From Dr. Cutrell’s antibiotic stewardship talk – see this helpful list of antibiotics with excellent PO bioavailability and take his advice to make the IV to PO switch when possible!
This week at morning report, we discussed TTP. Here is how you should think about the management of TTP:
Plasma Exchange: cornerstone of treatment. Perform daily until there is a complete response (see below).
Rituximab: beneficial to start early, there is data that suggests better remission rates when added to plasma exchange upfront.
Steroids: adjunctive because there is minimal data to back this up, but generally recommended if there is no contraindication.
These treatment modalities are initiated early and urgently in a patient with presumptive TTP. Treatment is continued until there is a complete response, which is defined by a platelet count above 150,000 for two consecutive days, together with normal or normalizing LDH and clinical recovery (ie end organ damage has resolved). After treatment, patients are most vulnerable to a recurrence within the first week after tapering of therapy. Patients are followed closely to assess for symptoms and for CBC/ADAMTS13 monitoring. What is unclear is what to do with patients who are asymptomatic but have a down trending/low ADAMTS13. In this situation, data suggests that treatment with rituximab can reduce the possibility of relapse, likely through decreasing the production of the antibodies inhibiting ADAMTS13.