clinical topic updates

Initiating Treatment in Patients With Immune Thrombocytopenia

by Adam Cuker, MD, MS

Overview

Platelet count is initially measured to determine disease severity and to determine the need for treatment in all patients newly diagnosed with immune thrombocytopenia (ITP). In pediatric populations, it is generally recommended that children with no bleeding or mild bleeding, such as those with petechiae or bruising, be managed with observation alone without medication regardless of their platelet counts. In newly diagnosed adults with ITP, it is generally recommended that those with platelet counts >50 x 109/L should not receive treatment, while those patients with platelet counts <30 x 109/L irrespective of bleeding symptoms should be administered treatment. Additional considerations for treatment initiation in adults include bleeding symptoms, upcoming medical procedures, concomitant antithrombotic therapy, comorbidities, lifestyle that may predispose the patient to trauma, patient values and preferences, and health-related quality of life. 

Expert Commentary

Adam Cuker, MD, MS

Assistant Professor of Medicine
Director, Penn Comprehensive Hemophilia and Thrombosis Program
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA

“When to initiate treatment is not always an easy decision. If the patient is having significant bleeding, then we initiate treatment, but if the patient is not having significant bleeding, we do our best to estimate the risk of bleeding based on factors like platelet count, patient age, whether he or she has had a prior history of bleeding, whether he or she has an indication for concomitant antithrombotic medication, and patient lifestyle.”

Adam Cuker, MD, MS

When to initiate treatment is not always an easy decision. If the patient is having significant bleeding, then we initiate treatment, but if the patient is not having significant bleeding, we do our best to estimate the risk of bleeding based on factors like platelet count, patient age, whether he or she has had a prior history of bleeding, whether he or she has an indication for concomitant antithrombotic medication, and patient lifestyle. Then we have to incorporate that into the patient’s own values and preferences. We recommend trying to keep the platelet count in most patients above 20 to 30 x 109/L, but I have a couple of patients who have platelet counts lower than that who are young, have never had any bleeding, and have a strong preference for avoiding medications and surgery. For those patients, after discussion of their values and preferences, we’ve made the decision together not to treat. On the other hand, I have other patients who are older, who I would judge to be at higher bleeding risk, who are more comfortable with the idea of taking medications, and who are more adverse to the idea of having a serious bleeding event. In these patients, we might have a relatively higher platelet count threshold for starting treatment, along with a higher target platelet count. For example, we might want to keep the platelet count above 50 x 109/L.

References

Khan AM, Mydra H, Nevarez A. Clinical practice updates in the management of immune thrombocytopenia. P T. 2017;42:756-763.

Neunert CE. Management of newly diagnosed immune thrombocytopenia: can we change outcomes? Blood Adv. 2017;1:2295-2301.

Neunert C, Lim W, Crowther M, et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011;117:4190-4207.

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