Assessment of a therapeutic strategy for adults with severe autoimmune thrombocytopenic purpura based on a bleeding score rather than platelet count

Service de Medecine Interne, Hopital Henri Mondor, 51 Avenue de Lattre De Tassigny, 94010 Creteil Cedex, France. mehdi.khellaf@hmn.ap-hop-paris.fr

BACKGROUND AND OBJECTIVES: The optimal treatment for patients with autoimmune thrombocytopenic purpura (AITP) and a platelet count < or =20x10(9)/L is intravenous immunoglobulin (IVIg) but this treatment is expensive and steroids are a good alternative in less severe cases. Since the occurrence of life-threatening hemorrhage in adult AITP is a rare event, the aim of our study was to validate a therapeutic strategy based on a bleeding score for the short-term management of adults with AITP and a platelet count < or =20x10(9)/L. DESIGN AND METHODS: We developed a method to quantify hemorrhage in adults with AITP. Bleeding severity was graded on a numerical scale based on physical examination. When the bleeding score was < or =8, the patients were treated with steroids alone. For scores >8, patients received IVIg (1 to 2 g/kg) in combination with oral steroids. A good response was defined as the lowering of the initial bleeding score within 2 days after treatment initiation regardless of the platelet count. RESULTS: We applied this strategy for the management of 60 consecutive adults (mean age 48+/-23 years) with AITP and a platelet count < or =20x10(9)/L/L (mean platelet count 6+/-5x10(9)/L/L). Based on this strategy, IVIg was required in only 50% of the patients and no life-threatening bleeding occurred in patients treated with steroids alone. INTERPRETATION AND CONCLUSIONS: A therapeutic strategy based on a bleeding score rather than the platelet count appears to be relevant and safe and is a good IVIg-sparing strategy.