DISCUSSION
About 20-30% of childhood ITP progresses to chronic ITP. (2, 16, 17) It
is important to predict which factors are important in the progression
of chronicity. Although it is difficult to assume which patient will
develop chronic ITP, in a systematic review and meta-analysis by
Heting-Pollé et al. advanced age at diagnosis, insidious onset disease,
absence of a history of infection preceding, high thrombocyte count at
diagnosis, female gender had been reported as risk factors of chronicity
in childhood ITP. (16) Deel et al. had evaluated 204 children with a
diagnosis of ITP. They also reported that progression to chronicity was
significantly increased in children above 8 years of age
(p<0.001). (18) We also found that the risk of progression of
chronicity was statistically significant. On the other hand, infantile
ITP patients are different than other age groups ITP patients. Farhangi
et al. examined 187 children under 2 years of age diagnosed with ITP.
They observed that patients ITP diagnosed under 3 months had more
chronicity than patients aged 3-24 months. (19)
insidious onset disease,
We did not see any effect of infections or vaccinations before acute ITP
on the chronicity (p: 0.2)
In Deel et al. study (18) they reported that ALC at diagnosis showed no
difference in chronic and acute ITP groups, however, at third, 6th, 9th
and 12th months of diagnosis ALC counts were found to be significantly
lower in the chronic group. In our study, ALC at diagnosis was lower in
the chronic ITP group at diagnosis and this difference was statistically
significant (p<0.0001). Our study has also shown that mean ANC
was higher in patients with chronic ITP than patients who resolved in
the first 12 months (p= 0.036), while there were no important
differences between the two groups according to mean platelet counts
(p=0.839).
Akbayram et al. studied possible predictors of chronicity in childhood
ITP and found that sex did not affect the progression of chronicity in
childhood ITP. In this study, we also found that there was no important
difference in the chronicity rate between males and females (20.19% vs
22.5%) patients (p=0.7). (20)
Although there are some studies, which support the superiority of IVIG
on, corticosteroids as initial therapy, there are studies, which showed
that initial therapy preference, makes no change on the progression of
chronicity.(21, 22)
Akbayram et al. evaluated the effect of initial therapy on the
progression of chronicity and reported no difference between high dose
steroids, low dose steroids, and IVIG therapy groups.(20) In our study;
either high dose methylprednisolone or IVIG was initiated as first-line
therapy. We also found no difference in the progression of chronicity
between HDMP and IVIG groups. Baronci et al. evaluated the treatment
response duration of treatment choice with high dose Methylprednisolone
(MP), low dose MP, IVIG, and high dose dexamethasone selection, with the
fastest response with high dose MP and IVIG. (23)
An alternate to therapy is ”watchful waiting” for ITP if the thrombocyte
count is > 20.000/mm3. Besides thrombocyte count, ”bleeding
score” is important in the decision of treatment options. (24)
Rituximab may be considered in chronic cases with bleeding, however,
splenectomy seems to be more efficient.(25-27) Interesting an
alternative therapy for chronic, pediatric ITP patients is a Japanese
medicine drug called cepharanthin. It is a bisbenzylisoquinoline
(biscolaurine) alkaloid group wide-ranged effective immunosuppressive
drug.(28) Yamazaki et al. were use this drug on 46 chronic-resistant,
<16 years Japanese ITP patients.(29) In this study shown
cepharantine has used a safe and effective alternative
corticosteroid-sparing drug.
Currently, in refractory cases, successful results have been reported
for TPO receptor agonist, romiplostim (30) and eltrombopag (31, 32) as a
second-line therapy option. In two splenectomized and five
non-splenectomized chronic ITP cases, we achieved a complete response to
eltrombopag therapy at a dose of 25-75mg/day PO.