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Brief Report

CLINICAL TRIALS AND OBSERVATIONS

A novel triple therapy for ITP using high-dose dexamethasone, low-dose

rituximab, and cyclosporine (TT4)
Philip Young-Ill Choi,1 Fernando Roncolato,2 Xavier Badoux,2 Sundra Ramanathan,2 Shir-Jing Ho,2 and Beng H. Chong1,2
1
St George Clinical School, University of New South Wales, Kogarah, NSW, Australia; and 2Department of Haematology, St George Hospital, Kogarah,
NSW, Australia

Promising reports of combination immunosuppression with high-dose dexamethasone

Key Points
and rituximab for the treatment of primary immune thrombocytopenia (ITP) have recently
Triple therapy is well tolerated emerged. They suggest a potential to further optimize the efficacy of therapy. We inves-
and effective in patients with tigate the use of a novel combination of conventional therapies in ITP given over 4 weeks.
chronic ITP. From 2011 to 2014, 20 patients were prospectively enrolled onto a single-arm phase 2b study
Relapse free survival was 92% to describe the safety, efficacy, and tolerability of oral dexamethasone 40 mg for days 1 to 4,
for responders after 12 months oral cyclosporine 2.5 to 3 mg/kg daily for day 1 to 28, and intravenous low-dose rituximab
100 mg for days 7, 14, 21, and 28. There were no therapy-related serious adverse side effects,
and 76% after 24 months.
6-month response rate was 60%, and treatment was well tolerated. Responders enjoyed
relapse-free survivals of 92% and 76%, respectively, at 12 and 24 months. This study highlights the possibility of achieving an enduring
remission from 4 weeks of therapy. This study is registered at www.anzctr.org.au (#ANZCTRN12611000015943). (Blood. 2015;126(4):500-503)

Introduction
Primary immune thrombocytopenia (ITP) is an autoimmune disorder low-dose rituximab 100 mg for days 7, 14, 21, and 28 (TT4). There was no
characterized by isolated thrombocytopenia in the absence of other loading dose for cyclosporine, trough levels were monitored weekly for toxicity,
causes.1 ITP is mediated by antiplatelet autoantibodies. Antibody-coated and doses were titrated to target 200 to 400 mg/L. Additional cycles of dexa-
platelets are phagocytosed by macrophages in the reticuloendothelial methasone were permitted if response was delayed. This study protocol was
approved by the South Eastern Sydney Local Health District Human Research
system, leading to accelerated platelet clearance.2 Macrophages also act
Ethics Committee and conducted in accordance with the Declaration of Helsinki.
as antigen-presenting cells interacting with CD81 and CD41 T cells that
in turn stimulate antibody-producing B cells.3 This pathogenic loop sus- Eligibility and end points
tains autoantibody production. T cell-mediated platelet lysis4 and mega-
karyocyte immunoinjury contribute to the diverse pathobiology of ITP.5 ITP patients $18 years of age were eligible to participate. The primary objective
was to investigate the safety, and to a lesser degree, the efcacy of TT4. The
Single-agent treatments have not been successful at inducing pro-
primary hematologic end point was 6-month response rate (RR). We used the
longed remission.6 With immunosuppressive monotherapy, ITP pa-
criteria of the International Working Group and the American Society of Hema-
tients usually require prolonged treatment, leading to unpleasant and tology practice guideline panel for ITP diagnosis and response.1,14,15 Treatment-
sometimes serious side effects.7,8 free survival (TFS) is dened as the time from TT4 protocol to the introduction of
Recent studies combining dexamethasone and rituximab in short further therapy for symptomatic or severe (,203109/L) thrombocytopenia.16
courses have reported encouraging results.9-13 We postulate that adding The supplemental Data available on the Blood Web site provides the inclusion
cyclosporine to this combination may induce a more enduring remission and exclusion criteria, as well as secondary end points. Adverse side effects were
by also targeting T cells and thereby briey suppressing all 3 immune monitored regularly by an independent safety review committee and graded
cell types implicated in sustaining the pathogenic loop. using the National Cancer Institute Common Terminology Criteria for Adverse
Suppressing these cells simultaneously has a risk of predisposing to Events scale, version 4.02.17
serious infections. We considered it appropriate to conduct a pilot study
Statistical methods
on a small number of patients with the aim of investigating the safety
and efcacy of the triple therapy. This phase 2b study was designed to terminate if sequential monitoring of
therapy-related serious adverse events revealed a higher than expected frequency
using a concave a-spending function.18 Subgroups were compared using
Fishers exact test for categorical data and the Mann-Whitney U test for quan-
Study design titative data. Exploratory logistic regressions were applied to 6-month RR for
cyclosporine levels, quantitative lymphocyte changes, and baseline demograph-
Twenty patients were randomly but nonconsecutively and prospectively enrolled ics including weight and body surface area (BSA) by Mostellar. Wilcoxon
onto a phase 2b study investigating triple therapy: oral dexamethasone 40 mg for matched-pairs signed-rank tests were used for changes in lymphocytes counts.
days 1 to 4, oral cyclosporine 2.5 to 3 mg/kg daily for days 1 to 28, and intravenous Kaplan-Meier survival curves were compared using Mantel-Cox log-rank testing

