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【摘要】 目的 观察大剂量甲泼尼龙(HDMP)和大剂量丙种球蛋白(HDIVIG)冲击治疗重症特发性血小板减少性紫癜(ITP)的短期疗效。方法 32例血小板<10×109/L的成人重症ITP患者随机分成HDMP和HDIVIG两组。HDMP组18例,给予甲泼尼龙1.0g/d,连用3d,接泼尼松1.5mg/(kg•d)。HDIVIG组14例,给予丙种球蛋白0.4g/(kg•d),连用3d,接泼尼松1.5mg/(kg•d)。治疗后7~10d测血小板数目。结果 HDMP组和HDIVIG组血小板上升至20×109/L需(4.1±1.8)天和(3.3±1.6)d。达50×109/L分别为(6.5±2.7)d和(5.9±2.5)d,差异均无统计学意义(P分别>0.20和>0.50)。结论 大剂量甲泼尼龙和大剂量丙种球蛋白治疗成人重症ITP短期提升血小板疗效相似。甲泼尼龙相对廉价,可广泛使用。�
【关键词】
特发性血小板减少性紫癜;甲泼尼龙;丙种球蛋白
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The short-term responses between high dose methylprednisolone and high dose intravenous immunoglobulin as initial therapy for severe idiopathic thrombocytopenic purpura in adult
WU Zhen-tian, CHEN Rong, YUAN Zhong-yong, et al.Hematology department of Mindong Hospital affiliated Fujian Medical University, Fu’an 355000,China
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【Abstract】 Objective To compare the short-term response between high dose methylprednisolone (HDMP) and high dose intravenous immunoglobulin(HDIVIG) in treating adults with severe idiopathic thrombocytopenic purpura(ITP). Methods Thirty-two adults with severe ITP and a platelet count below 10×109�/L were randomized to receive either 1.0 g/(kg•d）(n=18;group HDMP) or 0.4 g/kg/d (n=14; group HDIVIG) for 3 consecutive days, after that, every case was administered with prednisone［1.5 mg/(kg•d)=. Platelet counts were measured daily up to day 7~10. Results The days platelet ascending to 20×109�/L and 50×109�/L were（4.1±1.8） and（6.5±2.7） respectively in the HDMP group compared with（3.3±1.6）and（5.9±2.5） respectively in the HDIVIG group. There was no significant difference in the time platelet ascending to the above counts between the two groups with P>0.20 and P>0.50 respectively. Conclusion Both HDMP and HDIVIG treatments to severe ITP in adults are effective. The short-term responses of the two agents are similar. In contrast to intravenous immunoglobulin, methylprednisolone is cheep, so it may be widely used.�
【Key words】 idiopathic thrombocytopenic purpura; methylpredhnisolone; immunoglobulin
特发性血小板减少性紫癜(idiopathicthrombocytopenicpurpura,ITP)为血液科常见病、多发病。血小板减少,特别是0.5),见表1。两组治疗后2d、5d及7d血小板均明显上升(P=0.000)。组间和不同时点交互作用比较差异无统计学意义(P=0.380和0.671),见表1、图1。两组升高血小板至20×109/L及50×109/L所需时间相似,两者差异无统计学意义(P分别>0.20和>0.50),见表2。两组均未出现严重不良反应。�
3 讨论�
迄今为止,大剂量甲泼尼龙和大剂量丙种球蛋白短程冲击重症ITP是快速提升血小板的主要手段。大剂量丙种球蛋白突出缺点是费用高,许多患者无法接受。为此,大剂量甲泼尼龙成为临床医师特别是基层单位的重要选择。本文比较两种方案治疗重症ITP短期提升血小板疗效。�
本组32例成人重症ITP中,HDIVIG组治疗后血小板上升似乎较HDMP组稍快(表1,图1),但差别无统计学意义(表1),与Demircio等[2]在儿童患者中的研究相似。两组方案治疗后血小板达20×109/L所需时间分别为(3.3±1.6)d及(4.1±1.8)d(表2),差异无统计学意义(P>0.20),与文献[3]报道相符。由此可见,大剂量甲泼尼龙在治疗重症ITP、快速提升血小板以渡过安全期予减少病死率方面与大剂量丙种球蛋白有同等的疗效,而该文献[3]报道达50×109/L方面IVIG较HDMP稍快(P=0.04),此差异可能与剂量有关,该文献IVIG为0.7g/(kg•d),MP为15mg/(kg•d)。李绪香[4]将IVIG剂量提升到1.0g/(kg•d),近期疗效亦优于30mg/(kg•d)的MP。Benesch的研究证实IVIG剂量与疗效有关[5]。然而,IVIG剂量增加,其过敏反应和肝炎病毒传染及头痛等不良反应亦可能增加。该组病例MP为1.0g/d,IVIG为0.4g/(kg•d),均未出现严重不良反应。免疫抑制为糖皮质激素主要不良反应之一,但有学者[6]研究指出HDMP短程治疗ITP后患者血清IgA、IgG及IgM水平及CD3、CD4、CD8、CD19淋巴细胞反而有所升高,对有丝分裂原的反应丝毫未受影响,因此HDMP短程冲击治疗ITP免疫系统不受抑制。�
由此可见,HDMP短程治疗成人重症ITP疗效同HDIVIG,能迅速提升血小板于相对安全范围,无明显副作用,然而相对HDIVIG,HDMP费用较低,因此适宜临床广泛使用。�
参 考 文 献�
［1］ 张之南,沈递.血液病诊断及疗效标准.北京:科学出版社,2007:172-176.�
［2］ Demircio lu F, Saygi M, Yilmaz S,et al. Clinical features, treatment responses, and outcome of children with idiopathic thrombocytopenic purpura. Pediatr Hematol Oncol, 2009,26(7):526-532.�
［3］ Godeau B, Chevret S, Varet B, et al. Intravenous immunoglobulin or high-dose methylprednisolone, with or without oral prednisone, for adults with untreated severe autoimmune thrombocytopenic purpura:a randomised, multicentre trial. Lancet,2002,359(9300):23-29.�
［4］ 李绪香.大剂量甲基强的松龙与静脉输注免疫球蛋白治疗急性血小板减少性紫癜临床观察.中国医药导报,2006,3(35):69-70.�
［5］ Benesch M, Kerbl R, Lackner H, et al. Low-dose versus high-dose immunoglobulin for primary treatment of acute immune thrombocytopenic purpura in children: results of a prospective, randomized single-center trial. J Pediatr Hematol Oncol, 2003,25(10):797-800.�
［6］ Yetgin S, Yenicesu IC, Ersoy F. The effects of megadose methylprednisolone therapy on the immune system in childhood immune thrombocytopenia. Pediatr Hematol Oncol, 2005,22(5):401-407.
