ITP – Ideopathic Thrombocytopenic Purpura

Ideopathic thrombocytopenic purpura (ITP) is an autoimmune hemorrhagic disorder characterized by progressive platelet loss and bleeding. It is a systemic illness that produces purple patches caused by small hemorrhages from mucous membranes. Women are affected by this condition three times as often as men are. Platelet counts decline due to an immune attack triggered by antibodies that target specific antigens on the platelets. When the platelets enter the spleen, they are destroyed.

Patients with this disease often have a history of nosebleeds, bruising and hemorrhage, all of which increase as platelet levels decline. ITP becomes chronic in almost all adults and is generally acute and limited in children, although an estimated 10-30% of children will also become chronic (Tarantino, 2000). Mortality is high in patients with failed interventions.

Western Treatment Options

An expert panel established by the American Society of Hematology in 1994 extensively reviewed ITP-related research and published practice guidelines. It is clear that ITP management remains primarily empirical (Yang and Han, 2000).

There are three basic treatment options. Treatment with high-dose corticosteroids can be used to control the immune attack and put the disease in temporary remission. Most patients relapse after steroid doses are tapered. The use of intravenous immunoglobulin (IVIG) can be used to temporarily restore platelets. The presumed mechanism of action is thought to be by sparing of platelets via receptor site blockade. The beneficial effect of this treatment peaks at two weeks and lasts about one month on average.  Because most platelet destruction occurs in the spleen, spleen removal is the next course, which results in a 50-60% remission rate. Spleen removal is the other option, and has been in use since 1913.

TCM Understanding and Treatment of ITP

TCM textbooks and journal articles universally report high levels of success in treating ITP in both children and adults. Several published Chinese studies have shown that the diagnoses given by TCM doctors closely corresponds to measurable immune cell changes, including T lymphocyte subsets, NK cells, and platelet-associated IgG (Yang et al., 1995, Zhan et al., 1992). Furthermore, in a typical study of 66 patients, researchers reported improvement in platelet counts in four of five subgroups taking TCM prescriptions (Yang, 1992).
At the Shanghai Children’s Hospital , the Institute of TCM-WM (combined Chinese and Western medicine) did a clinical study of 41 children.  Of the 41 subjects, 36 had tiny hemorragic spots and larger purple skin patches, 28 had nasal hemorrhage, 5 had blood in the stool and 1 had a subcutaneous hematoma. The basic herbal prescription contained cooked rehmannia root, dang gui root (Angelica sinensis), red peony root (Paeonia rubra), qian cao gen root (Rubia cordifolia), psoralea seed (P. corylifolia), astragalus root (A. membranicus), cuscuta seed (C. chinensis), and da zao fruit (Ziziphus jujuba). After average treatment duration of 5.02 months, researchers reported that 24 cases were cured, six recovered, 10 improved, and one failed to respond, with a total effective rate of 97.6%.  Upon follow-up they discovered that 22 of the cured patients remained without recurrence for an average 10.4 months after withdrawal (She and Wu, 1991). This formula has been modified by research in China over the next decades, and other herbs used now include Hé shou wu (Polygonum multiflorum), Salvia root (dan shen / Salvia miltiorrhiza) and others.

It is important to realize that all TCM doctors trained in the modern era are aware of the modern immunological understandings, while herbs are empirically chosen and formulated based upon long-standing historical use for a variety of bleeding disorders. ITP in TCM is usually divided into two sets, traditionally called “Heat in the blood causing Yin deficiency,” and “Spleen Qi deficiency failing to hold the blood in the vessels.” These terms could be loosely translated as “inflammation-related hemorrhage” and “nutrient deficiency-related hemorrhage.” The basic herbal treatment formulations are similar for both groups, with a slightly increased emphasis on anti-inflammatory herbs for the former, and a slightly increased emphasis on herbs that improve digestion in the latter.

