Treatment of Immune Thrombocytopenia
Publication Date: December 3, 2019
Last Updated: March 14, 2022
Recommendations
Management of adult patients with newly diagnosed ITP
Corticosteroids vs observation
In adults with newly diagnosed ITP and a platelet count of <30 × 109/L who are asymptomatic or have minor mucocutaneous bleeding, the American Society of Hematology (ASH) guideline panel suggests corticosteroids rather than management with observation. (2⊕ooo)
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In adults with newly diagnosed ITP and a platelet count of ≥30 × 109/L who are asymptomatic or have minor mucocutaneous bleeding, the ASH guideline panel recommends against corticosteroids and in favor of management with observation. (1⊕ooo)
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The treating physician should ensure that the patient is adequately monitored for potential corticosteroid side effects regardless of the duration or type of corticosteroid selected. This includes close monitoring for hypertension, hyperglycemia, sleep and mood disturbances, gastric irritation or ulcer formation, glaucoma, myopathy, and osteoporosis. Given the potential impact of corticosteroids on mental health, the treating physician should conduct an assessment of health-related quality of life (HRQoL) (depression, fatigue, mental status, etc) while patients are receiving corticosteroids. (UGPS, )
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Inpatient vs outpatient management
In adults with newly diagnosed ITP and a platelet count of <20 × 109/L who are asymptomatic or have minor mucocutaneous bleeding, the ASH guideline panel suggests admission to the hospital rather than management as an outpatient. (2⊕ooo)
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In adults with an established diagnosis of ITP and a platelet count of <20 × 109/L who are asymptomatic or have minor mucocutaneous bleeding, the ASH guideline panel suggests outpatient management rather than hospital admission. (2⊕ooo)
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In adults with a platelet count of ≥20 × 109/L who are asymptomatic or have minor mucocutaneous bleeding, the ASH guideline panel suggests management as an outpatient rather than hospital admission. (2⊕ooo)
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The referring physician should ensure that the patient has follow-up with a hematologist within 24 to 72 hours of the diagnosis or disease relapse. (UGPS, )
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Duration and type of corticosteroids
In adults with newly diagnosed ITP, the ASH guideline panel recommends against a prolonged course (>6 weeks including treatment and taper) of prednisone and in favor of a short course (≤6 weeks). (1⊕ooo)
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The treating physician should ensure that the patient is adequately monitored for potential corticosteroid side effects regardless of duration or type of corticosteroid selected. This includes close monitoring for hypertension, hyperglycemia, sleep and mood disturbances, gastric irritation or ulcer formation, glaucoma, myopathy, and osteoporosis. Given the impact of corticosteroids on mental health, the treating physician should conduct an assessment of HRQoL (depression, fatigue, mental status, etc) while patients are receiving corticosteroids. (UGPS, )
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In adults with newly diagnosed ITP, the ASH guideline panel suggests either prednisone (0.5-2.0 mg/kg per day) or dexamethasone (40 mg per day for 4 days) as the type of corticosteroid for initial therapy. (2⊕ooo)
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The treating physician should ensure that the patient is adequately monitored for potential corticosteroid side effects regardless of the duration or type of corticosteroid selected. This includes close monitoring for hypertension, hyperglycemia, sleep and mood disturbances, gastric irritation or ulcer formation, glaucoma, myopathy, and osteoporosis. Given the impact of corticosteroids on mental health, the treating physician should assess HRQoL (depression, fatigue, mental status, etc) while patients are receiving corticosteroids. (UGPS, )
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Rituximab as initial treatment
In adults with newly diagnosed ITP, the ASH guideline panel suggests corticosteroids alone rather than rituximab and corticosteroids for initial therapy. (2⊕ooo)
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Management of adults with ITP who are corticosteroid-dependent or do not have a response to corticosteroids
Eltrombopag vs romiplostim
In adults with ITP for ≥3 months who are corticosteroid-dependent or unresponsive to corticosteroids and are going to be treated with a thrombopoietin receptor agonist (TPO-RA), the ASH guideline panel suggests either eltrombopag or romiplostim. (2⊕ooo)
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Second-line therapies: splenectomy, TPO-RA, and rituximab compared 1 against the other
In adults with ITP lasting ≥3 months who are corticosteroid-dependent or have no response to corticosteroids, the ASH guideline panel suggests either splenectomy or a TPO-RA. (2⊕ooo)
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In adults with ITP lasting ≥3 months who are corticosteroid-dependent or have no response to corticosteroids, the ASH guideline panel suggests rituximab rather than splenectomy. (2⊕ooo)
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In adults with ITP lasting ≥3 months who are corticosteroid-dependent or have no response to corticosteroids, the ASH guideline panel suggests a TPO-RA rather than rituximab. (2⊕ooo)
