Initial Treatment for Immune Thrombocytopenic Purpura (ITP)
Corticosteroids are the standard initial treatment for newly diagnosed ITP patients, with the addition of IVIG when rapid platelet count increase is required. 1, 2
When to Initiate Treatment
- Treatment is indicated for adults with newly diagnosed ITP who have platelet counts <30 × 10⁹/L 1
- Treatment is rarely indicated in patients with platelet counts above 50 × 10⁹/L unless there are additional risk factors for bleeding 1
- The decision to treat should be based on bleeding symptoms rather than platelet count alone, though counts <20-30 × 10⁹/L generally warrant treatment 3
- Consider patient-specific factors including bleeding history, comorbidities, activity level, medication use, and patient preference 1
First-Line Treatment Options
Corticosteroids
- Prednisone is the standard initial therapy, typically given at 0.5-2 mg/kg/day until platelet count increases (usually 30-50 × 10⁹/L) 1, 3
- Treatment should continue until response, then rapidly tapered and stopped in responders (and especially in non-responders) after 4 weeks to avoid corticosteroid-related complications 1
- Initial response to corticosteroids occurs in 70-80% of patients, but sustained responses are seen in only 20-40% of cases 3
Alternative Corticosteroid Regimen
- Dexamethasone (40 mg/day for 4 days) can be considered as an alternative to prednisone 1
- Dexamethasone may work faster in increasing platelet counts and appears to reduce severe adverse events compared to prednisone 4
- In one study, four cycles of dexamethasone given every 14 days produced an 86% response rate with 74% having responses lasting a median time of 8 months 1
When Rapid Platelet Increase is Needed
- Intravenous immunoglobulin (IVIG) should be added to corticosteroids when a more rapid increase in platelet count is required 1, 2
- Initial dose of IVIG should be 1 g/kg as a one-time dose; may be repeated if necessary 1, 2
- IVIG is particularly useful for stimulating rapid platelet increases before planned procedures 5
For Rh(D) Positive, Non-Splenectomized Patients
- IV anti-D (50-75 μg/kg) can be used as an alternative first-line option for Rh(D) positive, non-splenectomized patients 1, 3
- Should be avoided in patients with autoimmune hemolytic anemia 1
- Blood group, DAT, and reticulocyte count are required before treating with IV anti-D 1
Emergency Treatment for Severe Bleeding
- For patients with uncontrolled bleeding, combining first-line therapies is appropriate: prednisone and IVIG are recommended 1
- High-dose methylprednisolone may also be useful in this setting 1
- Other therapies that work rapidly include platelet transfusion, possibly in combination with IVIG, and emergency splenectomy 1
Special Populations
Pregnant Patients
- Pregnant patients requiring treatment should receive either corticosteroids or IVIG 1, 2
- Mode of delivery should be based on obstetric indications rather than platelet count 1, 2
Secondary ITP
- For HCV-associated ITP: antiviral therapy should be considered; if ITP treatment is required, initial treatment should be IVIG 1, 2
- For HIV-associated ITP: treatment of HIV infection with antiviral therapy should be considered first; if ITP treatment is required, initial treatment should consist of corticosteroids, IVIG, or anti-D 1
- For H. pylori–associated ITP: eradication therapy is recommended for patients who test positive 1, 2
Common Pitfalls and Caveats
- Prolonged corticosteroid use should be avoided due to significant side effects including weight gain, mood alterations, hypertension, diabetes, osteoporosis, and increased infection risk 3
- IVIG can cause headaches, renal failure, and thrombosis as rare but serious toxicities 1
- IV anti-D can cause hemolysis and rare cases of intravascular hemolysis, disseminated intravascular coagulation, and renal failure have been reported 1
- Treatment should aim to maintain a hemostatic platelet count (typically >30-50 × 10⁹/L) rather than normalizing platelet counts 3