Submitted March 3, 2015; accepted May 11, 2015. Prepublished online as The publication costs of this article were defrayed in part by page charge
Blood First Edition paper, May 13, 2015; DOI 10.1182/blood-2015-03-631937. payment. Therefore, and solely to indicate this fact, this article is hereby
marked advertisement in accordance with 18 USC section 1734.
The online version of this article contains a data supplement. 2015 by The American Society of Hematology

500 BLOOD, 23 JULY 2015 x VOLUME 126, NUMBER 4

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BLOOD, 23 JULY 2015 x VOLUME 126, NUMBER 4 TRIPLE THERAPY FOR ITP CAN BE SAFE AND EFFECTIVE 501

for response durability, TFS, and time to CD191 lymphocyte recovery. Tests Table 1. Baseline characteristics and initial platelet response to
were 2-sided, and P , .05 was considered statistically signicant. therapy
Parameter Responders Nonresponders P

Demographics
Median age (range) 50.2 (18.9-79.8) 51.9 (19.3-67.5) .9394
Males/females 10/2 1/7 .0045
Results and discussion
Median time from diagnosis 60 (1-206) 42 (3-215) .8345
Safety to TT4, months
Newly diagnosed or 3 4 .3563
Demographics are presented in Table 1. There were no deaths, therapy- persistent ITP
related serious adverse events, serum sickness, treatment interruptions, Chronic ITP 9 4
or delays caused by toxicity. There were 4 therapy-related grade III to Primary ITP 9 6 1.0000
IV adverse side effects: 3 patients with hypertension and 1 patient with Secondary ITP SLE SLE
APS APS
wound infection. These side effects were treated successfully. Concur-
Crohns disease
rent use of high-dose steroids and cyclosporine may have contributed to
2 or less prior lines 8 0 .0047
the hypertension observed. Other toxicities are described in supple- of therapy
mental Data. 3 or more prior lines 4 8
There was 1 hospitalization for inuenza: an 80-year-old man living of therapy
alone. One patient required intravenous antibiotics for a lower limb Median BSA 1.98 (1.65-2.39) 1.70 (1.48-2.29) .1878
laceration. One patient was admitted with reversible renal failure from Median weight, kg 80.(61-114) 67 (48-105) .2779
nonsteroidal anti-inammatory drugs 18 months after TT4 treat- Splenectomy, prior 1 1
ment. One nonresponding patient remained steroid dependent after Platelets
failing further therapies and presented with pulmonary aspergilloma Baseline, median 3109/L 18.5 (4-35) 16.0 (4-24) .2114
Day 7, median 109.0 (1-322) 45.0 (9-114) .0861
23 months after TT4.
Day 14, median 91.5 (6-413) 25 (9-252) .0566
Day 21, median 92.5 (14-393) 27.5 (8-79) .0051
Efficacy Day 28, median 144.5 (22-337) 18.5 (9-131) .0021
Day 60, median 108 (23-316) 20 (1-61) .0008
Overall, 12 of 20 patients (60%) responded. All maintained their re-
Patients with platelets 11 3 .0181
sponse for $7 months. Median time to response was 7.4 days. Complete .30 3 109/L, day 30
response was 30% at 6 months. Only 2 responders relapsed during a Patients with platelets 11 1 .0017
median follow-up of 17.5 months (range, 7-47 months). For responders, .30 3 109/L, at day 60
relapse-free survival at 12 and 24 months was 92% and 76%, respectively
(95% condence interval [CI], 53-98% and 30-93%, respectively). See
Figure 1 for details. B cells
Two nonresponders underwent splenectomy: 1 patient at 5 months
achieved complete response and another patient at 3 years after Peripheral CD191 B cells became undetectable for all patients by
completion of TT4 therapy achieved reduction in steroid dependence. day 28. B-cell recovery was earlier for patients ,50 years (median,
Despite failing the response criteria, further therapy was not required 6.5 months vs not reached; P 5 .0105), but no such associations were
