Treatment of idiopathic thrombocytopenic purpura
Etiology and pathogenesis Idiopathic thrombocytopenic purpura is often manifested as cutaneous mucosal purpura, nosebleed, bite, hematuria, menorrhagia and so on. Its pathogenesis is related to exogenous factors, diet, fatigue and seven emotions, with heat and blood stasis as the standard and qi deficiency and yin deficiency as the basis. Feel foreign evil, or eat spicy products, ...
Etiology and pathogenesis
Idiopathic thrombocytopenic purpura is often manifested as cutaneous mucosal purpura, nosebleed, bite, hematuria, menorrhagia and so on. Its pathogenesis is related to exogenous factors, diet, fatigue and seven emotions, with heat and blood stasis as the standard and qi deficiency and yin deficiency as the basis.
Feel the external evil, or the taste of food and spice, from yang to heat, or emotional stagnation, stagnation to fire, the evil poison contains, burning pulse, forcing blood to rush; Heat toxin is intrinsic, which will damage yin for a long time, fire due to yin deficiency will flourish, and deficiency heat will burn the pulse, which can also cause blood to overflow the pulse. Improper diet, strain, weakness of the body and spleen, and spleen failing to control blood can all cause blood to overflow without following menstruation. Overflowing skin is purpura, while upper outlet is clear, vomiting occurs, and lower energizer can cause blood in stool and urine.
When qi and blood go up and reach the brain, it will be a stroke, which is characterized by sudden fainting and unconsciousness; Long-term illness, loss of qi and blood, deficiency of both qi and blood, fatigue, dizziness, pale or sallow complexion, loss of appetite; If there is too much blood, the qi will be detached with the blood, which is a syndrome of detachment, manifested as unconsciousness, second, self-retention, limb paralysis; Patients taking glucocorticoids showed early symptoms of damp-heat accumulation, skin sores, dry mouth and bitter taste, followed by phlegm-dampness stagnation and qi deficiency and obesity. Long-term use of glucocorticoid can also be manifested as deficiency of both qi and yin or deficiency of both yin and yang, such as restless sleep, chills and cold limbs. Blood separated from meridians is blood stasis, and heat toxin can cause blood stasis, blood collateral obstruction due to yin deficiency, inability to advance due to qi deficiency, blood stasis blocking blood circulation, and blood not returning to meridians, leading to all kinds of bleeding.
For patients with chronic refractory ITP, such as glucocorticoid, immunosuppressant and splenectomy, it is difficult to continue treatment to improve platelet count. For those who are dependent on hormone therapy, in addition to combined therapy, Chinese medicine can use Baidihuang Pill for nourishing liver and kidney or Guifu Bawei Pill for warming spleen and kidney to reduce or avoid the rebound in the process of hormone reduction or withdrawal. Patients with latent infection in the body should be treated with traditional Chinese medicine to clear away heat, cool blood and detoxify, so as to eliminate the influence of latent infection as much as possible; In addition, on the basis of clearing away heat and cooling blood, nourishing yin and reducing fire, invigorating spleen and invigorating qi, we can treat liver syndrome differentiation, such as adding and subtracting drugs for liver heat, adding and subtracting Chaihu Indigo for liver yin deficiency, adding and subtracting Paeonia lactiflora for liver yin deficiency, and adding and subtracting Angelica Ziziphus Spinosae for liver blood deficiency, so that the platelet count can reach a safe range.
Diet therapy for patients with thrombocytopenia;
Lycium barbarum, red dates and egg soup: Lycium barbarum 10g, red dates 10g, Codonopsis pilosula 10g and 2 eggs. Put Fructus Lycii, Fructus Jujubae, and Radix Codonopsis into a casserole and cook into soup. After the eggs are cooked, remove the shells to get the eggs, and then cook them for a while to eat eggs and drink soup. This is 1 daily, taken twice.
Sheep spine soup: sheep spine (even tail) 1 tablet, cistanche deserticola 10g, dodder 10g, and appropriate amount of onion, ginger and salt. Crushing sheep spine; Soaking Herba Cistanches in wine overnight, and scraping off rough skin; Soaking Semen Cuscutae in wine for 3 days, drying in the sun, mashing, adding appropriate amount of water, adding sheep spine and Herba Cistanches, stewing until cooked, and adding Semen Cuscutae powder and seasoning. This is 1 day, taken twice on an empty stomach.
The number of platelets in the blood is lower than normal, which is called thrombocytopenia. The main clinical manifestations are skin and mucous membrane bleeding symptoms, such as purpura, gingival bleeding, hematemesis, melena, hematuria and so on. This disease belongs to the categories of "blood disease", "spot" and "fatigue" in traditional Chinese medicine. In the acute stage of treatment, the main methods are clearing away heat and toxic materials, cooling blood and removing blood stasis. The chronic stage is mainly to strengthen the spleen and regulate qi, and replenish qi and blood.
