Immune Thrombocytopenia Management (ASH 2019/2024)

Algorithm Steps

1. ▶

   Start

   Suspected ITP

   Isolated thrombocytopenia without other cause

   1. ●

      Action

      Confirm Diagnosis

      Exclude secondary causes

      • CBC with smear (isolated thrombocytopenia, normal morphology)
      • Exclude drug-induced (heparin, quinine, etc.)
      • HIV, HCV testing
      • H. pylori testing (treat if positive)
      • Consider ANA, antiphospholipid antibodies
      • Bone marrow only if atypical features
      1. ◆

         Decision

         Clinical Presentation

         Assess bleeding and platelet count

         1. ⚠

            Warning

            Severe/Life-Threatening Bleeding

            ICH, severe mucosal bleeding

            • Platelet transfusion (continuous if needed)
            • IVIG 1g/kg (can repeat in 24h)
            • High-dose methylpred 1g IV daily x3
            • Consider anti-D if Rh+ (spleen intact)
            • Tranexamic acid adjunct
            • Emergency splenectomy if refractory
            1. ●

               Action

               First-Line Therapy

               Corticosteroids

               • Prednisone 1mg/kg/day (max 80mg) x1-2 weeks, then taper
               • OR Dexamethasone 40mg daily x4 days (can repeat q2-4wk)
               • Short courses preferred over prolonged steroids
               • IVIG 1g/kg if rapid response needed (pre-procedure)
               1. ◆

                  Decision

                  Response to First-Line?

                  Platelet response and durability

                  1. ●

                     Action

                     Sustained Response

                     Platelets ≥30-50k maintained off steroids

                     • Taper and discontinue steroids
                     • Monitor for relapse
                     • ~30% achieve long-term remission
                     1. ✓

                        Outcome

                        ITP Managed

                        Goal: Plt sufficient to prevent bleeding, not normalize

                  2. ●

                     Action

                     Second-Line Therapy

                     For refractory or relapsed ITP

                     • TPO-RAs (romiplostim, eltrombopag) - preferred
                     • Rituximab 375mg/m² weekly x4 (spleen-sparing)
                     • Splenectomy (defer ≥12 months if possible)
                     • Mycophenolate, azathioprine, fostamatinib
                     • Clinical trial if available
                     1. ●

                        Action

                        TPO-RA Therapy

                        Thrombopoietin receptor agonists

                        • Romiplostim: 1-10 mcg/kg SQ weekly
                        • Eltrombopag: 50mg PO daily (25mg in Asians)
                        • Avatrombopag: 20mg PO daily
                        • Titrate to maintain plt 50-150k
                        • Can discontinue if sustained remission
                     2. ●

                        Action

                        Splenectomy

                        For refractory ITP

                        • ~60-70% durable response
                        • Vaccinate 2 weeks before (pneumococcal, Hib, meningococcal)
                        • Laparoscopic preferred
                        • Consider accessory spleen if relapse
         2. ●

            Action

            Plt <30k or Bleeding Symptoms

            Treatment typically indicated

         3. ●

            Action

            Plt ≥30k, Asymptomatic

            Observation may be appropriate

            • Close monitoring
            • Activity restrictions if very low
            • Treat before procedures
            • Patient education on bleeding signs