IVIG Prescriptions Guideline-Appropriate in Majority of French Adults With Severe Immune Thrombocytopenia

Among patients in a French hospital unit who were prescribed intravenous immunoglobulin (IVIG) for severe cases of immune thrombocytopenia (ITP), investigators found that the prescription of IVIG was considered valid according to French guidelines in a vast majority of cases, according to an analysis published in British Journal of Haematology.¹

Intravenous immunoglobulin is the gold-standard treatment for immune thrombocytopenia in adults. | Image Credit: © AkuAku | stock.adobe.com

International consensus regarding IVIG treatment for ITP is that the treatment should be reserved for the most severe forms of disease. French guidelines regarding ITP treatment have been recently updated; they indicate a similar stance, recommending that IVIG should be reserved for patients with a Khellaf score—a bleeding score used to quantify hemorrhage in adults with ITP—greater than 8.^1,2

If this is not the case, then the guidelines recommend only using IVIG for patients with ITP with a formal contra-indication to corticosteroids. Health authorities have repeatedly reinforced the need to comply with these guidelines, given difficulties procuring the treatment and the high financial and physical cost associated with it.^1,2

Despite the stringent guidelines, an analysis of ITP management in adults showed that approximately half of patients hospitalized with ITP received IVIG. This suggests that the use of IVIG in some patients is not compliant with guidelines. In this retrospective, monocentric study, the investigators sought to describe the prescribing practices of IVIG in ITP and assess compliance with national guidelines, as well as explain factors associated with deviations from the guidelines.^1,3

Patients hospitalized for ITP who received IVIG from 2016 to 2020 in the internal medicine unit of Henri Mondor Hospital in France were retrospectively examined. A total of 114 patients—accounting for 208 courses of IVIG—were included in the analysis.¹

Khellaf bleeding score was > 8 in 37.5% of cases, which validates IVIG prescription according to current French guidelines. In cases where Khellaf score was 8 or less, the main reason for IVIG use was known steroid resistance, observed in 33.7% of those cases. In addition, preparation for an invasive procedure (8.5%), preparation for childbirth (6.6%), and contra-indication to corticosteroids (3.3%) were identified reasons for not adhering to guideline recommendations.¹

Notably, 2.4% of cases specifically highlighted the presence of concomitant anti-coagulant therapy as the reason for IVIG use, despite still being considered non-compliant to the guidelines. In total, the investigators flagged 33 IVIG prescriptions (15.9%) in the study that were considered non-compliant in accordance with current guidelines.¹

A mixed-effects logistic regression model was performed due to the hypothesis proposed by the investigators that young age could be a factor linked with guideline non-compliance. The modeling indicated a trend towards younger age in patients whose IVIG prescription was non-compliant. This trend was reinforced after the Kehllaf score was recalculated in 65-years-and-older without taking into consideration age, dropping to ≤ 8 in 15 cases.¹

Overall, IVIG prescription was compliant with national guidelines in 84% of cases, showing overall good compliance. Room for improvement exists, according to the investigators, specifically for patients in preparation for invasive procedures or during pregnancy. A recommendation was made by the investigators that all patients with a new ITP diagnosis be tested for sensitivity to corticosteroids, so that the information is visible in their medical records.¹

Beyond this, clinicians and pharmacists globally should stay aware of the guidelines governing ITP management, and ensure that their prescribing practices are compliant.

“The conclusions from this retrospective study warrant further, prospective, studies in order to best adjust the Khellaf bleeding score to treat ITP patients efficiently, while preserving precious IVIG products,” the investigators wrote.¹

REFERENCES

1. Dubois S, Layese R, Liaml N, et al. When is the use of intravenous immunoglobulin appropriate in immune thrombocytopenia? BJ Haem. 2024. doi:10.111/bjh.19817

2. Godeau B, Aladjidi N, Perel Y, MARIH. Protocole national de diagnostic et de soins Purpura thrombopénique immunologique de l'enfant et de l'adulte. PNDS. 2017; 1–74. https://www.has-sante.fr/upload/docs/application/pdf/2017-06/dir36/pnds-_purpura_thrombopenique_immunologique.pdf

3. Michel M, Suzan F, Adoue D, et al. Management of immune thrombocytopenia in adults: a population-based analysis of the French hospital discharge database from 2009 to 2012. BJ Haem. 2015;170(2):218-222. doi:10.1111/bjh.13415