Morey Blinder, MD: Let’s think about the goals of first-line ITP therapy. What factors are going into treatment selection? What are your definitions of remission and disease control, and what discussions do you have regarding what to expect before initiating first-line therapy? Danny, do you want to start?

Daniel Landau, MD: Sure. Thank you. I think a lot of my conversations with patients are going to have to do with how dramatic their presentation is, whether they’re having the extensive purpura, bleeding events or whether it’s going to be a potentially more mild laboratory abnormality without other manifestations. One thing that I’ve noticed, and it has been described in a few papers, is that a number of people who have very active ITP just don’t feel well in general. This has been manifested in missed days of school, missed days of work, either as a result of the illness itself or of some complication of it. There are going to be some patient-dependent factors that are going to go into treatment-making decisions. In many papers, especially with the TPO medics, success was defined as a platelet count as greater than 50. That was relatively sustainable. That’s one of the targets, to get the platelets up, but especially with first-line therapy, I think most of us expect the platelets to normalize and hopefully remain normal for quite a while. Unfortunately, some of those first-line therapies, generally speaking, they’re very steroid intense. I can tell you, my patients get very upset with me when I have to do a very steroid-intense therapy. There’s a lot of explanation that goes into why I’m giving them insomnia and weight gain and everything else that goes along with it.

Morey Blinder, MD: I think steroids really are part of first-line therapy for the majority of patients. Do any of you 3 use much anti-D therapy in the initial management of ITP?

Daniel Landau, MD: Not recently.

Cindy Neunert, MD: We’re probably larger in our use in the pediatric population. We do use anti-D in the pediatric population. There were concerns surrounding the adverse effects, particularly with the FDA black box warning and the associated DIC [disseminated intravascular coagulation]. It becomes challenging because the children that you want that prompt platelet count response from anti-D immunoglobulin are the very children that come in and have significant bleeding, oftentimes already have a low hemoglobin and you really don’t want to take the risk of another 2-gram decline. We will use anti-D in the right setting in a patient who’s Rh positive with a spleen.

Transcript edited for clarity.