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Immune thrombocytopenia

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of immune thrombocytopenia are prepared by our editorial team based on guidelines from the American Society of Hematology (ASH 2019,2011) and the American College of Gastroenterology (ACG 2017).
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Diagnostic investigations

Laboratory evaluation, adult patients
As per ASH 2011 guidelines:
Obtain HCV infection and HIV serologies in all adult patients with ITP.
B
Obtain further hematological investigations if there are abnormalities other than thrombocytopenia (and perhaps findings of iron deficiency) on CBC or peripheral blood smear.
B
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  • Laboratory evaluation (pediatric patients)

  • H. pylori testing

Diagnostic procedures

Bone marrow biopsy, adult patients
As per ASH 2011 guidelines:
Consider performing a bone marrow biopsy in patients in whom CBC or peripheral blood smear shows abnormalities other than thrombocytopenia (and perhaps findings of iron deficiency).
C
Consider not routinely performing a bone marrow biopsy in patients with a clinical presentation that is typical of ITP.
D
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  • Bone marrow biopsy (pediatric patients)

Medical management

Indications for admission, adult patients
As per ASH 2019 guidelines:
Consider providing outpatient management, rather than hospital admission, in adults with a platelet count of ≥ 20×10⁹/L who are asymptomatic or have minor mucocutaneous bleeding.
C
Consider hospital admission in adults patients with newly diagnosed ITP and a platelet count of < 20 × 10⁹/L.
C
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  • Indications for admission (pediatric patients)

  • Indications for treatment (adult patients)

  • Indications for treatment (pediatric patients)

  • First-line therapy (adult patients)

  • First-line therapy (pediatric patients)

  • Second-line therapy (adult patients)

  • Second-line therapy (pediatric patients)

  • Management of corticosteroid side effects

Surgical interventions

Splenectomy, adult patients: as per ASH 2019 guidelines, consider either splenectomy or a thrombopoietin receptor agonist in adults with ITP lasting ≥ 3 months who are corticosteroid-dependent or have no response to corticosteroids.
C
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  • Splenectomy (pediatric patients)

Specific circumstances

Pregnant patients: as per ASH 2011 guidelines, use either corticosteroids or IVIG if treatment for ITP is required in pregnant patients.
B
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  • Patients with active hemorrhage

  • Patients with H. pylori-associated ITP

  • Patients with HCV-associated ITP

  • Patients with HIV-associated ITP

Patient education

Post-splenectomy counseling
As per ASH 2019 guidelines:
Provide counseling regarding antibiotic prophylaxis in patients who have undergone splenectomy.
E
Educate patients who have undergone splenectomy on prompt recognition and management of fever. Refer to current recommendations on pre- and postsplenectomy care.
E
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Preventative measures

Measles-mumps-rubella immunization
As per ASH 2011 guidelines:
Provide MMR immunization to children with ITP who are not immunized.
B
Provide MMR re-immunization to children with ITP who have already received a first dose of MMR vaccine, but in whom vaccine titers do not show adequate immunity.
B
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  • Pre-splenectomy immunizations

Follow-up and surveillance

Follow-up clinical assessment: as per ASH 2019 guidelines, schedule follow-up with a hematologist within 24 to 72 hours of hospital discharge in patients with newly diagnosed or relapsed ITP.
E
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