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 is indicated when:
- Platelet counts are <20-30 × 10⁹/L, particularly with bleeding symptoms 2, 3
- Active bleeding is present (CNS, GI, or genitourinary) 1, 3
- Urgent surgery is required 2, 3
- Comorbidities predispose to bleeding or anticoagulation is needed 2
Treatment is rarely needed if platelet count >50 × 10⁹/L unless active bleeding or high-risk situations exist. 2
First-Line Corticosteroid Options
Prednisone
- Initial response rate: 70-80% of patients 2, 3
- Sustained long-term response: only 20-40% 2
- Standard dosing: 0.5-2 mg/kg/day 2
- Works more slowly than dexamethasone but is the traditional standard 4
High-Dose Dexamethasone
- Initial response rate: up to 90% 2, 3
- Sustained response: 50-80% with 3-6 cycles 2
- Dosing: 40 mg/day for 4 days 2
- Achieves faster platelet response and appears safer with lower incidence of adverse events compared to prednisone 4
- Better option for patients with low platelet counts and active bleeding diathesis 4
Alternative First-Line Options When Corticosteroids Are Contraindicated or Rapid Response Needed
Intravenous Immunoglobulin (IVIg)
- Dose: 1 g/kg as a one-time dose, may be repeated if necessary 1
- Achieves platelet increase within 24 hours 1, 2, 3
- Should be combined with corticosteroids when more rapid platelet increase is required 1
- Concomitant corticosteroids enhance IVIg response and reduce infusion reactions 1, 3
- Side effects include headaches, rare renal failure, and thrombosis 1
Anti-D Immunoglobulin
- Only for Rh(D)-positive, non-splenectomized patients 1, 3
- Provides predictable, transient platelet increases 2, 5
- Dosing: 75 μg/kg produces better response than standard 50 μg/kg 1
- Premedication with acetaminophen or 20 mg prednisone reduces fever/chill reactions 1
- Rare but serious risk of intravascular hemolysis, DIC, and renal failure 1
Emergency Treatment for Severe Bleeding
For uncontrolled bleeding, combine prednisone plus IVIg 1, 3
Additional emergency options include:
- High-dose methylprednisolone 1, 3
- Platelet transfusion, possibly combined with IVIg 1, 3
- Emergency splenectomy in life-threatening situations 1, 3
Special Population Considerations
Pregnancy
- Either corticosteroids or IVIg are recommended as first-line treatment 1, 2
- Mode of delivery should be based on obstetric indications, not platelet count 1, 2
HIV-Associated ITP
- Treat HIV infection with antivirals first unless significant bleeding is present 1, 3
- If ITP treatment required: corticosteroids, IVIg, or anti-D 1
HCV-Associated ITP
- Consider antiviral therapy first 1, 3
- If ITP treatment required, initial treatment should be IVIg 1, 3
H. pylori-Associated ITP
- Eradication therapy should be administered for confirmed H. pylori infection 1
- Screen for H. pylori in ITP patients where eradication would be used if positive 1
Critical Corticosteroid Side Effects to Monitor
Short-term (relevant for initial treatment)
Long-term (if treatment extends beyond 6-8 weeks)
- Osteoporosis, avascular necrosis 2
- Hypertension, diabetes 2
- Immunosuppression with opportunistic infections 2
Common Pitfalls
Do not continue corticosteroids beyond 6-8 weeks due to significant morbidity risk 2. If patients fail initial therapy or require ongoing treatment, consider second-line options including splenectomy (80% initial response, 60-65% long-term response) or thrombopoietin receptor agonists, which are increasingly preferred before splenectomy 2, 3.
Bone marrow examination is not necessary for patients presenting with typical ITP features, regardless of age 1, avoiding unnecessary invasive procedures.
Always test for HCV and HIV at diagnosis 1, as these secondary causes require different treatment approaches.