Can glucocorticoid therapy be repeated in Immune Thrombocytopenic Purpura (ITP) if the condition recurs after a prolonged period of remission?

From the Guidelines

Yes, glucocorticoid therapy can be repeated in patients with immune thrombocytopenia (ITP) that relapses after a period of remission. The standard approach typically involves prednisone at 1-2 mg/kg/day for 2-4 weeks, followed by a slow taper over several weeks. Alternatively, high-dose dexamethasone at 40 mg daily for 4 days (repeated for 1-3 cycles if needed) may be used. When restarting therapy, it's essential to monitor for steroid-related side effects, especially if the patient has had prolonged or repeated courses. These side effects include hyperglycemia, weight gain, mood changes, insomnia, increased infection risk, osteoporosis, and adrenal suppression. Patients should receive appropriate prophylaxis such as calcium/vitamin D supplementation and possibly proton pump inhibitors. The effectiveness of repeated glucocorticoid therapy may diminish with subsequent relapses, and some patients may become steroid-dependent or refractory. In these cases, second-line treatments like rituximab, thrombopoietin receptor agonists (eltrombopag, romiplostim), or splenectomy might need consideration. The decision to repeat glucocorticoid therapy should be individualized based on the patient's previous response, duration of remission, side effect profile, and comorbidities, as suggested by recent studies 1.

Some key points to consider when deciding to repeat glucocorticoid therapy include:

• The patient's previous response to glucocorticoid therapy
• The duration of remission
• The side effect profile
• The presence of comorbidities
• The potential for steroid dependence or refractoriness
• The availability of second-line treatment options

It's also important to note that the use of thrombopoietin receptor agonists (TPO-RAs) has been shown to be effective in achieving sustained responses in some patients with ITP, and may be considered as an alternative to repeated glucocorticoid therapy 1. However, the decision to use TPO-RAs should be individualized based on the patient's specific needs and circumstances.

In terms of specific treatment regimens, the study by Mazzucconi et al. (2017) suggested that achieving complete response (CR) is a positive prognostic factor for achieving a subsequent durable response, which can, in turn, be prognostically correlated with achieving a sustained response 1. Additionally, the study by Newland et al. reported stable responses after discontinuation of a TPO-RA, with a median follow-up of 2.8 years (0.5-9.2 years) 1.

Overall, the decision to repeat glucocorticoid therapy in patients with ITP should be based on a careful consideration of the potential benefits and risks, as well as the individual patient's needs and circumstances.

From the Research

Repeating Glucocorticoid Therapy in ITP

• There is evidence to suggest that glucocorticoid therapy can be repeated in patients with immune thrombocytopenia (ITP) if the condition returns after a long period of time 2, 3.
• A study published in 2021 found that 3 out of 22 patients who needed a second line treatment received a second course of steroid, indicating that repeat glucocorticoid therapy is a viable option for some patients 2.
• However, the same study also notes that second line options for ITP treatment include splenectomy, thrombopoietin-receptor agonists (TPO-RAs), rituximab, and intravenous immunoglobulin, suggesting that repeat glucocorticoid therapy may not always be the first choice 2.
• Another study published in 2019 found that the addition of a glucocorticoid to a TPO-RA can promote response in refractory ITP patients, suggesting that combination therapy may be an option for patients who do not respond to repeat glucocorticoid therapy alone 4.
• A 2021 review of treatment options for adult patients with ITP who are unresponsive to or dependent on corticosteroid treatment notes that medical therapies such as TPO-RAs and rituximab are recommended, and that splenectomy should be delayed for at least 12 to 24 months to allow for more patients to achieve remission on medical therapies 3.

Treatment Options for ITP

• The treatment options for ITP include glucocorticoids, splenectomy, TPO-RAs, rituximab, and intravenous immunoglobulin 2, 3.
• A study published in 2024 found that eltrombopag, a TPO-RA, can induce a sustained response off-treatment in adult patients with ITP after first-line corticosteroid failure, with a median sustained response off-treatment duration of ~8 months until Month 12 5.
• Combination therapy with low dose glucocorticoid and a TPO-RA may be an option for patients unresponsive to a TPO-RA alone 4.
• A case report published in 2013 found that simultaneous use of romiplostin, eltrombopag, and prednisone was successful in severe thrombocytopenia of Evans syndrome refractory to hydrocortisone, splenectomy, intravenous IgG, and rituximab, suggesting that combined treatments may be more effective than sequential monotherapies 6.