D. Khyathi

11YO1T0006

Pharm-D

Case Presentation on �Idiopathic Thrombocytopenic Purpura (ITP)

Idiopathic Thrombocytopenic Purpura

• Idiopathic thrombocytopenic purpura (ITP) is a disorder that can lead to easy or excessive bruising and bleeding. The bleeding results from unusually low levels of platelets (the cells that help blood clot).
• Idiopathic thrombocytopenic purpura (ITP), also known as primary immune thrombocytopenic purpura and autoimmune thrombocytopenic purpura.

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Types of ITP

• The two types of ITP are acute (short-term) and chronic (long-lasting).
• Acute ITP is the most common form of the disorder. It usually lasts less than six months and mainly occurs in children.
• Chronic ITP lasts six months or longer. It’s most commonly seen in adults, although teenagers and younger children can be affected.
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ETIOLOGY

• ITP occurs when certain immune system cells produce antibodies against platelets. Platelets help your blood clot by clumping together to plug small holes in damaged blood vessels.
• The antibodies attach to the platelets. The body destroys the platelets that carry the antibodies.
• In children, the disease sometimes follows a viral infection. In adults, it is more often a long-term (chronic) disease and can occur after a viral infection, with use of certain drugs, during pregnancy, or as part of an immune disorder.
• ITP affects women more often than men. It is more common in children than adults. In children, the disease affects boys and girls equally.

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Symptoms

• Idiopathic thrombocytopenic purpura (ITP) may have no signs and symptoms. When they do occur, they may include:
• Easy or excessive bruising (purpura)
• Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs
• Bleeding from the gums or nose
• Blood in urine or stools
• Unusually heavy menstrual flow

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Treatment

• Most children recover with no treatment, many doctors recommend just watching them carefully and taking care of the bleeding symptoms.
• Some doctors recommend a short treatment with prednisone pills or intravenous infusions (given in a vein) of gamma globulin to increase the platelet count more quickly.
• Both medicines have some side effects.
• Corticosteroids remain the drugs of choice for the initial management of acute ITP.
• Oral prednisone, IV methylprednisolone, or high-dose dexamethasone may be used .

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• IV immunoglobulin (IVIG) has been the drug of second choice for many years.
• For Rh(D)-positive patients with intact spleens, IV Rho immunoglobulin (RhIG) offers comparable efficacy, less toxicity, greater ease of administration, and a lower cost than IVIG.
• RhIG can induce immune hemolysis (immune hemolytic anemia) in Rh(D)-positive persons and should not be used when the hemoglobin concentration is less than 8 g/dL.
• Rituximab is third-line therapy
• Platelet transfusions may be required to control clinically significant bleeding but are not recommended for prophylaxis
• If 6 months of medical management fails to increase the platelet count to a safe range (about 30,000/µL), splenectomy becomes an option
• Thrombopoietin receptor agonists (ie, eltrombopag, romiplostim) may maintain platelet counts at safe levels in adults with chronic ITP refractory to conventional medical management or splenectomy.

Demographic details

Name: XXX

Age: 12years

Gender: Female

Weight: 44kgs

Op date: 24/3/17

Ward: Paediatrics

Consultant:

Dr. K. Amarnath Reddy

D.C.H.,DNB,NALS(bombay)

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Subjective evidence:

Chief complaints:

• Decrease platelet count since 2 months.
• Minor gum bleed(once) 10 days back.

Past medical history:

• H/o dengue 2 months back.
• k/c/o ITP since 2mths.

Past medication history:

Family history:

• Nil.

Allergies:

• Nil.

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Objective evidence

7/01/17 Bone marrow aspiration report:

Impression: Features suggestive of immune thrombocytopenic purpura and mild erythroid hyperplasia with normoblastic cells.

23/11/16

Bleeding time:2min 30 sec(1-5min)

Clotting time: 7min 00sec (4-9min)

Assessment:

• Based on subjective and objective evidence the patient was known case of

Idiopathic Thrombocytopenic Purpura.

