To the Editor: A recent article in Blood, ''How I Treat Idiopathic Thrombocytopenic Purpura (ITP)'' by Cines and Bussel, was read with great interest [1]. Placing in perspective the new treatment modalities is useful to all hematologists, yet the only published data the authors cited to support their recommendations were a meta-analysis of patients with platelet counts below 30,000, which did not differentiate between treated and untreated patients. There are no publications extant that suggest that treatment-naive, otherwise healthy adult ITP patients with any platelet count are at risk for significant bleeding.
In 1988, Brox et al. showed a significant rise in the platelet count with high doses of ascorbic acid in refractory ITP patients [2]. Subsequent to Brox's report a study of ascorbic acid for the treatment of refractory ITP was published by Jubilirer [3], which failed to confirm Brox's data; however, it is to be noted that no bleeding episodes occurred in the treatment arm. In 1983 Burns and Saleem [4] published a review of the natural history of refractory ITP patients (steroid and splenectomy failures) and concluded that significant hemorrhagic events were extremely rare. In 2001 Vianelli et al. [5] reported on the long-term follow-up of 310 patients with ITP and concluded that ''prospective studies are required to evaluate whether it may be reasonable to treat only symptomatic patients independently of age.'' Since 1988 (Auerbach), steroids have not been used in any of more than 40 patient referrals irrespective of platelet counts without thrombocytopenia-related morbidity. For platelet counts > 10,000, vitamin C alone was prescribed and bruising was virtually eliminated. This result is not unexpected inasmuch as improvement in capillary fragility and wound healing are well-recognized salutary effects with vitamin C. For counts < 10,000 WinRho and/or Rituxan has been universally successful.
Therefore, it may not be unreasonable to suggest that our conventional approach to managing ITP in otherwise healthy adults (corticosteroids/ splenectomy) must be reexamined. Even in the pre IVIG, WinRho, and Rituxan era, bleeding was rarely encountered during splenectomies in ''refractory'' ITP patients. Our most important admonition, ''before else, do no harm,'' should be heeded before recommending potentially toxic therapies.