for 4 of 8 nonresponders. Overall, TFS was 75% at 12 months (95% found with response status, weight, or BSA. Median time to recovery
CI, 49-88%). was 14.9 months. Duration and depth of B-cell depletion did not in-
Two responders received an additional dexamethasone cycle: one uence patient response (P 5 .8999 and P 5 .8911, respectively).
within the rst 30 days because of a delayed response and another These results suggest a therapeutic ceiling effect from peripheral B-cell
within the rst 6 months when platelets transiently fell with a coryzal depletion not seen with CD41 T-cell suppression.
illness. The other 10 of 12 responders did not receive additional cycles
of dexamethasone. Six of 8 nonresponders received an additional cycle Immunoglobulins
of high-dose dexamethasone.
The following subgroups were associated with 6-month RR: male Two patients had preexisting hypogammaglobulinemia: immunoglob-
sex (P 5 .0045), ,3 prior lines of therapy (P 5 .0047), and an initial ulin (Ig)G levels fell from 6.6 to 2.1 g/L for 1 patient, but they remained
platelet response by day 28 (P 5 .0181) or day 60 (P 5 .0017). There between 5.0 and 6.0 g/L for the other (reference range, 7.0-16.0 g/L).
was no association between response and BSA, despite the use of xed Two patients developed transient hypogammaglobulinemia. Overall,
low-dose rituximab. IgG levels fell from baseline (median, 0.97 g/L for 6 months after
Odds ratios for male patients to be responders were 35.0 (95% CI, treatment; 95% CI, 0.09-3.2 g/L; P 5 .0093). IgM levels fell (median,
2.6-465; P 5 .007). Cyclosporine levels, BSA, lymphocyte depletion, 0.20 g/L; 95% CI, 0.06-0.45 g/L; P 5 .0068). No changes were ob-
immunoglobulin levels, prior therapies, and other baseline demograph- served in IgA levels. No correlation was observed between immuno-
ics did not signicantly inuence the patients response. globulin levels and response.

T cells Discussion

From day 7 to day 28, peripheral CD41 T cells fell by a median of Interpretation of our study is limited by the sample size. However, we
0.41 3 109/L (95% CI, 0.05-0.63 3 109/L; P 5 .0032) for all patients, did not observe excessive toxicity. TT4 was well tolerated by all
irrespective of response. However, responders had lower CD41 T cells patients including 4 patients .65 years of age. Most grades I to II
than nonresponders for 6 months after treatment (median, 0.62 vs therapy-related adverse side effects were attributable to high-dose
0.91 3 109/L; P , .0001). dexamethasone and resolved by day 7.
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502 CHOI et al BLOOD, 23 JULY 2015 x VOLUME 126, NUMBER 4

Figure 1. Platelet response, Kaplan Meier analyses and CD41 lymphocyte depletion. (A) Whisker plots of platelet counts during the first 12 months from responders. The
central horizontal bold line is the median; the cross is the mean; the lower and upper box limits are the first and third quartiles, respectively; and the whiskers include all data
points. One patient relapsed at month 7. (B) Kaplan-Meier analysis of all patients treated with TT4. Vertical marks indicate the last follow-up of an ongoing response; 47% of
the 20 treated patients were estimated to have a long-term response of .46 months from treatment. (C) Kaplan-Meier TFS curve for all patients. Median undefined, 75%
treatment free at 12 months (95% CI, 49-88%). (D) Whisker plots of CD41 T cells during the first 7 months: responders vs nonresponders. Median 0.62 vs 0.91 (P , .0001).
The central horizontal line is the median; the lower and upper box limits are the first and third quartiles, respectively; and the whiskers include all data points. CD41 counts
were not significantly lower in men compared with women (P 5 .1639).

