FEATURE
Drawing First Blood
We invite two experts to debate controversial
topics in hematology and health care
Rituximab or Splenectomy in
Steroid-Resistant ITP Patients?
Craig S. Kitchens, MD
Keith McCrae, MD
Disclaimer:
The following positions were assigned
to the participants and do not
necessarily reflect ASH opinions, the
participants’ opinions, or what they
do in daily practice.
Agree? Disagree? We want to hear
from you! Send your thoughts and
opinions on this controversial
issue to ashclinicalnews@
hematology.org.
ASHClinicalNews.org
Corticosteroids are the standard initial treatment for adult
patients with idiopathic thrombocytopenic purpura (ITP), while
splenectomy is considered second-line treatment. Drugs like
rituximab have led to a trend in
delaying or avoiding splenectomy. Should splenectomy remain
an early intervention, or should
clinicians exhaust all available
medical treatment options
before performing this irreversible procedure? ASH Clinical
News has invited Craig Kitchens, MD, and Keith McCrae,
MD, to debate the question:
“For ITP, should splenectomy
or rituximab be used as firstline therapy after steroids?”
Dr. Kitchens will be arguing for
splenectomy, and Dr. McCrae will
be arguing for rituximab.
Craig S. Kitchens, MD: Before we start
debating the question of which therapeutic approach is best for these patients, I
think we have to acknowledge that we are
very lucky to have a choice – for once – of
effective second-line therapies for our ITP
patients. With some other platelet disorders, like thrombotic thrombocytopenia
purpura (TTP), the second- or third-line
therapeutic options are not as effective.
We don’t have the luxury there of asking,
“Which of these two options is better?”
We have to ask, “Which is the least bad?”
Regarding our current topic, though,
each of these options – rituximab or
splenectomy – is effective and rather safe,
but I would say that there are definite
differences in long-term efficacy, with the
advantage going to splenectomy.
I do use rituximab, and I’m sure that
you recommend a splenectomy every now
and then.
Keith McCrae, MD: I’d agree with you that
we are in a privileged position. When I am
treating adult patients with ITP there are
certain situations when I would opt for
splenectomy. However, I choose rituximab
first for a few straightforward reasons: it
is quite effective, it is well-tolerated, and it
does offer the possibility for a durable remission of ITP. Also, many of my patients
simply do not want splenectomies.
In addition, I am concerned about the
emerging literature that has found that
there are, indeed, long-term consequences
of splenectomy that may not have been
fully appreciated. That is another issue
that weighs on my decision to reach for
rituximab first in patients with steroidresistant ITP.
Dr. Kitchens: I’ve been practicing hematology for a while, so I have seen a lot of
growth in this area. For a while, I was
known among my colleagues as a “defender of the spleen.” Nobody’s spleen was
coming out on my watch!
We would give patients all kinds of
medication – none of which were as
effective as rituximab – or we would
administer vinblastine-loaded platelets.
The problem with those approaches were
the response rates – only about 20 percent
of patients responded. We thought that
was just the natural course of the disease
in certain patients. A small percentage of
patients who had maintained a platelet
count of 60,000 would even come to clinic
and, all of a sudden, would reach a platelet
count of 320,000.
On top of that, I had seen several
patients who underwent splenectomy
with drastic and occasionally fatal postsplenectomy infections.
So, why did I switch from the
“defender of the spleen” to favoring
splenectomy in most situations? Well,
I have to say that I haven’t totally
abandoned other options. Frankly, I don’t
want to; there is just too much going on
in ITP.
“ e are very
W
lucky to have
a choice –
for once –
of effective
second-line
therapies for our
ITP patients.”
—CRAIG S. KITCHENS, MD
But, I have learned a lot of durable
lessons from my patients. Two unique
cases come to mind, both of whom had
ITP that would intermittently respond to
prednisone. Both were also missionaries
preparing to go to remote places in
Rwanda and Haiti, respectively, where
they would be pretty isolated from care.
The last thing they wanted was to have a
relapse of their ITP, or to find themselves
in a situation where they needed a blood
transfusion while there. Since we aren’t
able to check the patient’s platelet count
or dose-adjust the medication for an
extended period of time, we needed
something durable. So, we decided to
go with splenectomy for both of these
patients and they both did very well
Continued on page 49
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