According to a recent, thorough review of 15 Chinese clinical reports, the herbs used vary markedly from physician to physician in China.  However, fewer than 30 herbs are generally used, and they fall within four clear groupings—anti-inflammatory, hemostatic, digestion-strengthening and liver-nourishing. Administration of the various decoctions of herbs was reported to raise platelet levels to acceptable levels in many cases, and to normal levels in a few cases. The number of patients who did not relapse was about equal to the number who did. Many who discontinued herbs did not relapse for periods of time up to several months or longer. IgG levels also decreased in several studies (Dharmananda, 2000).

No independent verifications have ever been done in the West of these clinical reports. Possible mechanisms of action were shown in a series of in vitro pharmacological studies done in 1991 showing that platelet-producing cells in ITP patients were obviously underfunctioning. A 1% incubation of patient’s serum with a TCM herbal extract was able to increase platelet numbers close to normal, suggesting that the herbs might inhibit the antiplatelet antibodies, and/or facilitate reproduction, division and maturity of the platelet-producing  cells (Zhou et al., 1991).

Combining Western and Eastern Methods to Treat ITP

Western practitioners have not yet considered either nutritional or TCM herbal protocols as viable treatment options.  If we add TCM herbal treatment to the three known Western options, we end up with four main treatment methods:

• Corticosteroids (i.e. prednisone)
• IVIG/Anti-D  (Intravenous infusion of IgG)
• Splenectomy
• TCM herbs

Each of these treatment options presents a variety of clearly circumscribed problems. Side effects of prednisone treatment are serious and well known, and the effectiveness of the treatment declines over time. IVIG treatment is expensive, and relatively free of side effects, although the FDA reported 15 cases of hemoglobinemia and/or hemoglobinuria between March 1995 licensure and April 1999, giving an estimated 1.5% occurrence (Gaines, 2000). The main problem besides expense is that the effectiveness of this treatment also declines over time.

The herbs commonly used for TCM herbal treatment of ITP have a very low side effect profile, and are virtually devoid of serious side effects when acquired from a reputable TCM physician and properly administered. However, as mentioned, there is a deficiency of acceptable clinical proof of efficacy, and there have been no long-term studies to show if the treatments will lose effectiveness over periods of time longer than one year. There is a strong history of simultaneous use of steroids with TCM herbs with no interactive problems, but the same is not true of IVIG therapy, so I advise a minimum withdrawal of TCM herbs two days prior and three days subsequent to IVIG therapy to avoid direct interaction. It might be equally advisable to discontinue TCM herbs for up to three weeks to completely ensure there is no negative interaction weakening the IVIG.

Splenectomy has a limited initial success rate of 50-60%, and fatal sepsis is always possible as time passes after the operation because opsonin—a “glue” that helps bind antigens—is manufactured only in the spleen (Bell, 2000). In children, the estimated success rate ranges from 70% to 90%.  However, the long-term outcome of splenectomy in children has not been studied sufficiently (Tarantino, 2000). Most clinicians now believe the operation should be performed only when all other therapeutic options have been exhausted, and the patient has a platelet count less than 25,000/microL and is hemorrhaging (Bell, 2000).

For these reasons, researchers at the Division of Hematology/Oncology and General Internal Medicine at Northwestern University Medical School in Chicago hoped that maintenance therapy with IVIG treatment would “increase the rate of remission, allowing splenectomy to be avoided” (Bennett et al., 2000). Pediatric hematologists often postpone splenectomy when there is a reasonable possibility of spontaneous recovery. This consideration is of great importance because after splenectomy patients become ineligible for IVIg or prednisone treatment. However, there is no known reason why TCM therapy cannot still be used after the procedure, as long as you consider the sterility of the herbs.

Given this background, I propose that TCM treatment should be used for exactly the same reasons as IVIG or prednisone therapy. The evidence from China points to the possibility that herbs can improve platelet counts, though at a slower and less reliable rate than prednisone or IVIG therapy, while maintaining a low side effect profile. By giving clinicians a fourth option, the chances of successfully avoiding splenectomy increase, unless the TCM therapy is subsequently determined to be completely without merit.