Reply to: High-dose oral dexamethasone therapy in idiopathic thrombocytopenic purpura

Abstract

Reply to the Editor:Thank you for providing the opportunity to respond to the letter by Dr. Korones. His letter raises several important points regarding the use of pulse dexamethasone therapy in children with idiopathic thrombocytopenic purpura (ITP), and we offer the following response.We appreciate Dr. Korones' report of his experience with the use of high-dose oral dexamethasone therapy in children with chronic or refractory ITP. His three patients had moderate to severe toxicity, including severe myalgias, mood swings, and disorientation. These side effects are known to occur with corticosteroid administration and therefore are likely related to the therapy.Dexamethasone has potent immunosuppressive, immunomodulatory, and antiinflammatory properties and has side effects on virtually every organ system. At the high dose of dexamethasone used in patients with ITP (approximately 25 mg/m2 per day orally for 4 days), it is perhaps surprising that so few serious side effects have been encountered in three published studies.1Andersen JC Response of resistant idiopathic thrombocytopenic purpura to pulsed high-dose dexamethasone therapy.N Engl J Med. 1994; 330: 1560-1564Crossref PubMed Scopus (215) Google Scholar, 2Caulier MT Rose C Roussel MT et al.Pulsed high-dose dexamethasone in refractory chronic idiopathic thrombocytopenic purpura: a report on 10 cases.Br J Haematol. 1995; 91: 477-479Crossref PubMed Scopus (49) Google Scholar, 3Adams DM Kinney TR O'Branski-Rupp E Ware RE High-dose oral dexamethasone therapy for chronic childhood idiopathic thrombocytopenic purpura.J Pediatr. 1996; 128: 281-283Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Recent abstracts also have not reported severe toxic effects related to high-dose dexamethasone therapy.4Nugent D English M Hawkins D et al.High dose dexamethasone therapy for pediatric patients with refractory immune-mediated thrombocytopenic purpura (ITP) (abstract).Blood. 1994; 84: 186aGoogle Scholar, 5Moertel CL Smith C Nelson S Hilden J Lack of sustained response to high dose dexamethasone therapy in children with chronic immune-mediated thrombocytopenic purpura (ITP) (abstract).Blood. 1995; 86: 66aPubMed Google Scholar, 6Young RR Marchioli CC Basmaijan JH et al.Pulsed high-dose dexamethasone therapy in patients with idiopathic thrombocytopenic purpura (abstract).Blood. 1995; 86: 66aPubMed Google Scholar, 7Pignatti CB Rugolotto S Nobili B et al.Treatment of childhood chronic idiopathic thrombocytopenic purpura with high-dose dexamethasone (abstract).Blood. 1995; 86: 847aGoogle Scholar As we point out in our discussion, we believe that the prescription of dexamethasone as a single oral dose, given early in the morning, is important in limiting toxic effects.Of the seven children we described in our study, four continue to receive periodic pulses of high-dose dexamethasone therapy for severe thrombocytopenia. Patient 5 has taken dexamethasone every 4 to 8 weeks for the past 19 months and has reported no side effects except for weight gain. We have treated four additional patients with autoimmune cytopenias and have observed no serious side effects related to the dexamethasone therapy. Therefore we wonder if the severe side effects described by Dr. Korones are somehow related to the time of dosing of drug administration.We recognize that high-dose dexamethasone therapy is a relatively new therapy for ITP that may result in severe toxic effects, and again caution that larger trials will be necessary to validate our experience. Until then, however, we believe that pulsed doses of dexamethasone can be a convenient, inexpensive, and effective therapy for some patients with ITP.9/35/75813 Reply to the Editor:Thank you for providing the opportunity to respond to the letter by Dr. Korones. His letter raises several important points regarding the use of pulse dexamethasone therapy in children with idiopathic thrombocytopenic purpura (ITP), and we offer the following response.We appreciate Dr. Korones' report of his experience with the use of high-dose oral dexamethasone therapy in children with chronic or refractory ITP. His three patients had moderate to severe toxicity, including severe myalgias, mood swings, and disorientation. These side effects are known to occur with corticosteroid administration and therefore are likely related to the therapy.Dexamethasone has potent immunosuppressive, immunomodulatory, and antiinflammatory properties and has side effects on virtually every organ system. At the high dose of dexamethasone used in patients with ITP (approximately 25 mg/m2 per day orally for 4 days), it is perhaps surprising that so few serious side effects have been encountered in three published studies.1Andersen JC Response of resistant idiopathic thrombocytopenic purpura to pulsed high-dose dexamethasone therapy.N Engl J Med. 1994; 330: 1560-1564Crossref PubMed Scopus (215) Google Scholar, 2Caulier MT Rose C Roussel MT et al.Pulsed high-dose dexamethasone in refractory chronic idiopathic thrombocytopenic purpura: a report on 10 cases.Br J Haematol. 1995; 91: 477-479Crossref PubMed Scopus (49) Google Scholar, 3Adams DM Kinney TR O'Branski-Rupp E Ware RE High-dose oral dexamethasone therapy for chronic childhood idiopathic thrombocytopenic purpura.J Pediatr. 1996; 128: 281-283Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Recent abstracts also have not reported severe toxic effects related to high-dose dexamethasone therapy.4Nugent D English M Hawkins D et al.High dose dexamethasone therapy for pediatric patients with refractory immune-mediated thrombocytopenic purpura (ITP) (abstract).Blood. 