Meral İNALHAN, BELTİNGE DEMİRCİOĞLU KILIÇ, Müjgan ORAL, Serpil DEĞİRMENCİ, Arslan Özlem ÜNLÜTÜRK, Özlem TEMEL, Savaş İNAN

Çocukluk çağı akut immun trombositopeni olgularında farklı tedavi protokollerinin değerlendirilmesi

Amaç: Akut immun trombbsitopenikpurpura (ITP) nedeni ile başvuran olguların retrospektif olarak incelenmesi, demografik özelliklerinin belirlenmesi, tedavide uygulanan yüksek doz metil prednizölon (YDMP) ile intravenöz immunglobulin (MG) tedavi sonuçlarının karşılaştırılması. Gereç ve Yöntem: Ocak 1998 ile Şubat 2003 arasında akut ITP tanısı alan yaşları 1-14 yıl arasında değişen 23'ü erkek, 27'si kız 50 vakanın dosyaları incelendi. 24'üne i.v YDMP, 15'ine WIG ve ll'ine de trombosit sayısının yeterince yükselmemesi nedeni ile ardışık tedavi uygulanan vakalar değerlendirildi. Tedavinin 48, ve 72. saatinde trombosit sayılarına bakıldı. Bulgular: Tedavi başladıktan 48 saat sonra ortalama trombosit sayısı YDMP alanlarda 44.000/mm3, MG alanlarda 55.000/mm3, ardışık tedavi alanlarda 17.0001mm3, 72 saat sonra ortalama trombosit sajnsı YDMP alanlarda 83.000/mm3, WIG alanlarda 1'10.000/mm3, ardışık tedavi alanlarda 21.000/mm3 saptandı. Trombosit sayısının >50.000/mm3 olması için gereken süre YDMP alanlarda 3.6±1.5 gün, MG alanlarda 2.5+0.8 gün, ardışık tedavi alanlarda 10.8±4.6 gün olarak saptandı. Tedaviden sonra YDMP alanlarda %8, WIG alanlarda %13, ardışık tedavi alanlarda %54 oranında kronik ITP geliştiği saptandı. Sonuç: Akut ITP ile gelen olguların tedavisinde WIG ile YDMP'nin etkinliğinin değerlendirilmesinde belirgin fark olmadığı gözlendi. Ayrıca tedavinin başlangıcında trombosit sayısında yeterli yükselmenin olmaması nedeniyle ardışık tedavi uygulanması gerektiren vakalarda kronik ITP gelişme riskinin daha yüksek olduğu saptandı.

Anahtar Kelimeler:

Geriyedönük çalışma, Purpura, trombositopenik, Çocuk, Metilprednizolon, İmmünoglobulinler

The evaluation of different treatment protocols for acute immune thrombocytopenic purpura in childhood

Objective: The aims of this retrospective study were to compare the results of therapeutic efficacy of intravenous high^ dose methylprednisolone (HDMP) and intravenous immunoglobulin (WIG) for the treatment and to determine of demographic characteristics of cases. Methods: Data were collected from hospital medical records between January 1998 and February 2003. We evaluated 50 cases (23 male, 27 female), aged between 1-14 years, diagnosed as acute immune idiopathic thrombocytopenic purpura. 24 cases were treated with HDMP, 15 cases with WIG',11 cases whom the consecutive therapy was started because of inadequate elevation in platelet counts therapies. At the end of 48 hours and 72 hours of therapy, platelet counts were determined. Results: After 48 hours of treatment, mean platelet counts were determined as 44x10(9)/L in the group who received HDMP, 55 x 10(9)/L in the group given MG and 17x10(9)/L in the group given consequtive tretment. After 72 hours of treatment, mean platelet counts were determined as 83x10(9)IL in the group who received HDMP, 110x10(9)/L in the group given WIG and 21 x 10(9)IL group given consequtive tretment. The time required to platelet counts increased at a level of > 50 xlO(9)/L was 3.6±1.5 days in the group who received HDMP, 2.5±0.8 in the group who received WIG, 10.8±4.6 days in the group who received consequtive treatment. Chronic immune thrombocytopenic purpura (ITP) developed in 8% of children who received HDMP, 13% of children who received IVIG, 54% of children who received consequtive treatment. Conclusion: When assessing the effectivity of WIG and HDMP therapy in the treatment of acute ITP we found no difference between these two modalities. In patients by whom the consecutive therapy was started because of inadequate elevation in platelet counts, the risk of developing chronic ITP was increased.

