What is the initial treatment for Immune Thrombocytopenic Purpura (ITP)?

Initial Treatment for Immune Thrombocytopenic Purpura (ITP)

Corticosteroids are the standard first-line treatment for adults with newly diagnosed ITP requiring therapy, with prednisone (0.5-2 mg/kg/day) or high-dose dexamethasone (40 mg/day for 4 days) as the primary options. 1, 2

When to Initiate Treatment

Treatment decisions should be based primarily on bleeding symptoms rather than platelet count alone:

• Treatment is indicated for platelet counts <20-30 × 10⁹/L, particularly when accompanied by bleeding symptoms 2, 3
• Treatment is rarely needed if platelet count >50 × 10⁹/L unless the patient has active bleeding, requires surgery, has comorbidities predisposing to bleeding, or needs anticoagulation 2
• Immediate treatment is required for patients with active CNS, gastrointestinal, or genitourinary bleeding, or those requiring urgent surgery 2
• Observation alone is appropriate for children with no bleeding or only mild skin manifestations (bruising and petechiae) regardless of platelet count 1

First-Line Treatment Options for Adults

Corticosteroids (Primary Option)

Standard prednisone (0.5-2 mg/kg/day) achieves initial response in 70-80% of patients, though sustained long-term response occurs in only 20-40% 1, 2

High-dose dexamethasone (40 mg/day for 4 days) offers faster platelet response with initial response rates up to 90% and sustained response of 50-80% with 3-6 cycles 2

Corticosteroid treatment should be administered for no longer than 6-8 weeks, as prolonged exposure triggers severe adverse events including weight gain, cataracts, mood alterations, hypertension, hyperglycemia, osteoporosis, and infections 1, 2

IVIG (Adjunctive or Alternative Option)

IVIG (1 g/kg as a one-time dose) should be used when rapid platelet increase is required, achieving increases within 24 hours 1, 2

IVIG can be combined with corticosteroids for enhanced response and reduced infusion reactions when more rapid platelet increase is needed 1

IVIG or anti-D should be used as first-line treatment if corticosteroids are contraindicated 1

Anti-D Immunoglobulin (Limited Use)

Anti-D is only appropriate for Rh(D)-positive, non-splenectomized patients and provides predictable, transient platelet increases 2, 4

Anti-D therapy should not be used in children with hemoglobin decreased due to bleeding or with evidence of autoimmune hemolysis 1

First-Line Treatment for Pediatric Patients

For pediatric patients requiring treatment, a single dose of IVIG (0.8-1 g/kg) or a short course of corticosteroids should be used as first-line treatment 1

IVIG should be used if a more rapid increase in platelet count is desired in children 1

A single dose of anti-D can be used as first-line treatment in Rh-positive, non-splenectomized children requiring treatment 1

Special Population Considerations

Pregnancy

Pregnant patients requiring treatment should receive either corticosteroids or IVIG 1, 2

The mode of delivery should be based on obstetric indications, not platelet count 1, 2

HIV-Associated ITP

Treatment of HIV infection with antiviral therapy should be considered before other treatment options unless the patient has clinically significant bleeding complications 1

If ITP treatment is required, initial treatment should consist of corticosteroids, IVIG, or anti-D 1, 2

HCV-Associated ITP

For patients with HCV-associated ITP, antiviral therapy should be considered in the absence of contraindications, though platelet count should be closely monitored due to risk of worsening thrombocytopenia from interferon 1

If ITP treatment is required, initial treatment should be IVIG 1, 2

H. pylori-Associated ITP

Eradication therapy should be administered for patients found to have H. pylori infection based on urea breath tests, stool antigen tests, or endoscopic biopsies 1

Screening for H. pylori should be considered for patients with ITP in whom eradication therapy would be used if testing is positive 1

Critical Monitoring and Side Effects

Short-term corticosteroid side effects include mood swings, weight gain, fluid retention, Cushingoid features, and hyperglycemia 2

Long-term corticosteroid side effects include osteoporosis, avascular necrosis, hypertension, diabetes, skin changes, cataracts, and immunosuppression with opportunistic infections 2

Patients requiring on-demand administration of corticosteroids after completing first-line induction treatment should be considered non-responders and promptly switched to alternative therapy 1

Common Pitfalls to Avoid

Do not use treatment to normalize platelet counts—the goal is to achieve and maintain platelet count ≥50 × 10⁹/L as necessary to reduce bleeding risk 5

Avoid excessively prolonged corticosteroid use beyond 6-8 weeks, as this leads to substantially worse clinical outcomes compared to early switch to second-line treatment 1

Do not perform bone marrow examination in patients presenting with typical ITP features, as it is unnecessary irrespective of age 1

Excessively fast tapering of corticosteroids should never be performed as it can lead to undesired effects 1