response, platelet counts over 20.000/mm3, 50.000/mm3, and 100.000/mm3 obtained on the first, second, third, and seventh days of treatment were compared.
Results: Sixty patients with acute ITP diagnosis receiving pulse steroid therapy were included in the study. Platelet counts of the patients in group 2, who received pulse steroids in two doses, reached ≥20.000/mm³ on the second day [median, (2–3) days], ≥50.000/mm³ on the third day [median, (2.7–3.5) days], ≥100.000/mm³ on the fifth day [median, (3–5) days], which were significantly lower than the platelet counts of the patients in the first group on the third day [median, (2–5) days], fifth day [median, (4–7) days], and seventh day [median, (4–7) days], respectively (p<0.001, p<0.001, p=0.004).
Conclusion: This study shows that administration of IV pulse steroid therapy in two doses is more effective in increasing the platelet count in early period in patients with acute ITP, especially whose platelet count is less than 20.000/mm³, and when we prefer to increase the platelet counts rapidly due to risk of intracranial hemorrhage.

Akut Ýmmün Trombositopenik Purpura Tedavisinde Tek veya Ýki Doz Pulse Metilprednizolon Kullanýmý

Amaç: Akut Ýmmün Trombositopenik Purpura (ÝTP) tedavisinde hemostazý saðlayacak trombosit düzeyini en hýzlý þekilde elde etmek temel hedeftir ve bu amaçla ilk 48 saat içinde trombosit sayýsýnda hýzlý artýþ yapmasý nedeni ile intravenöz (ÝV) pulse steroid kullanýmý yaygýndýr. Ýntravenöz pulse steroid tedavisi, genellikle sabahlarý tek doz þekilde, metilprednizolon olarak uygulanmaktadýr. Yarýlanma ömrü nedeni ile oral tedavilerde genellikle iki dozda kullanýlan metilprednizolonun pulse tedavide iki dozda kullanýmýna dair bir etkinlik çalýþmasý bulunmamaktadýr. Bu çalýþmada, medikal tedavi gereken hastalarda, en etkili ve ekonomik yönden en ucuz tedavi þekli olan pulse steroid tedavisinin, tek veya iki dozda verilmesinin trombosit sayýsýný yükseltme hýzý açýsýndan farklý olup olmadýðýný araþtýrmayý amaçladýk.
Gereç ve Yöntem: Akut ITP tanýsý uygun klinik, laboratuvar ve kemik iliði bulgularý ile trombosit sayýsýnýn <100000/mm3 olmasý olarak belirlendi. Hastalarýn hepsi kemik iliði aspirasyonu ile taný aldýlar ve yatýrýlarak izlendiler. Trombosit sayýsý 20000/mm3 altýnda olan, ýslak purpura veya aktif kanama þikayeti bulunan tüm hastalara tedavi verildi. Tedavi uygulanacak hastalar rastgele olarak, iki tedavi grubuna ayrýldý. Birinci gruba iv pulse metilprednizolon (30 mg/kg/gün, üç gün ve 20 mg/kg/gün, dört gün) sabah erken saatte tek doz, ikinci gruba ayný toplam doz sabah-akþam (12 saatte bir) olacak þekilde ikiye bölünerek verildi. Pulse steroid tedavisinden önce ve tedavinin 1., 2., 3., 5., 7. gününde hemoglobin, beyaz küre ve trombosit sayýlarý incelendi ve her iki grubun tedaviye cevap hýzlarýný belirlemek için trombosit sayýsýnýn 20000/mm3, 50000/mm3 ve 100000/mm3’ün üzerine çýkma süreleri, tedavinin 1., 2., 3., 5. ve 7. günlerinde karþýlaþtýrýldý.
Bulgular: Çalýþmaya iv pulse steroid tedavisi alan toplam 60 ITP’li hasta dahil edildi. Ýki dozda pulse steroid alan 2. gruptaki hastalarýn trombosit düzeylerinin 20000/mm3 ve üzerine ulaþma süresi [ortanca 2 (2-3) gün], 50000/mm3 ve üzerine ulaþma süresi [ortanca 3 (2.7-3.5) gün], 100000/mm3 ve üzerine ulaþma süresi [ortanca 5 (3-5) gün], tek doz alan 1. gruptaki hastalardan [sýrasýyla ortanca 3 (2-5) gün, ortanca 5 (4-7) gün, ortanca 7 (4-7) gün] anlamlý olarak daha kýsaydý (sýrasýyla p<0.001, p<0.001, p=0.004).
Sonuç: Bu çalýþma, akut ÝTP’de trombosit sayýsýnýn 20000/mm3’den düþük ve intrakranial kanama riski olan, trombosit sayýsýný hýzla yükseltmek istediðimiz hastalarda, iv pulse steroid tedavisinin ilacýn yarýlanma ömrü dikkate alýnarak, oral tedavide olduðu gibi iki dozda verilmesinin trombosit sayýsýnýn erken dönemde daha hýzlý yükselmesinde etkili olduðunu göstermektedir.