A Randomized Study of IVIG vs. IVIG With High Dose Methylprednisolone in Childhood ITP.
Information source: The Hospital for Sick Children
ClinicalTrials.gov processed this data on August 23, 2015 Link to the current ClinicalTrials.gov record.
Condition(s) targeted: Immune Thrombocytopenic Purpura
Intervention: Methylprednisolone and IVIG (Drug); Placebo and IVIG (Drug)
Phase: Phase 3
Status: Recruiting
Sponsored by: The Hospital for Sick Children Official(s) and/or principal investigator(s): Manuel Carcao, MD, Principal Investigator, Affiliation: The Hospital for Sick Children Victor Blanchette, MD, Principal Investigator, Affiliation: The Hospital for Sick Children
Overall contact: Manuel Carcao, MD, Phone: 416-813 5367, Email: manuel.carcao@sickkids.ca
Summary
Childhood immune thrombocytopenia purpura (ITP) is a disorder characterized by the
production of antibodies against platelets, resulting in enhanced destruction of platelets.
Most children with ITP present with low platelet counts (PC) but minimal bleeding. Very
rarely a child may present with a severe life-threatening bleed, such as a bleed in the
head. In this case it is very important that the PC be raised as quickly as possible. The
combination of corticosteroids and intravenous gammaglobulin (IVIG) is commonly used in the
management of such severe bleeding in children with ITP to quickly raise the PC and yet this
treatment combination has not been tested against using IVIG alone. If it is shown that the
combination of these agents does result in a quicker rise in PC then when using IVIG alone
would support the use of this combination therapy in emergency situations.
As we can not ethically conduct this study in patients with life-threatening bleeds, we plan
to study patients with ITP and PC less than 20 X 109/L, but without life threatening
bleeding. Eligible patients will be randomized to one of these 2 regimens (IVIG + placebo or
IVIG + IV corticosteroids). The study is designed as a double-blind trial, where the
patient or the treating physician will not be aware of the regimen that a patient is
randomized to. PC's will be measured as a surrogate measure of bleeding risk; bleeding
scores (a score generated by observing patients for bleeding symptoms) will be used to grade
bleeding severity, and adverse effects to treatment will be monitored by the means of
questionnaires throughout the study.
Clinical Details
Official title: A Randomized Study of IVIG vs. IVIG With High Dose Methylprednisolone in Rapidly Augmenting Platelet Counts in Childhood ITP.
Study design: Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Double Blind (Subject, Investigator), Primary Purpose: Treatment
Primary outcome: The rapidity of rise in Platelet Count
Secondary outcome: Days to PC falling to < 20 x 109/LAdverse Effects of therapy Quality of life changes over time and between the treatment groups
Detailed description:
Rarely children with immune thrombocytopenia purpura (ITP) can present with severe or
life-threatening bleeding. In these cases it is very important that the platelet count be
raised as quickly as possible. Several studies have shown that IVIG and corticosteroids on
their own can raise platelet counts, but few studies have examined how the combination of
IVIG and corticosteroids compares to IVIG alone in raising platelet counts in childhood ITP.
Yet despite the lack of conclusive evidence to indicate that steroids given together with
IVIG is more effective, this combination treatment is often given when children present with
a life-threatening bleed, e. g. intracranial bleed. In addition to presumed greater
effectiveness of giving the two agents together there is also evidence to show that the
combination of IVIG with steroids may have other beneficial effects, in addition to greater
effectiveness at raising platelet counts. This can include reducing side effects of IVIG.
We propose to compare the effectiveness of the combination of IVIG with corticosteroids to
IVIG alone in raising platelet counts in children with ITP and a platelet count less than 20
x 109/L. Patient will be eligible only if they in conjunction with their treating physician
have decided to be treated with IVIG. In this way they will require an intravenous
regardless of study participation. The primary outcome is the rise in platelet count as
reflected by the platelet count at 24 hours.
Hypothesis:
IVMP and IVIG, administered together, will
1. increase the PC faster, and
2. minimize the adverse effects of IVIG, and
3. lead to a more sustained increase in PC (longer time before needing retreatment) If it
is shown that the combination of these agents does result in a quicker rise in PC, this
would support and justify the use of the combination therapy in emergency situations.
Study Proposal and Methods:
We propose to prospectively evaluate 2 treatment regimens in patients with childhood ITP:
Regimen A: Placebo followed by IVIG 1 g/kg (Gamunex® Immune Globulin Intravenous [Human],
10%; Bayer)* x 1 dose Regimen B: Combination therapy (IV MP (Solu-Medrol®, Upjohn) 30 mg/kg
(max. 1 g) over 30 min followed by IVIG 1 g/kg (Gamunex® Immune Globulin Intravenous
[Human], 10%; Bayer)* x 1 dose
*Gamunex will be given according to manufacturer's guidelines. Gamunex has been demonstrated
to be safely and effectively administered by means of a rapid infusion protocol whereby it
can be given over a period of 2 hours (although in some cases it needs to be given at a
slower rate over a longer period of time).
Eligibility
Minimum age: 1 Year.
Maximum age: 17 Years.
Gender(s): Both.
Criteria:
Inclusion Criteria:
- ages 1-17 yr. followed at participating centers
- diagnosed with primary ITP
- present with a PC < 20 x 10^9/L
- patient and attending physician have decided on treatment of ITP
Exclusion Criteria:
- initial presentation with ITP
- splenectomy
- life-threatening hemorrhage e. g. proven or suspected intracranial hemorrhage (ICH),
major gastrointestinal hemorrhage with cardiorespiratory decompensation
- organ-threatening hemorrhage e. g. hemorrhage into the eye
- contraindication to IVIG ( renal disease with creatinine > x 2 upper list of normal )
- contraindication of IV methylprednisolone ( diabetes mellitus, hypertension, peptic
ulceration )
- prior failure to attain a PC level over 50 X 109 within 2 weeks of treatment with
IVIG of 0. 8 to 1 g/kg or IV methyl-prednisolone (max 1 gram ) within 6 months prior
to study entry
- co-existing situations that could affect platelet response to therapy e. g. sepsis,
fever > 38. 5°C ( orally or equivalent), splenomegaly (spleen tip > 2 cm below costal
margin), Disseminated Intravascular Coagulation (DIC) - defined by a fibrinogen level
< 1. 0 g/dL and elevated D-dimer levels, surgery
- pregnancy (a mandatory urine pregnancy test will be obtained on all post-pubescent
female patients). Such patients can only be eligible once the urine pregnancy test
results are confirmed to be negative.
Locations and Contacts
Manuel Carcao, MD, Phone: 416-813 5367, Email: manuel.carcao@sickkids.ca
Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada; Recruiting Manuel Carcao, MD, Phone: 416-813 5367, Email: manuel.carcao@sickkids.ca Victor Blanchette, MD, Phone: 416 813 5852, Email: victor.blanchette@sickkids.ca Manuel Carcao, MD, Principal Investigator
Additional Information
Starting date: August 2005
Last updated: November 19, 2014
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