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The treating physician should ensure that patients have appropriate immunizations prior to splenectomy and that they receive counseling regarding antibiotic prophylaxis following splenectomy. The treating physician should also educate the patient on prompt recognition and management of fever and refer to current recommendations on pre- and postsplenectomy care. (UGPS, )
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Management of children with newly diagnosed ITP
Outpatient vs inpatient management
In children with newly diagnosed ITP and a platelet count of <20 × 109/L who have no or mild bleeding (skin manifestations) only, the ASH guideline panel suggests against admission to the hospital and in favor of management as an outpatient. (2⊕ooo)
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In children with newly diagnosed ITP and a platelet count of ≥20 × 109/L who have no or mild bleeding (skin manifestations) only, the ASH guideline panel suggests against admission to the hospital and in favor of management as an outpatient. (2⊕ooo)
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The referring physician should ensure that the patient has follow-up with a hematologist within 24 to 72 hours of diagnosis. (UGPS, )
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Treatment vs observation
In children with newly diagnosed ITP who have no or minor bleeding, the ASH guideline panel suggests observation rather than corticosteroids. (2⊕ooo)
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In children with newly diagnosed ITP who have no or minor bleeding, the ASH guideline panel recommends observation rather than IV immunoglobulin (IVIG). (1⊕⊕⊕o)
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In children with newly diagnosed ITP who have no or minor bleeding, the ASH guideline panel recommends observation rather than anti-D immunoglobulin. (1⊕⊕⊕o)
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Corticosteroid duration and type
In children with newly diagnosed ITP who have non–life-threatening mucosal bleeding and/or diminished HRQoL, the ASH guideline panel recommends against courses of corticosteroids longer than 7 days and in favor of courses 7 days or shorter. (1⊕ooo)
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In children with newly diagnosed ITP who have non–life-threatening mucosal bleeding and/or diminished HRQoL, the ASH guideline panel suggests prednisone (2-4 mg/kg per day; maximum, 120 mg daily, for 5-7 days) rather than dexamethasone (0.6 mg/kg per day; maximum, 40 mg per day for 4 days). (2⊕ooo)
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Treatment of children with non–life-threatening bleeding and/or diminished HRQoL
In children with newly diagnosed ITP who have non–life-threatening mucosal bleeding and/or diminished HRQoL, the ASH guideline panel suggests corticosteroids rather than anti-D immunoglobulin. (2⊕⊕oo)
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In children with newly diagnosed ITP who have non–life-threatening mucosal bleeding and/or diminished HRQoL, the ASH guideline panel suggests either anti-D immunoglobulin or IVIG. (2⊕⊕oo)
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In children with newly diagnosed ITP who have non–life-threatening mucosal bleeding and/or diminished HRQoL, the ASH guideline panel suggests corticosteroids rather than IVIG. (2⊕⊕oo)
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Management of children with ITP who do not have a response to first-line treatment
Second-line therapies: splenectomy, TPO-RA, and rituximab compared 1 against the other
In children with ITP who have non–life-threatening mucosal bleeding and/or diminished HRQoL and do not respond to first-line treatment, the ASH guideline panel suggests the use of TPO-RAs rather than rituximab. (2⊕ooo)
312101
In children with ITP who have non–life-threatening mucosal bleeding and/or diminished HRQoL and do not respond to first-line treatment, the ASH guideline panel suggests TPO-RAs rather than splenectomy. (2⊕ooo)
312101
In children with ITP who have non–life-threatening mucosal bleeding and/or diminished HRQoL and do not respond to first-line treatment, the ASH guideline panel suggests rituximab rather than splenectomy. (2⊕ooo)
312101
The treating physician should ensure that the patient has appropriate immunizations prior to splenectomy and that they receive counseling regarding antibiotic prophylaxis following splenectomy. The treating physician should educate the patient on prompt recognition and management of fever and refer to current recommendations on pre- and postsplenectomy care. (UGPS, )
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Recommendation Grading
Disclaimer
Overview
Title
Treatment of Immune Thrombocytopenia
Authoring Organization
American Society of Hematology
Publication Month/Year
December 3, 2019
Last Updated Month/Year
July 28, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the management of ITP.
Target Patient Population
ITP in adults and children with newly diagnosed, persistent, and chronic disease refractory to first-line therapy who have non–life-threatening bleeding
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D013921 - Thrombocytopenia, D007107 - Immune System, D013920 - Thrombocythemia, Essential
Keywords
corticosteroids, thrombocytopenia, Immune-Related Adverse Events
Source Citation
Blood Adv (2019) 3 (23): 3829–3866.
https://doi.org/10.1182/bloodadvances.2019000966