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Immune Thrombocytopenia Management (ASH 2026 adult update; ASH 2019 paediatric)

Immune Thrombocytopenia Management (ASH 2026 adult update; ASH 2019 paediatric): Suspected ITP → Confirm ITP: exclude other causes → Not ITP if haemolys...

Pathway Overview

22 steps

Algorithm Steps

22 total

  1. 01Start

    Suspected ITP

    Isolated platelet count <100 × 10⁹/L with no other cause found yet

  2. 02Action

    Confirm ITP: exclude other causes

    ITP is a diagnosis of exclusion. Same-day haematology advice if platelets <20 × 10⁹/L or any mucosal bleeding; otherwise review within 24–72 hours.

    • FBC, reticulocytes and blood film reviewed by a haematologist or pathologist; exclude EDTA pseudothrombocytopenia
    • Drug and toxin history: heparin, quinine (tonic water), valproate, alcohol, recent vaccines
    • HIV, HCV and HBV serology (before IVIg or rituximab); blood group; DAT
    • Pregnancy test if of childbearing potential; immunoglobulin levels in children
    • Adults: consider H. pylori breath or stool test; ANA; antiphospholipid tests only if APS features
    • Bone marrow only if atypical features (systemic symptoms, other cytopenias, abnormal film) or to exclude MDS in age >60 years
  3. 03Warning

    Not ITP if haemolysis, schistocytes or other cytopenias: urgent haematology

    These conditions need different, urgent treatment.

    • Schistocytes, haemolysis, fever, neurological or renal signs: think TTP or HUS
    • Recent heparin: think HIT. Abnormal clotting tests or fibrinogen: think DIC
    • Pregnancy with hypertension or abnormal LFTs: think pre-eclampsia or HELLP
  4. 04Warning

    If severe or life-threatening bleeding: platelets, IVIg and IV steroid together

    For example intracranial or gastrointestinal bleeding. Give all at once, not in turn. Stop antiplatelets and anticoagulants if possible. Adult doses unless stated.

    • Platelet transfusion now (bolus, then repeat or continuous); never delay for imaging or surgery in intracranial bleeding
    • IVIg 1 g/kg IV daily for 1–2 days (max 2 g/kg per course); child 0.8–1 g/kg, repeat after 24 h if no rise
    • Methylprednisolone IV up to 1 g daily for 1–5 days, or dexamethasone 40 mg daily for 4 days; child methylprednisolone 30 mg/kg daily (max 1 g)
  5. 05Action

    If severe bleeding: adjuncts, and next steps if no response

    Involve haematology now. Mechanical valve or recent stent: seek advice before stopping antithrombotics.

    • Local measures (endoscopy, nasal packing); red cell transfusion as needed
    • Tranexamic acid (adult up to 1 g IV three times a day) as an adjunct; avoid if haematuria
    • No response to platelets and IVIg: add a TPO-RA; consider vincristine
    • Emergency splenectomy is rarely used
  6. 06Decision

    Child (under 18 years)?

    After any emergency treatment, continue by age group

  7. If Yes
    1. 07Decision

      Child: mucosal bleeding or reduced quality of life?

      Mucosal bleeding that is not life-threatening, or ITP that limits daily life

    2. If Yes
      1. 08Action

        Child with mucosal bleeding: short steroid course or IVIg

        Paediatric haematology to lead. Steroid courses 7 days or shorter.

        • Prednisone 2–4 mg/kg/day (max 120 mg/day) for 5–7 days, then stop (preferred)
        • Or dexamethasone 0.6 mg/kg/day (max 40 mg/day) for 4 days
        • Or IVIg 0.8–1 g/kg IV once if a fast rise is needed
        • Anti-D is not available for ITP in Australia or New Zealand
      2. 09Action

        Child with no response to first-line treatment: TPO-RA preferred

        ASH 2019: TPO-RA rather than rituximab or splenectomy. Screen for hepatitis B before rituximab.

        • Romiplostim is TGA-approved from age 1 year when ITP has lasted at least 6 months; eltrombopag for chronic ITP after other treatments fail
        • Rituximab rather than splenectomy if a TPO-RA is not suitable
        • Splenectomy: vaccinate at least 2 weeks before; counsel on antibiotics and fever
      3. 10Outcome

        ITP managed: ongoing haematology follow-up

        Goal: platelets high enough to prevent bleeding, not a normal count

      If No
      1. 11Action

        Child with skin bleeding only: observe, no drugs

        Observation rather than steroids, IVIg or anti-D, whatever the platelet count (ASH 2019)

        • Outpatient care; haematology review within 24–72 hours
        • Admit if the diagnosis is uncertain, social concerns, lives far from hospital, or follow-up is not assured
        • Teach bleeding warning signs; avoid drugs that impair platelet function
        • Reassess if mucosal bleeding starts
      2. Path rejoins step 10Shared downstream outcome
    If No
    1. 12Decision

      Adult: pregnant?

      Pregnancy changes drug choice and platelet targets

    2. If Yes
      1. 13Action

        Pregnant: oral corticosteroid or IVIg first line; obstetric haematology

        Do not use the non-pregnant adult steps below. Exclude pre-eclampsia, HELLP, TTP and gestational thrombocytopenia.