Our study included 12 of 20 patients (60%) who failed $3 prior Despite xed low-dose rituximab, we were surprised to see no
lines of therapy. Steroid resistance was notably increased in 4 of the disadvantage with increasing BSA or male sex. The latency of
7 patients who had 2 prior lines of therapy. These cases are all less likely response reported with low-dose rituximab22 may be ameliorated by
to respond or spontaneously remit than treatment-nave ITP.9,11 adding dexamethasone.11
Although treatment with TT4 was more successful for patients who A major advantage of TT4 is its short duration of therapy (28 days)
had failed ,3 lines of therapy, long-standing disease was not a disad- and yet 60% of patients enjoyed prolonged remissions of $7 months
vantage. The improved outcome for men in our study has not been without further therapy. Protocols using low-dose rituximab will be
reported in studies previously using rituximab either alone19 or in com- attractive where funding resources are limited. Although our study
bination with dexamethasone.10 Our study suggests that male ITP shows encouraging results, the incremental benet of cyclosporine
patients may benet from T-cell suppression, but this requires con- to rituximab and dexamethasone remains unresolved, and random-
rmation by further studies. ized controlled trials are required.
As CD41 T cell activation is part of the pathogenic loop sustaining
ITP, suppressing their activation seems a reasonable target. Supporting
this hypothesis, cyclosporine monotherapy has demonstrated efcacy
in chronic and refractory ITP.20,21 In these studies, platelet counts in- Acknowledgments
creased within 4 weeks of commencement. In our study, CD41 counts
fell during this time. Although dexamethasone alone may cause some T The authors thank Roslyn Ristuccia for assistance in study protocol
cell suppression, we postulate a synergism with cyclosporine that may design and Elena Simon Mendoza for assistance in coordinating
lead to improved platelet responses, at least for a subset of ITP patients. study and collecting data; both are from the St George Clinical Trial
We included 5 patients with secondary ITP. Treatment of their un- Unit. The authors also thank Dr Amanda Hugman, Professor Szu-Hee
derlying conditions was inadequate to control their thrombocytopenia. Lee, Dr Freda Passam, and Dr Stephanie Hayes for assistance in con-
Excluding their data had no signicant impact on the study outcomes. ducting the study.
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BLOOD, 23 JULY 2015 x VOLUME 126, NUMBER 4 TRIPLE THERAPY FOR ITP CAN BE SAFE AND EFFECTIVE 503

edited the manuscript; and B.H.C. conceived the idea, designed

Authorship the study protocol, analyzed and interpreted the data, and edited
the manuscript.
Contribution: P.Y.-I.C. designed the study protocol, coordinated Conict-of-interest disclosure: X.B. has received speakers fees
the study, collected, analyzed, and interpreted the data, wrote the from Roche. B.H.C. is on the speakers bureau and receives research
rst draft of the manuscript, and edited the manuscript; F.R. funding from GSK and Amgen. The remaining authors declare no
provided intellectual and clinical input and edited the manuscript; competing nancial interests.
X.B. provided intellectual and clinical input and edited the Correspondence: Beng H. Chong, Level 4, Clinical Services
manuscript; S.R. provided intellectual and clinical input and Building, St George Hospital, Gray St, Kogarah, NSW 2217,
edited the manuscript; S.-J.H. provided intellectual input and Australia; e-mail: [email protected].

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 From www.bloodjournal.org by guest on December 19, 2015. For personal use only.

2015 126: 500-503

doi:10.1182/blood-2015-03-631937 originally published
online May 13, 2015

A novel triple therapy for ITP using high-dose dexamethasone, low-dose

rituximab, and cyclosporine (TT4)
Philip Young-Ill Choi, Fernando Roncolato, Xavier Badoux, Sundra Ramanathan, Shir-Jing Ho and
Beng H. Chong

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