Diet therapy for thrombocytopenia can be selected:
1) Cirsium japonicum 15g, red glutinous rice 50g. Take thistle soup, cook red glutinous rice into porridge with medicinal juice, and add appropriate amount of brown sugar after porridge is finished.
Efficacy: detoxify and eliminate carbuncle, cool blood and stop bleeding. Used for dietotherapy in acute phase.
2) buffalo horn 15g, 50g of red glutinous rice, decocting rhinoceros horn or buffalo horn in water for 30 minutes to get juice, cooking the juice and red glutinous rice into porridge, and adding appropriate amount of brown sugar after the porridge is finished.
Efficacy: clearing away heat, cooling blood and detoxifying. Used for dietotherapy in acute phase.
3) 250g shepherd's purse. Wash, blanch with boiling water, remove, cut into pieces, and serve with seasonings such as tofu, salt, monosodium glutamate and sesame oil. Used for acute diet therapy.
4) 20 grams of Agrimonia pilosa and 50 grams of red glutinous rice. First, decoct Agrimonia pilosa to get juice, add red glutinous rice to cook porridge, and add appropriate amount of brown sugar to take after porridge is finished.
Efficacy: tonify deficiency and stop bleeding. Used for chronic diet therapy.
5) Bovine bone marrow 50g, red glutinous rice 100g. Cook porridge together. Add proper amount of salt, monosodium glutamate, onion and Jiang Mo after porridge is done. Suitable for chronic diet therapy.
1. general therapy: acute cases mainly have massive bleeding within 1 ~ 2 weeks after onset, so activities should be reduced at the initial stage of onset to avoid trauma, especially head trauma, and severe cases should be kept in bed. Infection should be actively prevented and controlled. Aspirin can cause bleeding and must be avoided. Give enough liquid and digestible diet to avoid oral mucosal damage. In order to reduce bleeding tendency, a large number of vitamins C and P are often given. Compression hemostasis was performed on patients with local bleeding. General cases do not need special treatment. If there is serious bleeding or suspected intracranial bleeding, various hemostatic measures should be actively taken. Mild bleeding or chronic cases in remission do not need special treatment, but trauma should be avoided to prevent infection. Sometimes minor respiratory infection can lead to serious recurrence. For patients with severe bleeding or long-term treatment, the following special treatments should be given.
2. Infusion of new blood or platelets: it can only be used as an emergency treatment for severe bleeding. Due to the existence of anti-platelet antibodies in patients' blood, the imported blood can be quickly destroyed and the life span is short (several minutes to several hours). Therefore, blood transfusion or platelets can not effectively increase the number of platelets. However, some people think that platelet transfusion can quickly reduce capillary fragility and reduce bleeding tendency.
3. Adrenal cortical hormone: It is generally believed that the curative effect of hormone is due to: ① reducing capillary permeability of hair cells and reducing bleeding tendency; ② Decrease the immune response, reduce the production of PAIgG, and inhibit the phagocytosis of spleen mononuclear macrophages on platelets with antibodies. Therefore, the bleeding phenomenon of ITP patients can be improved quickly after early application of a large number of hormones. At present, hormone therapy is still advocated for patients with moderate or serious illness within 1 month (especially within 2 weeks). The principle of medication is early, large amount and short course of treatment. Generally, prednisone 60 mg/m2 d (2 mg/kg d) is taken orally for 2-3 times, or/kloc-0 times in the morning. If the bleeding is serious, you can take prednisone orally to120mg/m2 d, or drip hydrocortisone 400mg/m2·d or flumethasone/kloc-0 ~15mg/m2 d intravenously, and change it to prednisone 60mg/m2·d after the bleeding improves. Generally, the drug is used for about 3 weeks, and the longest is no more than 4 weeks, and it is gradually reduced until the drug is stopped.
4. Intravenous infusion of high-dose gamma globulin: For children with severe bleeding or above, high-dose refined gamma globulin (IgG) can also be infused intravenously, about 0.4g/kg·d, for 5 days. About 70% ~ 80% patients can increase platelet count. However, this kind of refined product is expensive and difficult to popularize for a while.
5. Immunosuppressant: Those who fail to respond to hormone therapy can still try: ① Vincristine is injected intravenously once a week at a dose of 1.5 ~ 2mg/m2 (the maximum dose is 2mg/ time); Or 0.5 ~ 1 mg/m2 and 250ml of normal saline are given slowly intravenously each time, and the course of treatment is 4 ~ 6 weeks 1. Platelets increased after taking the drug, but most patients decreased after stopping taking the drug, and only a few of them could be relieved for a long time. Because the curative effect is short, it is more suitable for preoperative preparation. ② Cyclophosphamide was given orally at 2 ~ 3 mg/kg d or intravenously at 300 ~ 600 mg/m2, 65,438 0 times a week. The effective time is 2 ~ 6 weeks, and the drug can be stopped if it is ineffective after 8 weeks. Effective patients can continue to take medicine for 4 ~ 6 weeks. (3) azathioprine1~ 3 mg/kg d, generally effective in one month. These immunosuppressants can be used in combination with corticosteroids.