        • Prednisone 20 mg daily, then the lowest dose that works; or IVIg 1 g/kg IV (1–2 days); combine them if one alone fails
        • Platelets 20–30 × 10⁹/L without bleeding are safe for most of pregnancy; aim for ≥50 × 10⁹/L for delivery and usually ≥70 × 10⁹/L for neuraxial anaesthesia (plan early with the obstetric anaesthetist)
        • Avoid MMF, vinca alkaloids, danazol and other unlisted immunosuppressants
        • Rituximab only for very severe cases; TPO-RA only late in pregnancy after other treatments fail (specialist decision)
        • Labour: avoid fetal scalp electrodes, fetal blood sampling, ventouse and rotational forceps; mode of delivery by obstetric indication
        • Newborn: cord blood platelet count; if low, repeat at day 3–5
      2. Path rejoins step 10Shared downstream outcome
      If No
      1. 14Decision

        Adult, not pregnant: platelets <30 × 10⁹/L or more than minor bleeding?

        Minor bleeding means skin bleeding (petechiae, bruises) only

      2. If Yes
        1. 15Warning

          Before adult treatment: check diabetes, infection, HBV, thrombosis, liver

          These conditions change which drug is safe.

          • Diabetes, psychiatric illness or active infection: high-dose steroid may harm; IVIg alone is an option (slow infusion if diabetes, renal impairment, age >65 or past thrombosis)
          • HBsAg or anti-HBc positive: no rituximab until a liver specialist advises; active hepatitis B: do not give
          • Past thrombosis or liver disease: caution with TPO-RAs (thrombosis; eltrombopag liver toxicity)
        2. 16Action

          Adult, platelets <30 × 10⁹/L or bleeding: start treatment

          Not for pregnancy or children (see their steps). ASH 2026: corticosteroid plus rituximab or plus a TPO-RA, rather than corticosteroid alone (conditional). Consider admission if newly diagnosed with platelets <20 × 10⁹/L.

          • Dexamethasone 40 mg daily for 4 days (1–3 cycles; consider 20 mg if older), or prednis(ol)one 1 mg/kg/day (max 80 mg) for up to 2 weeks, then taper
          • Stop all corticosteroid within 6 weeks, including the taper; monitor BP, glucose, mood and sleep
          • Add rituximab 375 mg/m² weekly for 4 doses, or a TPO-RA at its standard starting dose; if both respond, taper the steroid first
          • If rituximab and TPO-RAs are not available: corticosteroid alone
          • IVIg 1 g/kg IV (1–2 days) with the steroid if a rapid rise is needed; diabetes, renal impairment, age >65 or past thrombosis: slowest practicable rate, check creatinine
          • Australia: rituximab is not PBS-funded for ITP; TPO-RAs are TGA-approved only after inadequate response to earlier treatment
        3. 17Decision

          Lasting response off corticosteroid?

          No means: no response, relapse after taper, or steroid-dependent (needs >5 mg/day prednisone)

        4. If Yes
          1. 18Action

            Responded: taper and stop, then watch for relapse

            Aim for platelets that prevent bleeding (usually >20–30 × 10⁹/L), not a normal count

            • Taper corticosteroid to stop within 6 weeks
            • On a TPO-RA: taper the steroid first; the TPO-RA duration depends on response and stability
            • Regular platelet counts; relapse or steroid dependence: go to second-line treatment
            • Teach bleeding warning signs
          2. Path rejoins step 10Shared downstream outcome
          If No
          1. 19Action

            No response, relapse or steroid-dependent: second-line treatment

            ASH 2026: a TPO-RA (strong recommendation) or rituximab (conditional). Not in pregnancy (see pregnancy step).

            • TPO-RA: eltrombopag, romiplostim or avatrombopag (see next step)
            • Rituximab 375 mg/m² weekly for 4 doses (other schedules used); screen HBV first; vaccinate first if splenectomy may follow
            • TPO-RA and rituximab unsuitable or declined: MMF, a BTK inhibitor or a SYK inhibitor (ASH 2026, conditional)
            • Australia: fostamatinib, rilzabrutinib and danazol are not on the ARTG (danazol only via SAS); other options include azathioprine, dapsone (test G6PD first) or ciclosporin (specialist)
            • Steroid-dependent or refractory: refer to a tertiary ITP centre; consider a clinical trial
          2. 20Action

            If a TPO-RA is used: start low and titrate to platelets ≥50 × 10⁹/L

            Use the lowest dose that keeps platelets ≥50 × 10⁹/L. Check platelets weekly until stable, then monthly.

