Important considerations regarding the selection of corticosteroids or intravenous immunoglobulin as frontline treatment for immune thrombocytopenia, especially during the COVID-19 pandemic.
Bhavesh Shah, RPh, BCOP: I wanted to mention a little more about steroids. We know that these ITP [immune thrombocytopenia] patients will be on steroids, sometimes for a long time. People don’t realize the long-term impact of steroids that these patients have. I came across a patient who was on steroids for over 18 years, and they had to come off because of the adverse effects that they were experiencing. Unfortunately, adverse effects are the biggest downfall of steroids; patients have developed diabetes, osteoporosis, cataracts, hypertension, and so on. There are so many adverse effects that steroids cause.
I am curious to know your perspectives. There are 2 different steroids we can use, prednisone and dexamethasone. What’s preferred at each of your institutions when managing ITP patients?
David Hughes, PharmD, BCOP: Both have advantages and disadvantages. In our practice at Boston Medical Center, we tend to prefer dexamethasone. It allows for a shorter burst; you can give a 40-mg dose over 4 days and then stop. The downside with prednisone is that when you give someone 1 mg/kg/day, you eventually need to taper that. Unfortunately, we’ve also run into cases in the clinic, where it’s hard to taper a patient, not only from an adverse-effect profile but also a rebound effect from their platelets. We’ve had patients we’ve tried to taper off prednisone, and their platelets end up plummeting. Early on in the disease, when looking to see a patient’s response to steroids, dexamethasone, at least at our institute, tends to be the go-to steroid.
Ali McBride, PharmD, MS, BCOP, FASHP, FAzPA: I agree in regard to dexamethasone. Dexamethasone is the go-to. In the initial New England Journal of Medicine study, where patients were given dexamethasone in a 4-day burst as initial treatment, we constantly use that. Dexamethasone also has the advantage of stimulation tests, which tests for the condition Cushing syndrome. We are worried about some of those long-term utilization pieces, which can cause chronic effect. Again, Bhavesh, you stated it best, a patient on steroids for 18 years could develop Cushing syndrome. They can develop other issues such as diabetes and uncontrolled sugars. In these cases, that stimulation test can also address any adrenal issues that may hit the HPA [hypothalamic pituitary adrenal] axis because of long-term steroid use. Dexamethasone is used, but we also have patients on prednisone, although dexamethasone is the preferred treatment. It’s always a good discussion, more academic, based on what we do, and the physician who was trained. From my standpoint, there’s not too much of a difference, but in the majority of cases we are going to use a dexamethasone-based treatment.
Bhavesh Shah, RPh, BCOP: That’s great feedback. It depends on the provider that’s treating the patient. As you had mentioned, Dave, dexamethasone offers that short burst that you can give a patient and have a fast response sometimes. But 40 mg of dexamethasone is also not the most tolerated dose.
I want to shift gears to COVID-19 [coronavirus disease 2019]. As David had mentioned, COVID-19 has had an impact on the treatments for ITP. I’m thinking about IVIg [intravenous immunoglobulin] because plasma is the resource used to make IVIg. We know that a lot of the plasma is actually being utilized for treating COVID-19 patients. If we think about many of these states that have significant surges or stay-home orders, you can imagine that people are not going to donate plasma during these times. Also, many of the plasma donation centers, about 50% of them, are around the borders of Texas. There’s definitely a concern from providers that we may potentially see a shortage of IVIg because we might not be able to get enough raw material because of COVID-19. In addition, with the EUA [emergency use authorization] approving convalescent plasma for treatment of COVID-19, there may also be a limit on what’s going toward manufacturing. Keep that in mind as providers are using IVIg judiciously at your institution to make sure that there is appropriate guidelines and management of the disease.