A comment on "a prospective, multicenter study of low dose decitabine in adult patients with refractory immune thrombocytopenia" by Zhou et al.

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We have read the article “A prospective, multicenter study of low dose decitabine in adult patients with refractory immune thrombocytopenia” by Zhou et al.1 In this prospective study, refractory immune thrombocytopenia (ITP) patients were treated with a hypomethylating agent, decitabine, which is being used as a standard of care for myelodysplastic syndrome and unfit acute myeloid leukemia patients. Though ITP has been previously treated with other immunosuppresive chemotherapeutic agents like vinctistine, cyclosporine and mycofenolate, novel agents with reasonably mild toxicity profiles were not unusual or unexpected. The study has reported promising results however we have certain doubts. First of all, as the latest three guidelines have stated, spontaneous remissions are quite unlikely in patients who have reached the 12 months’ milestone, but not impossible.2-4 In this regard, the response to decitabine might attributable to probable spontaneous remissions, not entirely, but is still debatable. Bone marrow aspiration and biopsy with chromosome analysis is recommended to all patients at this point, both to prove the diagnosis and check the cellularity and morphology. Before starting a treatment with an agent novel for this group of patients, bone marrow examination would increase the quality of the knowledge. Likewise, the detection of antiplatelet antibodies, especially against the epitopes on GP Ib and IIb/IIIa may be used, not as an initial workup but in chronic or refractory patients to support the diagnosis of ITP. But, in this study, the value of the seropositivity in terms of response to decitabine is less valuable to bone marrow examination, especially after the completion of treatment.2 Second is the status of Helicobacter pylori in refractory ITP patients. It is suggested that H. pylori should be sought and eradicated if detected in all refractory patients with noninvasive methods, like urea breathe test or stool antigen test.2, 3 Response after eradication is not uncommon and in this study, H. pylori status should have been stated to increase the homogeneity of the patients. Our last comment is the value, guides have placed on combinations. Combination of all alternatives (which have failed as monotherapies) may be used in refractory patients, including corticosteroids with thrombopoietin receptor agonists (TPO-RAs) as a dual therapy, or addition of low dose immunosuppresants.2-4 In conclusion, it is debatable that immunosuppresants towards cell cycle even with a low toxicity profile may be a reasonable approach for ITP, which has an individual pathogenesis and progress in every patient. Supporting data of the bone marrow before and after treatment as well as the failures of all suggested steps of treatments are essential.