When is the use of intravenous immunoglobulin appropriate in immune thrombocytopenia?

Abstract

Intravenous immunoglobulin (IVIg) is the gold standard treatment for severe cases of immune thrombocytopenia (ITP). However, its cost, limited duration of efficacy and market supply tension have led French guidelines to reserve IVIg for ITP patients with formal contra-indications to corticosteroids, with French bleeding score ('Khellaf score') > 8, and corticosteroid-resistant patients either with Khellaf score ≤ 8 or in preparation for an invasive procedure or during pregnancy. We studied the prescribing practices of IVIg for ITP in real-life conditions and assessed their compliance with French guidelines. A monocentric retrospective study was conducted between 2016 and 2020 among 114 patients hospitalized in our unit, for a total of 208 IVIg treatments. In 37% of cases, the Khellaf score was >8, validating IVIg prescription according to French guidelines. In the remaining cases, reasons noted for use of IVIg included corticosteroid resistance (33.7%), preparation for an invasive procedure (8.5%), context of pregnancy (6.6%) and contra-indication to corticosteroids (3.3%). After analysis, IVIg prescription was considered valid according to current French guidelines in 84.4% of cases. Non-compliant IVIg prescription was more frequent in younger patients (p = 0.027). Concomitant anti-coagulation was also noted as an argument for IVIg prescription outside of the current French guidelines.

Keywords: immune thrombocytopenia; intravenous immunoglobulin.

FIGURE 1

Flowchart of patient inclusion. Reasons for exclusion are noted on the right. A total of 114 patients, amounting to 208 IVIg treatments, were included. *SCID, severe combined immunodeficiency.

FIGURE 2

IVIg prescriptions according to Khellaf bleeding score. Number of IVIg infusions is recorded on y‐axis, according to the Khellaf bleeding score at time of prescription. Khellaf bleeding scores are grouped from 0 to 2, 3 to 5, 6 to 8, 9 to 11, 12 to 14 and ≥15. Vertical line separates IVIg perfusions prescribed for Khellaf scores > 8 from the others.

FIGURE 3

IVIg treatment motives. IVIg treatment motives clearly stated in hospitalization reports are reported in this pie chart. Percentages are with regard to total number of IVIg treatments. Cases where Khellaf score was >8 are highlighted as they were immediately considered compliant with prescription guidelines. *Other: In three cases, IVIg was administered as a therapeutic test in order to confirm ITP diagnosis.

FIGURE 4

Analysis of compliance with IVIg prescription guidelines. Three cases of potentially compliant IVIg prescriptions were further analysed: pregnancy, preparation for invasive procedures and contra‐indications to steroids. Total IVIg prescriptions in these cases are noted at the top of each column. The blue and grey part of each column, respectively, indicate number of prescriptions deemed compliant and non‐compliant in each case.