Should rituximab be used before or after splenectomy in patients with immune thrombocytopenic purpura?

The anti-CD20 monoclonal antibody rituximab has been used to treat patients with chronic immune thrombocytopenic purpura. This review discusses whether the optimal timing for this therapy is before splenectomy, or after failure of splenectomy.

No study has directly compared rituximab to splenectomy in patients with chronic immune thrombocytopenic purpura. Rituximab produces an initial response in approximately 60% of cases, with no significant difference between splenectomized and nonsplenectomized patients. Long-term complete responses are observed in 15-20% of cases. Adverse events related to the drug were usually mild or moderate, with a low incidence of infections. Long-term safety data, however, are still lacking. Deaths have been reported for 2.9% of immune thrombocytopenic purpura cases treated with rituximab, but they could not be attributed to the study drug.

Both the response rate and the response duration appear lower following rituximab than following splenectomy. Although the side effects may be fewer, there is insufficient evidence to support the replacement of splenectomy with rituximab as a second-line treatment of chronic immune thrombocytopenic purpura outside a clinical trial. At the present time, the use of immunotherapy before splenectomy can be recommended only in patients at high risk for splenectomy and in those not willing to undergo surgery.