Wednesday, August 24, 2011

To J Dean and TomD on AIHA, FCR, PCR, and flu shots

Friends, please please please, ask me medical questions only using email, not in the comments as I can not respond to your questions without your email address that I don't have. It is frustrating for all of us

My email is listed on my blog: for that purpose.

Remember I can not give medical advice and all my suggestions are only fodder for discussion with your doctors who know you best and must be discussed with them.

J Dean- I see very little advantage in PCR over FCR in terms of AIHA risk. Both P and F are purine analogues with similar toxicities. Both can cause auto-immune problems. P may be a touch safer in terms of auto-immunity but it can and does cause big problems similar to F in terms of wiping out red cells and platelets.

Instead talk to your doctor about HDMP +R (high dose methylprednisilone and rituximab. Or Dr. Rai's protocol of RCD (see study below) or a trial or single agent ofatuzamab.

I don't know enough about the circumstances to give strong advice, but I personally would never ever do PCR after getting bad AIHA from FRC. Never. And I think most CLL experts would agree. Not all, but most. Get a second opinion!

Here is a recent article on RCD

Rituximab, cyclophosphamide and dexamethasone (RCD) effectively target lymphocytes and inhibit autoimmune processes.

Auto-immunehemolytic anemia (AIHA) and idiopathic thrombocytopenic purpura (ITP) are known complications of CLL.

Dr Rai and his colleges used the follow formulation to treat AIHA in CLL patients.

Rituximab 375 mg/m(2) i.v. infusion given on day 1,

cyclophosphamide 750-1000 mg/m(2) i.v. on day 2 and

dexamethasone 12 mg day 1-7 given every 3 weeks. Response to

treatment was seen in all 20 patients with CLL with AIHA. Median

hemoglobin pre-treatment was 8 g/dL. The median change in

hemoglobin was 5.2 g/dL and the median post-treatment

hemoglobin level was noted to be 13.1 g/dL. Median duration of

response was 22 months.

Fifty percent of evaluable patients converted to Coombs negative with

median duration of response of 41 months vs. 10 months for those

who did not convert.

Steroid-refractory immune thrombocytopenia was present in three

patients and all responded to RCD. There were no hospitalisations or

infections directly related to RCD. RCD is a safe and effective regimen

in the treatment of immune cytopenias associated with CLL.

Source: Leuk Lymphoma. 2009 Apr 23; 1-8

If your doctor is not familiar with these protocols, absolutely you must get a second opinion. In fact you should get a second opinion any way. Sorry to be so emphatic, but in case tou didn't notice, I am worried that PCR may not be the best therapy for your man.

TomD- It seems a bit early for flu shots. I have not been following the CDC weekly reports to see if they are predicting an early flu season, but I worry that a shot in August won't do you much good in February at what might be the height of flu activity.

Two shots, one how and one in six to twelve weeks, is always a possibility as is the experimental use of ranitidine to boost response.

I would go for the higher dose myself, but it is just a best guess. It is supposed to help the elderly with their reduced response to vaccines, so it makes sense it would help us too, but there is no proof.

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