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