Correspondence
High-Dose Dexamethasone as Initial Treatment for Immune Thrombocytopenic Purpura
N Engl J Med 2003; 349:2267-2268December 4, 2003
- Article
To the Editor:
Cheng et al. (Aug. 28 issue)1 conclude from their uncontrolled study that a short course of high-dose dexamethasone (40 mg per day for four consecutive days) is an effective treatment for adults with newly diagnosed immune thrombocytopenic purpura. Our prospective, controlled study involving 122 adults with newly diagnosed immune thrombocytopenic purpura and a mean platelet count of less than 10,000 per cubic millimeter clearly demonstrated that intravenous immune globulin (0.7 g per kilogram of body weight per day for three days) was more effective in the short term than high-dose methylprednisolone (15 mg per kilogram per day for three days).2 We emphasize that the corticosteroid dose we used was three times the dose used by Cheng et al. For this reason, we believe that intravenous immune globulin should be the initial treatment for adults with severe immune thrombocytopenic purpura.
We also believe that the high percentage of patients who had a long-term response in the study by Cheng et al. (42 percent) could reflect the natural history of immune thrombocytopenic purpura in adults rather than an effect of high-dose corticosteroids. In our study, the remission rate at one year did not differ according to the initial treatment (intravenous immune globulin alone or with oral prednisone for 18 days or high-dose methylprednisolone alone or with oral prednisone for 18 days) and was similar to the remission rate reported by Cheng et al. These results suggest that intravenous immune globulin and corticosteroids do not modify the natural history of immune thrombocytopenic purpura in adults and support the assumption that these treatments have only a delaying action.
2 ReferencesBertrand Godeau, M.D.
Philippe Bierling, M.D., Ph.D.
Hôpital Henri Mondor, 94000 Créteil, France
bertrand.godeau@hmn. ap-hop-paris. fr 1
Cheng Y ,Wong RSM ,Soo YOY , et al. Initial treatment of immune thrombocytopenic purpura with high-dose dexamethasone. N Engl J Med 2003;349:831-836
Full Text | Web of Science | Medline2
Godeau B ,Chevret S ,Varet B , et al. Intravenous immunoglobulin or high-dose methylprednisolone, with or without oral prednisone, for adults with untreated severe autoimmune thrombocytopenic purpura: a randomised multicentre trial. Lancet 2002;359:23-29
CrossRef | Web of Science | Medline
Author/Editor Response
As we mention in our article, about 30 to 40 percent of adults with immune thrombocytopenia may have a sustained response to various corticosteroid regimens. We agree with Godeau and Bierling that this may reflect the natural history of the disease. Our high-dose dexamethasone treatment may identify this group — that is, patients who are likely to have a sustained response — earlier and expose them to a shorter course of corticosteroid therapy and therefore fewer side effects. We did not suggest that our dexamethasone treatment has a higher overall response rate than standard prednisone therapy. Our study treatment is also not comparable to intravenous immune globulin as the initial treatment. As Godeau and Bierling mention, intravenous immune globulin therapy is much more expensive than high-dose dexamethasone, and there was no difference in the long-term outcome between their intravenous immune globulin group and the corticosteroid group.1 Therefore, a short course of high-dose corticosteroids may be a good initial treatment option for many patients with immune thrombocytopenic purpura.
1 ReferencesRaymond S.M. Wong, M.B., Ch.B.
Yannie O.Y. Soo, M.B., Ch.B.
Gregory Cheng, M.D., Ph.D.
Chinese University of Hong Kong, Shatin NT, Hong Kong, China
gcheng@cuhk.edu. hk 1
Godeau B ,Chevret S ,Varet B , et al. Intravenous immunoglobulin or high-dose methylprednisolone, with or without oral prednisone, for adults with untreated severe autoimmune thrombocytopenic purpura: a randomised multicentre trial. Lancet 2002;359:23-29
CrossRef | Web of Science | Medline