            • Eltrombopag 50 mg PO daily (25 mg if East or South-East Asian ancestry or hepatic impairment); max 75 mg daily
            • Eltrombopag: take 2 h before or 4 h after antacids, dairy, calcium or iron; monitor LFTs (stop rules in the PI)
            • Romiplostim 1 microgram/kg SC weekly (actual body weight); adjust by 1 microgram/kg; max 10 micrograms/kg weekly
            • Avatrombopag 20 mg PO daily with food; max 40 mg daily; adjust start dose with fluconazole or rifampicin (see PI)
            • Platelets >200 × 10⁹/L: reduce the dose; >400 × 10⁹/L: withhold, then restart at a lower dose when the count falls (see PI)
            • No response after 4 weeks at the maximum dose, or side effects: switch to another TPO-RA
            • Tell patients about thrombosis risk, especially if they had a past thrombosis
          3. 21Action

            Splenectomy: selected adults, ideally after ITP ≥12 months

            For failure of or intolerance to several medical treatments, a wish to avoid long-term drug treatment, or urgent need after poor response to medical treatment. Delay for at least 1 year from diagnosis if possible, because remission can occur.

            • Vaccinate (pneumococcal, meningococcal, Hib) at least 2 weeks before
            • Counsel on antibiotic prophylaxis, a fever action plan and lifelong sepsis and thrombosis risk
            • Laparoscopic splenectomy preferred
            • Review at least yearly: platelets, vaccines; relapse after 1 year: look for an accessory spleen
          4. Path rejoins step 10Shared downstream outcome
        If No
        1. 22Action

          Adult, platelets ≥30 × 10⁹/L, no or minor bleeding: observe

          ASH 2019 recommends against corticosteroids here. Consider treatment if on an anticoagulant or antiplatelet, near 30 × 10⁹/L, other comorbidities, a planned procedure, or age >60 years.

          • Outpatient care with haematology follow-up and repeat platelet counts
          • Avoid drugs that impair platelet function where possible
          • Plan platelet-raising treatment with haematology before any procedure
          • Teach bleeding warning signs; re-enter this pathway if bleeding or platelets fall below 30 × 10⁹/L
        2. Path rejoins step 10Shared downstream outcome

Guideline Source

American Society of Hematology 2026 Guidelines for Immune Thrombocytopenia (ITP): Initial and Second-Line Therapy in Adults with Primary ITP (focused update of ASH 2019)

DOI: 10.1182/bloodadvances.2026021269View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Australia: first-line rituximab or TPO-RA (ASH 2026) is outside TGA-approved use and not PBS-funded; access varies.
  • Emergency bleeding and pregnancy steps rest on expert consensus (International Consensus Report 2019; ANZ consensus 2022), not on ASH recommendations.
  • ITP is a diagnosis of exclusion; secondary ITP (SLE, HIV, HCV, lymphoproliferative disease, drugs) needs treatment of the cause.
  • Neonatal thrombocytopenia and procedure-specific platelet targets are not covered.

Contraindicated Populations

Neonates (neonatal alloimmune or maternal-antibody thrombocytopenia)Thrombotic microangiopathy (TTP, HUS), HIT, DIC or HELLPSecondary ITP where the cause needs its own treatment

Applicable Regions

USEUAUNZGlobal

AU: Anti-D is not available for ITP. IVIg needs BloodSTAR authorisation (National Blood Authority criteria). Rituximab is not PBS-funded for ITP. Eltrombopag, romiplostim and avatrombopag are PBS authority items for severe thrombocytopenia and are TGA-approved after inadequate response to earlier treatment. Fostamatinib and rilzabrutinib are not on the ARTG.

EU: Anti-D is not available in Europe for ITP.

NZ: Anti-D is not available for ITP. IVIg is available first line at the haematologist's discretion via NZ Blood Service.

US: Eltrombopag, romiplostim, avatrombopag, fostamatinib and rilzabrutinib are available.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Immune Thrombocytopenia Management (ASH 2026 adult update; ASH 2019 paediatric)?

The Immune Thrombocytopenia Management (ASH 2026 adult update; ASH 2019 paediatric) is a management clinical algorithm for Hematology & Oncology. It provides a structured decision tree to guide clinical decision-making, based on American Society of Hematology 2026 Guidelines for Immune Thrombocytopenia (ITP): Initial and Second-Line Therapy in Adults with Primary ITP (focused update of ASH 2019).

What guideline is the Immune Thrombocytopenia Management (ASH 2026 adult update; ASH 2019 paediatric) based on?

This algorithm is based on American Society of Hematology 2026 Guidelines for Immune Thrombocytopenia (ITP): Initial and Second-Line Therapy in Adults with Primary ITP (focused update of ASH 2019) (DOI: 10.1182/bloodadvances.2026021269).

What are the limitations of the Immune Thrombocytopenia Management (ASH 2026 adult update; ASH 2019 paediatric)?

Known limitations include: Australia: first-line rituximab or TPO-RA (ASH 2026) is outside TGA-approved use and not PBS-funded; access varies.; Emergency bleeding and pregnancy steps rest on expert consensus (International Consensus Report 2019; ANZ consensus 2022), not on ASH recommendations.; ITP is a diagnosis of exclusion; secondary ITP (SLE, HIV, HCV, lymphoproliferative disease, drugs) needs treatment of the cause.; Neonatal thrombocytopenia and procedure-specific platelet targets are not covered.. Individual patient factors may require deviation from these recommendations.

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