Romiplostim in Newly Diagnosed ITP Resistant to 1st Line Treatment – Case Study
In patients with immune thrombocytopenia (ITP), effectively stopping and controlling bleeding can be complicated in some cases. This includes scenarios such as open wounds. One way to stabilize platelet count can be through administering a thrombopoietin receptor agonist (TPO-RA). The following case study presents a successful treatment of newly diagnosed ITP.
Case Description
A 72-year-old woman intentionally caused a deep cut on the right side of her neck. This was followed by massive bleeding and overall destabilization with a significant drop in blood pressure (BP 60/38 mmHg). The 10 cm long wound was deep and continuously bleeding. Upon admission, several large subcutaneous bleedings were observed on both the torso and limbs.
Upon arrival at the emergency room, hemoglobin level was 47 g/l and platelet count was 2 × 109/l. There were no signs of disseminated intravascular coagulation (DIC). Closer examination revealed that the wound had also affected the right carotid artery, with CT scans showing a 2 mm wall damage. An immediate operation was indicated to suture the a. carotis wall and the wound. During the perioperative period, 14 units of packed red blood cells, 40 units of platelets, and 14 units of fresh frozen plasma were administered. The family described bleeding manifestations for several days before this incident, leading to an ITP diagnosis.
Treatment began with intravenous immunoglobulins (IVIG) combined with prednisolone 1 mg/kg. Simultaneously, empirical treatment was initiated to eradicate Helicobacter pylori. This had little effect and even after 6 days of treatment, resistant thrombocytopenia and bleeding from the gastrointestinal tract, hematuria, and oozing from the surgical wound persisted. At this point, TPO-RA romiplostim was started at an initial dose of 3 μg/kg/day. Six days after its first administration, platelet count rose to 19 × 109/l, hematuria stopped, and wound bleeding ceased. On day 13 of treatment, a splenectomy was performed, again with massive needs for blood derivatives. Immediately after splenectomy, platelet count rose above 100 × 109/l, and bleeding manifestations disappeared. On day 17, romiplostim administration was discontinued as platelet count normalized completely. Steroids were gradually withdrawn.
Six months after diagnosing ITP, platelet count again dropped to 4 × 109/l, without active bleeding but with numerous hematomas. IVIG and steroids were administered again without effect, so TPO-RA was promptly reinitiated with good results.
Conclusion
The administration of romiplostim in the context of acute bleeding and emergency surgery has been repeatedly described in the literature. Its early use can be highly effective even in cases of de novo diagnosed ITP with life-threatening bleeding resistant to standard first-line therapy.
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Source: Watanabe R., Tabayashi T., Tomikawa T. et al. Successful early romiplostim use in a case of severe immune thrombocytopenia with critical carotid arterial injury. Int J Hematol 2017; 105: 100–103, doi: 10.1007/s12185-016-2094-z.
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