Updated guidelines for immune thrombocytopenic purpura: Expanded management options

Sherwin DeSouza; Dana Angelini

doi:10.3949/ccjm.88a.20201

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TABLE 1

Current vs previous guidelines on immune thrombocytopenic purpura in adults

	2019	2011
Nomenclature	Corticosteroid dependence recognized as an entity needing intervention
Diagnosis	Diagnosis of ITP not discussed	Workup including HIV, hepatitis C testing, and bone marrow biopsy discussed
Criteria for admission	Inpatient vs outpatient Inpatient: Platelet count < 20 × 10⁹/L asymptomatic or minor symptoms and new diagnosis Outpatient: Platelet count ≥ 20 × 10⁹/L asymptomatic or minor symptoms or established ITP	Inpatient vs outpatient not discussed
First-line therapy	Choice of agent Either prednisone (0.5–2.0 mg/kg/day) or dexamethasone (40 mg/day for 4 days); dexamethasone preferred if rapidity of response is valued Corticosteroids alone vs in combination. Prefer corticosteroids alone rather than in combination with rituximab for initial treatment Duration of therapy Recommends in favor of short course (≤ 6 weeks) and against longer course of prednisone (> 6 weeks including taper)	Choice of agent Anti-D immunoglobulins added as a treatment option for Rh-positive, nonsplenectomized patients Duration of therapy Longer course of steroid (prednisone 1 mg/kg × 21 days followed by taper) recommended over shorter course
Second-line therapy	Introduces concept of shared decision-making with patients, particularly with regard to the choice of second-line therapy Provides guidance on considerations while choosing second-line therapy	Choice of therapy Splenectomy if steroids fail TPO-RA for relapse after splenectomy or if splenectomy is contraindicated Rituximab after failure of steroids, IVIG, or splenectomy
Special populations and other considerations	Elderly Raises concern regarding potential complications of steroid use in elderly and those with diabetes Cost Considers eltrombopag more cost-effective than romiplostim Rituximab and splenectomy are considered cost-equivalent, but TPO-RAs are more expensive and may not be covered by all insurance payers	Discusses management of ITP in pregnancy and treatment of secondary ITP

HIV = human immunodeficiency virus; ITP = immune thrombocytopenic purpura; IVIG = intravenous immune globulin; TPO-RA = thrombopoietin-receptor agonist