Initial Treatment for Immune Thrombocytopenic Purpura (ITP)
Corticosteroids are the standard first-line treatment for newly diagnosed ITP requiring therapy, with high-dose dexamethasone (40 mg/day for 4 days) offering superior response rates and tolerability compared to standard prednisone. 1
When to Initiate Treatment
Treatment decisions should be based on platelet count thresholds and bleeding symptoms:
- Treat when platelet count is <20-30 × 10⁹/L, particularly if bleeding symptoms are present 1
- Treatment is rarely needed if platelet count >50 × 10⁹/L unless active bleeding, planned surgery, bleeding-predisposing comorbidities, or anticoagulation requirements exist 1
- Immediate treatment is mandatory for active CNS, GI, or genitourinary bleeding, or urgent surgical needs 1
- The goal is achieving platelet count ≥50,000/μL to reduce bleeding risk, not normalizing counts 2
First-Line Corticosteroid Options
High-Dose Dexamethasone (Preferred)
- Dose: 40 mg/day for 4 days, repeated every 2-4 weeks for 1-4 cycles 1, 2
- Initial response rate: up to 90% 1
- Sustained long-term response: 50-80% with 3-6 cycles 1
- Faster platelet response compared to prednisone 3
- Better tolerability with lower incidence of adverse events due to shorter treatment duration 3
Standard Prednisone (Alternative)
- Dose: 0.5-2 mg/kg/day for 2-4 weeks, then rapid taper 1, 2
- Initial response rate: 70-80% 1
- Sustained long-term response: only 20-40% 1
- Response time: several days to several weeks 2
High-Dose Methylprednisolone (Severe Cases)
Adjunctive Therapy for Rapid Platelet Recovery
Intravenous Immunoglobulin (IVIg)
- Add IVIg when rapid platelet increase is required (within 24 hours) 1, 4
- Dose: 1 g/kg as a one-time dose, may be repeated if necessary 4, 2
- Response rate: up to 80% 2
- Typical response time: 2-4 days 2
- Combine with corticosteroids for enhanced response and reduced infusion reactions 1
Anti-D Immunoglobulin (Limited Use)
- Only for Rh(D)-positive, non-splenectomized patients 1, 4
- Dose: 50-75 μg/kg 2
- Provides predictable, transient platelet increases 1, 5
- Avoid in patients with autoimmune hemolytic anemia 2
Emergency Management for Life-Threatening Bleeding
Combination therapy is required:
Special Populations
Pregnant Patients
- Either corticosteroids or IVIg can be used as first-line treatment 1, 4
- Mode of delivery should be based on obstetric indications, not platelet count 1, 4
HIV-Associated ITP
HCV-Associated ITP
H. pylori-Positive Patients
- Eradication therapy is recommended 4
Pediatric Patients
- Observation without treatment is preferred for children with no or minor bleeding 2
- For non-life-threatening mucosal bleeding: dexamethasone 0.6 mg/kg/day or prednisone 2-4 mg/kg/day 2
- Alternative: IVIg 0.4 g/kg/day for 5 days or 1 g/kg/day for 1-2 days 2
Critical Monitoring and Side Effects
Corticosteroid Side Effects to Monitor
Short-term: mood swings, weight gain, fluid retention, Cushingoid features, hyperglycemia 1
Long-term: osteoporosis, avascular necrosis, hypertension, diabetes, skin changes, cataracts, immunosuppression with opportunistic infections 1
Avoid prolonged corticosteroid use beyond 6-8 weeks due to detrimental effects 1, 2
Pre-Treatment Screening
Screen for secondary causes before initiating treatment:
- HCV and HIV testing recommended for all patients 4
- Rule out antiphospholipid syndrome, autoimmune disorders, common variable immune deficiency, drug-induced thrombocytopenia 4
- Bone marrow examination is not necessary for typical ITP presentation 4, 2
Second-Line Considerations
If patients fail initial corticosteroid therapy after 4 weeks or require ongoing treatment beyond 6-8 weeks:
- Splenectomy: 80% initial response, 60-65% long-term response 1
- Thrombopoietin receptor agonists (TPO-RAs) like romiplostim: increasingly preferred before splenectomy due to high response rates 1, 6
- Romiplostim is indicated for patients who have had insufficient response to corticosteroids, immunoglobulins, or splenectomy 6