PB0719 - Early treatment of rituximab combined with eltrombopag for secondary thrombocytopenic purpura in rheumatoid arthritis: a case report

Background: Autoimmune disease was usually one of the important causes in Secondary immune thrombocytopenic purpura (ITP). There were few reports about treatment of refractory thrombocytopenic purpura in rheumatoid arthritis (RA).

Aims: We reported a case of refractory ITP in which changes in platelet-related markers with therapeutic agents are worthy of the attention of clinicians.

Methods: The peripheral blood plates and immature platelet fraction were measured before and after the clinical changes of different therapeutic drugs. We evaluated the effectiveness of treatment based on the reduction of ecchymosis and count of platelet in this patient.

Results: After admission, she was given dexamethasone, methylprednisolone, intravenous immunoglobulin (IVIG), cyclosporine and platelet infusion (Figure 1). The ecchymosis on her neck and arms did not subside. Bone marrow smear indicated scattered thrombocytopenia. The platelet count was 9×10^9/L, and the immature platelet fraction (IPF) was 33.9%.
Then she started to take EPAG 25mg daily for 3 days. The platelet count was 14×10^9/L, and the IPF was 28.0%. It was suggested that the use of low dose EPAG alone was not effective in increasing platelet count. On the same day, she received the first course of rituximab 100mg combined with EPAG 25mg. One week later, the platelet count was 119×10^9/L, and the IPF was 9.6%. Her bruises had basically faded. Continue to give the second cycle of rituximab 100mg combined with EPAG 25mg, ciclosporin 150mg and prednisone 40mg daily for 3 days. The platelet count was 211×10^9/L, and the IPF was 7.4%. After 2 weeks, the patients reported no new petechiae on her buccal mucosa and limbs during telephone follow-up. The changes of platelet count and IPF with treatment regimen were shown (Figure 2).

Conclusion(s): Early treatment of rituximab combined with EPAG was beneficial to patients with refractory ITP in RA. IPF may be an auxiliary indicator for predicting efficacy.