Keywords:

Retrospective Studies, Purpura, Thrombocytopenic, Child, Methylprednisolone, Immunoglobulins,

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1.Yu-Waye Chu, MD, James Korb, MD, and Kathleen M. Sakamoto, MD. Idiopathic Thrombocytopenic Purpura. Pediatrics in Review 2000 March; 21(3):95-103 2.Hagenstrom H., Schlenke P. Platelet-associated IgG for differential diagnosis of patients with thrombocytopenia. Thromb. Haemost 2000;84:779-783 3.Beardsley DS, Nathan DG. Platalet abnormalities in ifancyand childhood. ImNathan DG, Orkin SH, eds. Hematology of Infancy and Childhood, 5th ed
Philadelphia: WB Saunders company,1998;1574-1578 4.Blanchette V. Childhood chronic immune thrombocytopenia. Blood Rev. 2002; 16:23-26 5.Bolton-Maggs,, PHB. Immune thrombocytopenic purpura. Arch. Dis. Child 2000; 83:220-222 6.Olcay L, Yetkin S. Trombositopeniler. Kath Dergisi 1995; 16:801-822 7.Imbach P, Blanchette VS, Nugent D, Künhe T
Immune thrombocytopenic purpura: immediate andlong term effects of intravenous immunoglobulin. In: Kazatchkine MD, Morel A, (eds). Intravenous Immunoglobulin Research and Therapy. Interlaken: Parthenon Publishing, 1996; 135-141 8.Medenos D,Buchanan G. Current contrversies in the management of idiopathic thrombocytopenic purpura during childhood. Pediatr clin North Am 1996; 43:757-769 9.Bithell TC. Thrombocytopenia causes by immunologic platelet destruction: Idiopathic thrombocytopenic purpura (ITP), Drug- Induced thrombocytopenia, and miscllaneous forms. In: Lee GR, Bithell TC, Foerster S, Athens JW, Lukens JN, (eds). Wintrobe's Clinical Heamatology. 9th ed
London: . Lea&Febiger, 1993; 1329-1355 10.Moussalem M, Yasinse N. Immune thrombocytopenic purpura in childhood: a Lebanase perspective. Molecular Immunology 2003; 39:1105-1107 11.Nugent DJ. Childhood immune throm bocytopenic purpura. Blood Rev 2002; 16:27-29 12.Iyori H, Bessho F, Ookawa H, et al, Japanese study group on childhood ITP. Ann. Hematol 2000;79:691-695 13.Lanzkowsky P. Manual of Pediatric Hematology and Oncology. 3nded. Churchill Livingstone, 1999
14.Lilleyman JS. Intracranial haemorrage in idiopathic thrombocytopenic purpura . Arch Dis Child 1994; 71:251-253 15.Buchanan GR, de Alarcon PA, Feig SA et al
Akut idiopathic thrombocytopenic purpura- management in childhood (letter). Blood 1997; 89:1464-1466 16.Rosthoj S, Nielsen S, Pedersen FK. Randomized trial comparing intravenous immunoglobulin with methylprednisolone pulse therapy inakut idiopathic thrombocytopenic purpura. Danish l.T.P. Study Group
Acta Pediatr 1996; 85:910-915 17.Erduran E, Aslan Y, Gedik Y, Orhan F. A randomized and comperative study of intravenous immunoglobulin and mega dose methylprednisolone treatments in children with akut idiopathic thrombocytopenic purpura. Turk J Pedietr 2003 Oct-Dec; 45(4):295-300 18.Albayrak D, Islek I, Kalaycı AG, Gurses N. Acute immune thrombocytopenic purpura: a comperative study of very high oral doses of methylprednisolone and intravenously administered intravenous immunoglobulin. J Pediatr 1994 Dec; 125 (6Pt1):1004-1007 19.Ancona KG, Parker RI, Atlas MP, Prakash D
Randomized trial of high dose methylprednisolone versus intravenous immunoglobulin fort he treatment of acute Idiopathic thrombocytopenic purpura in children. J Pediatr Hematol Oncol 2002 Oct; 24(7):540-544 20.Dallar Y, Yıldırmak Y, Tanyer G, Evis B. Son 10 yılda takip edilen idiopatik trombositopenik purpurah çocuk olguların değerlendirilmesi. T klin Pediatri 1993; 2:183-187