6. Other drugs: Danazol (DNZ), a non-positive synthetic androgen, has been tried at home and abroad in recent years. In the treatment of refractory chronic ITP patients, the immediate effect is good and the maintenance time is short, which is of certain value to patients who need to temporarily raise platelets to prepare for splenectomy.
7. Splenectomy: The remission rate of chronic ITP by splenectomy is 70% ~ 75%. However, we should carefully grasp the surgical indications and postpone splenectomy as much as possible.
Side effects of long-term use of hormones
Hormone is the most important anti-inflammatory and immunosuppressive drug for lupus erythematosus. Corticosteroids have been used to treat lupus erythematosus for more than 50 years. In this short history, there are both successful experiences and failed lessons. In the process of continuous exploration and intermittent discussion, people come to the conclusion that the application of any drug has both positive and negative effects. As far as hormones are concerned, good use can be said to be a life-saving medicine, and it is not too much to compare it to a bridge to health. However, if it is not used well, hormones may become poison and its side effects.
1, infection: Because it can inhibit the body's response to inflammation, the body's ability to resist infection is reduced. Therefore, superficial or slight infection may evolve into systemic infection, and static infection may turn into active infection, which may cause the migration and spread of purulent lesions, tuberculosis and other potential lesions. Therefore, we should pay attention to the prevention of infection, carefully observe the condition, reduce the dosage and stop taking drugs in time when necessary, and be sure to use drugs in combination when acute infection and poisoning occur.
2. Posture changes: Many patients receiving hormone therapy may have posture changes, which will affect their spirit and mood. Because long-term use of hormones can redistribute fat, patients may have posture changes such as full moon face, buffalo back, trunk obesity, skinny limbs, centripetal obesity, acne, hirsutism, purple skin, etc., which may affect their appearance.
3. Diabetes: Hormones can increase liver glycogen, supplement blood sugar and induce diabetes. When using glucocorticoid in large quantities, we should pay attention to the changes of blood sugar and urine sugar. If hyperglycemia occurs, hypoglycemic drugs and insulin treatment should be given when necessary. However, with the decrease of hormone dosage, the dosage of hypoglycemic agents or insulin can be reduced.
4. Osteoporosis: Hormones can decalcify bones and turn them into osteoporosis. Osteoporosis refers to the reduction of bone mass per unit volume, just like building a house reduces the amount of steel bars and is easy to cause fractures. Aseptic osteonecrosis, especially femoral head necrosis, is also a common complication, but its pathogenesis may be femoral head necrosis caused by blood circulation disorder and capillary inflammation of femoral head, which is also called aseptic necrosis of femoral head because it is not caused by bacterial infection. Therefore, patients who use hormones for a long time must make regular bone mineral density measurements to be aware of it. At the same time, taking vitamins and calcium preparations at the same time as taking hormones can reduce the decrease of bone mass caused by corticosteroids and prevent osteoporosis. Proper physical exercise can promote bone blood circulation and metabolism, and help to prevent osteoporosis and femoral head necrosis. Calcium supplementation is a long-term task, and patients must persist and persevere in order to achieve better curative effect.
5, peptic ulcer: hormones can stimulate gastric acid, pepsin secretion, too much digestive juice can often cause gastritis, gastric and duodenal ulcers, and even perforation and bleeding. If patients have digestive tract symptoms, they should be taken together with antacids when taking hormones to protect the gastric mucosa from damage. Ranitidine, Chen Bailu and others. Commonly used in clinic, it can be used as a synergistic drug for oral hormone drugs.
6. Electrolyte disorder and hypertension: Hormones can cause water and sodium retention and edema. Many patients have hypertension. Due to the increase of potassium excretion, patients often have low potassium. For patients with congestive heart failure or obvious peripheral edema, hormones with little influence on water and salt metabolism should be selected, and the electrolyte balance of patients should be checked regularly. Hormone drugs are often used to treat patients with hypertension, especially lupus nephropathy. At this time, on the one hand, we should minimize the dosage of hormones, on the other hand, we should use antihypertensive drugs appropriately, such as propranolol and captopril. Although some antihypertensive drugs may have side effects on lupus constitution, they still need to be used decisively after weighing the pros and cons.
7. Others: When a large number of corticosteroids are used, patients may obviously appear excitement, irritability, euphoria, mental irritability, insomnia, depression or psychosis. When a large number of corticosteroids are used for a long time, muscle weakness, muscle atrophy, even myositis, elevated intraocular pressure, even glaucoma and cortical gland dysfunction may occur. Irregular menstruation and even amenorrhea are also common.