1994; 84: 186aGoogle Scholar, 5Moertel CL Smith C Nelson S Hilden J Lack of sustained response to high dose dexamethasone therapy in children with chronic immune-mediated thrombocytopenic purpura (ITP) (abstract).Blood. 1995; 86: 66aPubMed Google Scholar, 6Young RR Marchioli CC Basmaijan JH et al.Pulsed high-dose dexamethasone therapy in patients with idiopathic thrombocytopenic purpura (abstract).Blood. 1995; 86: 66aPubMed Google Scholar, 7Pignatti CB Rugolotto S Nobili B et al.Treatment of childhood chronic idiopathic thrombocytopenic purpura with high-dose dexamethasone (abstract).Blood. 1995; 86: 847aGoogle Scholar As we point out in our discussion, we believe that the prescription of dexamethasone as a single oral dose, given early in the morning, is important in limiting toxic effects.Of the seven children we described in our study, four continue to receive periodic pulses of high-dose dexamethasone therapy for severe thrombocytopenia. Patient 5 has taken dexamethasone every 4 to 8 weeks for the past 19 months and has reported no side effects except for weight gain. We have treated four additional patients with autoimmune cytopenias and have observed no serious side effects related to the dexamethasone therapy. Therefore we wonder if the severe side effects described by Dr. Korones are somehow related to the time of dosing of drug administration.We recognize that high-dose dexamethasone therapy is a relatively new therapy for ITP that may result in severe toxic effects, and again caution that larger trials will be necessary to validate our experience. Until then, however, we believe that pulsed doses of dexamethasone can be a convenient, inexpensive, and effective therapy for some patients with ITP. Thank you for providing the opportunity to respond to the letter by Dr. Korones. His letter raises several important points regarding the use of pulse dexamethasone therapy in children with idiopathic thrombocytopenic purpura (ITP), and we offer the following response. We appreciate Dr. Korones' report of his experience with the use of high-dose oral dexamethasone therapy in children with chronic or refractory ITP. His three patients had moderate to severe toxicity, including severe myalgias, mood swings, and disorientation. These side effects are known to occur with corticosteroid administration and therefore are likely related to the therapy. Dexamethasone has potent immunosuppressive, immunomodulatory, and antiinflammatory properties and has side effects on virtually every organ system. At the high dose of dexamethasone used in patients with ITP (approximately 25 mg/m2 per day orally for 4 days), it is perhaps surprising that so few serious side effects have been encountered in three published studies.1Andersen JC Response of resistant idiopathic thrombocytopenic purpura to pulsed high-dose dexamethasone therapy.N Engl J Med. 1994; 330: 1560-1564Crossref PubMed Scopus (215) Google Scholar, 2Caulier MT Rose C Roussel MT et al.Pulsed high-dose dexamethasone in refractory chronic idiopathic thrombocytopenic purpura: a report on 10 cases.Br J Haematol. 1995; 91: 477-479Crossref PubMed Scopus (49) Google Scholar, 3Adams DM Kinney TR O'Branski-Rupp E Ware RE High-dose oral dexamethasone therapy for chronic childhood idiopathic thrombocytopenic purpura.J Pediatr. 1996; 128: 281-283Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Recent abstracts also have not reported severe toxic effects related to high-dose dexamethasone therapy.4Nugent D English M Hawkins D et al.High dose dexamethasone therapy for pediatric patients with refractory immune-mediated thrombocytopenic purpura (ITP) (abstract).Blood. 1994; 84: 186aGoogle Scholar, 5Moertel CL Smith C Nelson S Hilden J Lack of sustained response to high dose dexamethasone therapy in children with chronic immune-mediated thrombocytopenic purpura (ITP) (abstract).Blood. 1995; 86: 66aPubMed Google Scholar, 6Young RR Marchioli CC Basmaijan JH et al.Pulsed high-dose dexamethasone therapy in patients with idiopathic thrombocytopenic purpura (abstract).Blood. 1995; 86: 66aPubMed Google Scholar, 7Pignatti CB Rugolotto S Nobili B et al.Treatment of childhood chronic idiopathic thrombocytopenic purpura with high-dose dexamethasone (abstract).Blood. 1995; 86: 847aGoogle Scholar As we point out in our discussion, we believe that the prescription of dexamethasone as a single oral dose, given early in the morning, is important in limiting toxic effects. Of the seven children we described in our study, four continue to receive periodic pulses of high-dose dexamethasone therapy for severe thrombocytopenia. Patient 5 has taken dexamethasone every 4 to 8 weeks for the past 19 months and has reported no side effects except for weight gain. We have treated four additional patients with autoimmune cytopenias and have observed no serious side effects related to the dexamethasone therapy. Therefore we wonder if the severe side effects described by Dr. Korones are somehow related to the time of dosing of drug administration. We recognize that high-dose dexamethasone therapy is a relatively new therapy for ITP that may result in severe toxic effects, and again caution that larger trials will be necessary to validate our experience. Until then, however, we believe that pulsed doses of dexamethasone can be a convenient, inexpensive, and effective therapy for some patients with ITP. 9/35/75813