Intravenous immunoglobulin G and anti-D as therapeutic interventions in immune thrombocytopenic purpura

Immune thrombocytopenic purpura (ITP) is a disorder caused by accelerated d estruction of antibody-coated platelets in the reticuloendothelial system ( RES), especially the spleen. Inhibition of RES function following intraveno us administration of high-dose immunoglobulin G (IVIG) or intravenous anti- D leads to rapid, albeit usually temporary, reversal of thrombocytopenia in the majority of children and adults with ITP. In emergency situations high -dose IVIG is preferred over anti-D because of the more rapid rate of plate let response; for maintenance therapy in Rh positive ITP patients (e.g. chi ldren with chronic ITP pre-splenectomy) anti-D is preferred because of its comparable efficacy to IVIG plus ease of administration and lower cost. In children with typical acute ITP and platelet counts <20x10(9)/L IVIG is pre ferred over anti-D; however other approaches in this patient cohort should be considered before high-dose IVIG, specifically careful observation alone with therapy given only to children with clinically significant haemorrhag e or short course oral prednisone at a starting dose of approximately 4 mg/ kg/day. Studies are required to define the short and longer term effects of both IVIG and anti-D on the immune system in order to plan more rational u se of these immunomodulatory therapies in this model autoimmune disorder. ( C) 1998 Published by Elsevier Science Ltd. All rights reserved.