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Planning

Pharmacist Intervention

• No drug drug interactions were found.

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Medication error:

• Pharmacist dispensed Tranexamic acid + Mefenamic acid instead of Tranexamic acid.

Adverse drug reaction:

• With the use of prednisolone for a month patient had developed a acne.

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• Tranexamic acid should be used in caution as no studies done in children or young childrens.
• Norethisterone dose was given 15mg/day, it is maximum for adults, so reduction of dose should be needed in pediatrics.

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Patient counseling

Regarding drugs

• Avoid certain over-the-counter drugs that can affect platelet function, including aspirin, ibuprofen (Advil, Motrin), and the blood-thinning medication warfarin (Coumadin).
• Some medicines and supplements can affect platelets and increase chance of bleeding. Common examples are aspirin or ibuprofen.
• Patient may take oral formulation with food to minimize gastric irritation.

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Life style modifications

• Choose low-impact activities instead of competitive sports or other high-impact activities to decrease your risk of injury and bleeding.
• Some safe activities are swimming, biking (with a helmet), and walking. Do the physical activities that are safe for the patient.
• Take precautions such as regular use of seatbelts and wearing gloves while working with knives and other tools.
• Eat a wide variety of fresh food Avoid canned and frozen foods and leftovers. The nutritional value of food deteriorates with time. A wide variety of food assures body gets the variety of nutrients it needs.
• Eat whole foods Eat whole grain cereals, brown rice, and whole wheat products. Reduce the amount of white flour, white rice and processed foods. Processed grains are stripped of their natural nutrient-rich coating.�

• Eat organic foods
• Eat un-sprayed foods grown using natural fertilizers. Some pesticides and herbicides have been shown to exacerbate autoimmune diseases and lower platelets. Additives and preservatives can increase the disease-causing free radicals in your body.
• Reduce sugar�Reduce the amount of white refined sugar as well as fructose, corn syrup, honey and other sweeteners. Limit fruit and fruit juice. Sugar contributes to an acidic disease-promoting body condition.
• Reduce dairy products�Reduce or eliminate milk, cheese, ice cream, and yogurt from your diet based on your reaction to these foods and other dietary needs. Dairy foods have been shown to contribute to mucus formation and exacerbate some autoimmune diseases.
• Eat healthy fats�Use olive or canola in cooking and baking. Avoid hydrogenated, partially hydrogenated or trans-fats. These contribute to free radical damage. Reduce the amount of deep fried food which also adds to the free radical load.

• Eat green�Eat as many leafy greens as possible, especially kale and collards. Add sea vegetables (sea weed) to the diet. These choices contain large amounts of calcium, minerals, and vitamin K to help clotting.
• Limit meat�Rely on lean, white fish, whole grains and beans and some nuts for protein. Meat is often laced with residual antibiotics, hormones, and saturated fat.
• Avoid problem foods�Reduce the amount of blueberries, red/purple grape products, garlic, onions, ginger, ginseng, and tomatoes. These foods can interfere with blood clotting. Avoid food and drinks containing quinine. These can lower platelets.
• Avoid allergic foods�Many people have delayed food allergies that produce vague and difficult-to-diagnose symptoms. If you don’t feel well, consider having a food allergy test.
• Chew the food well�Chewing each bite until it is liquid can aid digestion, aid the passage of nutrients into blood stream, and promotes healthy alkaline blood chemistry.

• Drink pure warm water�Drink plenty of filtered or bottled water at room temperature or above. Taking periodic sips of hot water can cleanse impurities from the body. Ice water can slow and hinder the digestive process. Tap water may contain small amounts of chemicals that are harmful. 

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References

• Leon shargel, Alan H, Paul F, Larry N. Comprehensive pharmacy review for naplex. 8^th edition. 2013.
• Joseph T. Dipiro, Barbara G. Wells, Celicy V. Dipiro. Pharmacotherapy handbook 7^th edition.
• Truven health analytics, micromedex solutions, 2017.

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