Overuse of Corticosteroids as a Serious Problem in ITP
Corticosteroids (CS) are a common part of the treatment for immune thrombocytopenia (ITP). However, their administration is associated with significant short-term and long-term toxicity, and the goal should be to minimize their use to the shortest possible duration. Early combination with other medications could be helpful in this regard.
Adverse Effects of CS in ITP Patients
Corticosteroids remain a crucial component of first-line treatment for immune thrombocytopenia. There are several reasons for this: low cost, high initial response rate, and acceptable short-term toxicity. However, it is well known that prolonged or repeated use of CS is associated with significant toxicity. Surveys have shown that more than 95% of ITP patients treated with CS reported adverse effects, with over one-third of these patients reducing or discontinuing the therapy because of these issues.
It is recommended to monitor explicitly for potential adverse effects of CS, such as mood disorders, stomach irritation, hyperglycemia, insomnia, myopathy, or weight gain. Long-term complications include osteoporosis or glaucoma. Administration of CS increases the risk of bone fractures by 75% within three months of starting treatment and induces measurable losses in bone mineral density within six months.
For this reason, various recommendations emphasize short-term CS administration with a maximum of six weeks in adults with ITP. Overall, a sustained response in terms of platelet count for ≥ 6 months of monitoring can be estimated at about 30%.
Real-world Clinical Practice vs. Recommendations
The overprescribing of corticosteroids in newly diagnosed ITP is well documented in the literature, yet clinical practice remains relatively inconsistent regarding the administration schemes of these drugs. Furthermore, CS are most commonly used strategies even in the second and third lines of treatment (in combination with other drugs), being administered in > 80% of cases. Various surveys show that even after three months of treatment episodes of ITP, many adults are still on CS monotherapy. While pulse therapy of CS is sometimes tried, evidence of its effectiveness is limited.
For the reasons mentioned above, emphasis should be placed on preventing the overuse of CS and earlier incorporation of other treatment options that are more suitable for long-term use.
Alternatives to Corticosteroids
The initial line of treatment for ITP besides CS generally includes immunoglobulins (IVIG) and, in some countries, anti-D antibodies. Further lines include mainly thrombopoietin receptor agonists (TPO-RA), rituximab, fostamatinib, or splenectomy.
Early combination of CS with drugs now considered part of further therapeutic lines could be crucial for the overall reduction in CS overuse. Combining TPO-RA with CS has the potential to reduce CS exposure in the first four weeks of treatment by a third, additionally being associated with a lower risk of CS dependency in the subsequent weeks of therapy.
Conclusion
It is very important to strive to reduce corticosteroid toxicity resulting primarily from their prolonged administration. Proactive combination of CS with other medications in the first line of treatment could benefit many patients, as well as careful monitoring of signs of corticosteroid toxicity.
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Source: Cuker A., Liebman H. A. Corticosteroid overuse in adults with immune thrombocytopenia: cause for concern. Res Pract Thromb Haemost 2021; 5 (6): e12592, doi: 10.1002/rth2.12592.
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