Although the record does not clearly support ITP, it is a reasonable diagnosis in the context of other CBC values. In three large cohorts of adults who had failed multiple therapeutic modalities, patients were treated with the regimen of anti-CD20 used to treat B-cell lymphoma—375 mg/m2 weekly for 4 weeks. Approximately 50% of patients had a partial or complete response, and about 33% had durable remissions. Rituximab for other than first line has been recommended in a recent treatment review in a major journal and is being increasingly used. Medicare lists it as reimbursable.
A recent critical review states: “While these studies clearly document the therapeutic efficacy of rituximab in chronic, refractory ITP in both adults and children, we still do not know which ITP patients should receive rituximab therapy. …further trials are definitively needed in order to determine the place of rituximab in the treatment of ITP.” However, it is generally accepted that some patients can benefit from Rituxan and obtain long term remissions of their disease.
NICEmade no firm recommendatiosn based on the evidence that is reported in this summary for adults includes a systematic review and meta-analysis, 2 that have been published since the systematic review, and a retrospective cohort study comparing rituximab with splenectomy. Also included in the evidence summary is a systematic review of studies in children and young people.
NICE, Immune (idiopathic) thrombocytopenic purpura: rituximab. Evidence summary [ESUOM35] Published date: October 2014
Carson, K et al, “Progressive multifocal leukoencephalopathy after rituximab therapy in HIV-negative patients: a report of 57 cases from the Research on Adverse Drug Events and Reports project.” Blood. 2009 May 14;113 (20):4834-40
Donald M. Arnold, MD, MSc; Francesco Dentali, MD; Mark A. Crowther, MD, MSc; Ralph M. Meyer, MD; Richard J. Cook, PhD; Christopher Sigouin, MSc; Graeme A. Fraser, MD; Wendy Lim, MD, MSc; and John G. Kelton, MD Systematic Review: Efficacy and Safety of Rituximab for Adults with Idiopathic Thrombocytopenic Purpura Ann INtern Med 2 January 2007 | Volume 146 Issue 1 | Pages 25-33
Stas et al, Rituximab chimeric anti-CD20 monoclonal antibody treatment for adults with chronic idiopathic thrombocytopenic purpura Blood, 15 August 2001, Vol. 98, No. 4, pp. 952-957
Idiopathic Thrombocytopenic Purpura (ITP) and Anti-CD20 Monoclonal Antibody: A Case Report.
Clinical and Applied Thrombosis/Hemostasis, October 1, 2006; 12(4): 489 – 492
S. Berentsen Rituximab for the treatment of autoimmune cytopenias
Haematologica, December 1, 2007; 92(12): 1589 – 1596.
M. Ruggeri, S. Fortuna, and F. Rodeghiero
Heterogeneity of terminology and clinical definitions in adult idiopathic thrombocytopenic purpura: a critical appraisal from a systematic review of the literature
Haematologica, January 1, 2008; 93(1): 98 – 103.
ASH Education Book December 6, 2013 vol. 2013 no. 1 276-282 .
Arnold DM, Heddle NM, Carruthers J et al. (2012) A pilot randomized trial of adjuvant rituximab or placebo for nonsplenectomized patients with immune thrombocytopenia. Blood 119: 1356−62. doi 10.1182/blood-2011-08-374777
Auger S, Duny Y, Rossi JF et al. (2012) Rituximab before splenectomy in adults with primary idiopathic thrombocytopenic purpura: a meta-analysis. British Journal of Haematology 158: 386−98. doi: 10.1111/j.1365-2141.2012.09169.x
Gudbrandsdottir S, Birgens HS, Fredericksen H et al. (2013) Rituximab and dexamethasone vs dexamethasone monotherapy in newly diagnosed patients with primary immune thrombocytopenia. Blood 121: 1976−81. doi: 10.1182/blood-2012-09-455691
Liang Y, Zhang L, Gao J et al. (2012) Rituximab for children with immune thrombocytopenia: a systematic review. PLoS ONE 7: doi: 10.1371/journal.pone.0036698
Moulis G, Sailler L, Sommet A et al. (2013) Rituximab versus splenectomy in persistent or chronic adult primary immune thrombocytopenia: an adjusted comparison of mortality and morbidity. American Journal of Haematology 89: 41−6. doi: 10.1002/ajh.23580