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Three Part Question

In [children with idiopathic thrombocytopenic purpura] is [intravenous immunoglobin better than steroids] at [improving platelet count]?

Clinical Scenario

A ten year old girl is admitted with a widespread petechial rash and bleeding gums. A full blood count demonstrates a platelet count of 3,000/mm3 and a diagnosis of idiopathic thrombocytopenic purpura is made. You decide that she warrants medical treatment but have seen both steroids and intravenous immunoglobulins used previously by colleagues. You wonder which treatment is most effective.

Search Strategy

Using medline database via PUBMED from 1966 to week 1 March 2014-03-01
The Cochrane Libraray
[acute] AND [idiopathic thrombocytopenic purpura] AND [children] AND [intravenous immunoglobulin] AND [steroid]

Search Outcome

PUBMED – 54 papers were found of which 5 were relevant. Cochrane: 53 citations with 1 new paper found

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Erduran et al. 2003 Turkey	42 children with ITP and platelet counts ≤ 20,000/microl	Randomized and comparitive study (2)	Mean time to achieve platelet count >20,000/microL	4.1 days in steroid group and 2.9 days in IVIG group (p<0.05)	Used ‘megadose’ methylprednisolone of 30mg/kg/d for 3 days, then 20mg/kg/day for 4 days
			% of patients with platelet counts>20,000/microL at 48 hours	50% in steroids group and 86% in IVIG group (p<0.05)
			Mean platelet count after a month	No significant difference between 2 groups (p>0.05)
Ancona et al 2002 USA	77 children with ITP requiring treatment (extensive bruising and platelet count <10,000/microL)	Randomised trial (2)	% of patients with platelet count >50,000/microL within 48 hours	80% of IVIG group and 60% of steroid group	Decision to treat based on clinical presentation, not specific platelet count, which may lead to results being difficult to replicate.
			Platelet rise at 24, 48 and 72 hours	IVIG group had significantly higher counts than steroid group in all 3 time frames
Gereige et al. 2000 USA	148 children hospitalised with acute ITP	Retrospective study (1)	Platelet count at 24 hours	IVIG in combination with high dose steroids was the most effective than single treatment
Blanchette et al 1994 Canada	146 children with acute ITP and platelet count ≤20x(9)/L	Randomised trial (2)	Time taken to achieve a platelet count of >50 x 10(9)/L	Single dose IVIG led to the quickest response in platelet count.
Hord et al 1993 USA	61 children admitted with platelet count <20,000/mm3	Retrospective study (1)	Time to platelet count ≥50,000/mm3	IVIG significantly more effective in first 36 hours but no significant difference by 72 hours
Fujisawa et al 2000 Japan	Children with acute ITP, divided into groups with platelet count <10 x 10(3)/microL and 10 to 29 x 10(3)/microL, with and without mucosal	Randomised control trial (2)	Platelet count and haemorrhagic manifestationIVIG significantly increased platelet count when platelets <10 x 10(3)	IVIG significantly increased platelet count when platelets <10 x 10(3)

Comment(s)

Acute ITP is an acquired disorder which is characterised by immune mediated platelet destruction. Although the vast majority of children do not require treatment, one of the most serious complications is intracranial haemorrhage. The evidence behind two of the commonest treatments, IVIG and steroids, continues to be inconsistent, as demonstrated by the above studies. Ultimately both IVIG and steroids are shown to be effective in increasing platelet counts in children with acute ITP, although IVIG has been demonstrated to lead to a quicker response.

Clinical Bottom Line

Both IVIG and steroids significantly increase platelet counts in children with acute ITP, however, IVIG is the most rapidly effective.

References

1. Erduran E, Aslan Y, Gedik Y, Orhan F A randomized and comparative study of intranvenous immunoglobulins and mega dose methylprednisolone treatments in children with acute idiopathic thrombocytopenic purpura. Turk J Paediatr 2003 Oct-Dec; 45(4):295-300
2. Ancona KG, Parker RI, Atlas MP, Prakash D Randomized trial of high dose methylprednisolone versus intravenous immunoglobulin for the treatment of acute idiopathic thrombocytopenic purpura in children J Paediatr Hematol Oncol 2002 Oct;24(7):540-4
3. Gereige RS, Barrios NJ Treatment of childhood acute immune thrombocytopenic purpura with high-dose methylprednisolone, intravenous immunoglobulin, or the combination of both P R Health Sci J 2000 Mar;19(1):15-18
4. 4. Blanchette V, Imbach P, Andrew M, Adams M, McMillan J, Wang E, Milner R, Ali K, Barnard D, Bernstein M, et al Randomised trial of intravenous immunoglobulin G, intravenous anti-D, and oral prednisolone in childhood acute immune thrombocytopenic purpura Lancet 1994 Sep 10; 334(8924):703-7
5. Hord JD, Grossman NJ Intravenous corticosteroid versus intravenous gammaglobulin in the treatment of acute immune thrombocytopenic purpura Pediatr Hematol Oncol 1993 Oct-Dec;10(4):323-7
6. 6. Fujisawa K, Iyori H, Ohkawa H, Konishi S, Bessho F, Shirahata A, Miyazaki S, Akatsuka J; Japanese Study Group on Childhood ITP A prospective, randomized trial of conventional, dose-accelerated corticosteroids and intravenous immunoglobulin in children with newly diagnosed idiopathic thrombocytopenic purpura Int J Hematol 2000 Oct;72(3):376-83