What is the treatment for Immune Thrombocytopenic Purpura (ITP) with gastrointestinal (GI) bleeding?

From the Guidelines

For a patient with immune thrombocytopenia (ITP) presenting with gastrointestinal bleeding, immediate treatment should include platelet transfusions to address active bleeding, along with first-line therapy of high-dose corticosteroids (prednisone 1-2 mg/kg/day or dexamethasone 40 mg/day for 4 days) as recommended by the international consensus report on the investigation and management of primary immune thrombocytopenia 1.

First-Line Treatment

The use of corticosteroids, such as prednisone, is the standard initial treatment for ITP, and it may also reduce bleeding by directly affecting blood vessels 1. The dose of prednisone is usually 0.5 to 2 mg/kg/day until the platelet count increases to 30-50 × 10^9/L, which may take several days to several weeks. However, it's crucial to rapidly taper and stop prednisone in responders and non-responders after 4 weeks to avoid corticosteroid-related complications.

Management of GI Bleeding

Concurrently, the GI bleeding should be managed with proton pump inhibitors, such as pantoprazole 40 mg IV twice daily, and endoscopy should be performed once platelets reach >50,000/μL to identify and treat the bleeding source.

Second-Line Options

If first-line treatments fail, second-line options include thrombopoietin receptor agonists (eltrombopag 50 mg daily or romiplostim 1-10 μg/kg weekly), rituximab (375 mg/m² weekly for 4 weeks), or splenectomy, as discussed in the context of transitioning patients with immune thrombocytopenia to second-line therapy 1. The choice of second-line therapy should consider the patient's specific situation, including the presence of bleeding, the response to first-line therapy, and the potential risks and benefits of each option.

Quality of Life and Morbidity Considerations

The treatment approach should prioritize rapidly increasing platelet counts to safe levels (>30,000/μL) to stop bleeding and allow for diagnostic and therapeutic interventions for the GI hemorrhage, while also considering the impact on the patient's quality of life and minimizing morbidity, as highlighted in the discussion on tapering and discontinuation of thrombopoietin receptor agonists in immune thrombocytopenia 1.

Key points to consider in the management of ITP with GI bleeding include:

• The importance of prompt treatment to address active bleeding and increase platelet counts
• The role of corticosteroids as first-line therapy
• The management of GI bleeding with proton pump inhibitors and endoscopy
• The consideration of second-line options, including thrombopoietin receptor agonists, rituximab, and splenectomy
• The need to prioritize the patient's quality of life and minimize morbidity in the treatment approach.

From the FDA Drug Label

ALVAIZ should be used only in patients with ITP whose degree of thrombocytopenia and clinical condition increase the risk for bleeding. Use the lowest dose of ALVAIZ to achieve and maintain a platelet count greater than or equal to 50 x 10^9/L as necessary to reduce the risk for bleeding.

Treatment of ITP with bleeding GI:

• Eltrombopag (PO) can be used to treat thrombocytopenia in patients with persistent or chronic immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy and whose degree of thrombocytopenia and clinical condition increase the risk for bleeding, such as bleeding GI.
• The goal of treatment is to achieve and maintain a platelet count greater than or equal to 50 x 10^9/L as necessary to reduce the risk for bleeding.
• Initial dose regimen for adult and pediatric patients 6 years and older with ITP is 36 mg orally once daily, except in patients who are of East-/Southeast-Asian ancestry or who have mild to severe hepatic impairment 2.

From the Research

Treatment of ITP with Bleeding GI

• The treatment of immune thrombocytopenia (ITP) with bleeding gastrointestinal (GI) symptoms typically involves the use of corticosteroids, intravenous immunoglobulins, and other therapies to increase platelet count and control bleeding 3, 4.
• In cases of severe bleeding, platelet transfusions may be used in conjunction with other treatments, such as intravenous immunoglobulin, to rapidly increase platelet count and control bleeding 5.
• The choice of treatment for ITP with bleeding GI symptoms depends on the severity of the bleeding, the patient's overall health, and the presence of other underlying medical conditions 4.
• Novel agents, such as splenic tyrosine kinase inhibitors and Bruton kinase inhibitors, are being developed and may offer new treatment options for patients with ITP and bleeding GI symptoms 3.

First-Line Treatments

• First-line treatments for ITP include corticosteroids, intravenous immunoglobulins, and anti-D immunoglobulin 6.
• Intravenous immunoglobulins (IVIG) have been shown to be effective in increasing platelet count and controlling bleeding in patients with ITP, and may be used as a first-line treatment 6, 7.
• Corticosteroids, such as prednisone and methylprednisolone, may also be used as first-line treatments, but may have more side effects than IVIG 6, 7.

Treatment Outcomes

• Treatment outcomes for ITP with bleeding GI symptoms vary depending on the severity of the bleeding and the effectiveness of the treatment 4.
• In general, treatment with corticosteroids, intravenous immunoglobulins, and other therapies can increase platelet count and control bleeding in most patients with ITP 3, 4.
• However, some patients may not respond to treatment, or may experience recurrent or refractory ITP, and may require additional treatments or alternative therapies 4, 5.