Treatment of Immune Thrombocytopenia

Publication Date: December 3, 2019

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)
312101
The referring physician should ensure that the patient has follow-up with a hematologist within 24 to 72 hours of diagnosis. (UGPS, )
312101

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

Publication Month/Year

December 3, 2019

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