Evaluation and Management of Immune Thrombocytopenia

8/2/2019 Evaluation and Management of Immune Thrombocytopenia

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HistoryIsolated bleeding symptoms with low platelet

No constitutional symptoms like weight loss,bone pain, night sweat

Physical examinationBleeding w/o hepatosplenomegaly,lymphadenopathy or stigmata of congenitalconditions



Complete blood countIsolated thrombocytopenia ( plt < 100).

Anaemia – significant blood loss.Normal – RBC index, WBC and differential

Peripheral blood smear – Platelets normal tolarge in size. RBC and WBC morphologynormal



Bone marrow exam- UnnecessaryIn patients with typical features of ITP prior to

treatment with steroid, splenectomy orpatient who fail I.V Ig therapy

Bone marrow exam – NecessaryAbnormal history, physical exam, FBC orPeripheral blood film



All adult patients with newly diagnosed ITPshould test for HIV and HCV.

Insufficient evidence – routine use of antiplatelet, antiphospholipid and ANA,thrombopoietin levels or platelet parameters



Treatment strategies in ITP- A platelet count for adequate hemostatis

RATHER than normal platelet count- Discussion with patient- Severity of bleeding- Anticipated surgical procedures- Medication side effect- Health- related Quality of life



1. Assessment of Disease Statusa)Bleeding – timing, loacation, severity

Risk factor for bleeding – use of antithrombotic agents or high-risk occupationsb) Anticipated surgical proceduresc) Compliance with recommended treatmentd) Bleeding – interfer with daily activities/ cause

anxiety



2. General considerationa) Majority pt with no bleeding/mild bleeding –

observation alone regards of platelet countb) First line treatment – observation,corticosteroid, IV Ig or anti-DImmunoglobulin( Anti-D)

c) Anti- D use with caution . FDA – severehemolysis. Not for pt with low Hb or evidenceof autoimmune hemolysis



a) Treat patient with plt < 30b) Longer course of corticosteroid over shorter

coursec) IV Ig used with corticosteroid when rapidincrease of platelet needed

d) Either IV Ig or Anti- D maybe used as first lineif corticosteroids contraindicated.



1. Assessment of Disease Statusa) Bleeding – timing, loaction, severityb) Any change in history/ physical diagnosis - ?

another diagnosis causing thrombocytopeniac) Any contraindication to splenectomyd) Effect of ITP on patient’s work/school/ participation in activitiese) Respond intermittently to current drug

treatmentf) Side effects from current treatmentg) How patient cope psychological with low

platelet count?



2. General considerationa) Pt with plt > 30 and asymptomatic after

splenectomy do not require further therapy

b) If previous treatment with corticosteroid , IV Igor Anti- D has been successful, these optionsmaybe used as needed to prevent bleeding

c) If previous treatment with corticosteroid, IV Igor Anti- D unsuccessful, subsequentmanagement may include splenectomy,rituximab, thrombopoietin receptor agonists ormore potent immunosuppresion



3. Special consideration for Adulta) Splenectomy – failed corticosteroid, similar efficacy with

open or laparoscopic proceduresb) Rituximab – Risk of bleeding, failed corticosteroid, IV Ig or

splenectomyc) Thrombopoietin Receptor Agonists – at risk of bleeding

and relapse after splenectomy/ contraindication tosplenectomy and failed 1 other therapy. Also for risk of bleeding after failed 1 line of therapy such as

corticosteroid/IV Ig and not undergone splenectomyd) High dose Dexamethasone – no comment in currentguideline

e) Immunosuppression – Insufficient data for specificrecommendations

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Evaluation and Management of Immune Thrombocytopenia