What are the guidelines for blood transfusion in patients with Immune Thrombocytopenic Purpura (ITP)?

From the Guidelines

Blood transfusions should be reserved for ITP patients with active, severe bleeding or those requiring urgent surgical procedures when the platelet count is dangerously low (typically below 10,000-20,000/μL). When needed, a standard adult dose is one unit of apheresis platelets or 4-6 units of random donor platelets. The transfused platelets will likely be destroyed more quickly than normal due to the autoimmune antibodies, so concurrent treatment with IVIG (1 g/kg) or high-dose steroids (methylprednisolone 1 g/day for 1-3 days) may help prolong platelet survival, as suggested by the American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia 1.

Key Considerations

• First-line treatments for ITP focus on reducing platelet destruction and increasing production through medications like corticosteroids, IVIG, anti-D immunoglobulin, or TPO receptor agonists rather than direct platelet replacement.
• Blood transfusions carry risks including allergic reactions, transfusion-related acute lung injury, and alloimmunization, which must be weighed against potential benefits in each clinical situation.
• The American Society of Hematology 2019 guidelines for immune thrombocytopenia suggest a TPO-RA rather than rituximab for adults with ITP lasting $3 months who are corticosteroid-dependent or have no response to corticosteroids 1.
• Patient education and shared decision-making are encouraged, taking into account individual patient factors such as duration of ITP, frequency of bleeding episodes, comorbidities, age, and patient values and preferences 1.

Management Approach

• The choice of treatment should be individualized based on the specific clinical situation and patient characteristics.
• Splenectomy should be delayed for at least 1 year after diagnosis whenever possible, due to the potential for spontaneous remission in the first year 1.
• The use of recombinant factor VIIa (rfVIIa) and antifibrinolytic agents may be considered in specific situations, but their efficacy and safety must be carefully evaluated 1.

From the FDA Drug Label

Rescue therapies (i.e., corticosteroids, IVIG, platelet transfusions, and anti-D immunoglobulin) were permitted for bleeding, wet purpura, or if the patient was at immediate risk for hemorrhage.

The use of blood transfusions is mentioned as a rescue therapy for patients with ITP, specifically for bleeding, wet purpura, or if the patient is at immediate risk for hemorrhage 2.

From the Research

ITP Blood Transfusion

• Immune thrombocytopenic purpura (ITP) is a disease where the immune system attacks platelets, increasing the risk of bleeding 3.
• The treatment of ITP focuses on maintaining a sufficient platelet count to decrease the risk of bleeding, rather than normalizing the platelet count 3.
• In cases of critical hemorrhage, platelet transfusion, corticosteroids, and intravenous immune globulin (IVIG) may be initiated as soon as possible 4.
• For less severe bleeding, platelet transfusions are not recommended, and treatment consists of corticosteroids by themselves or in conjunction with IVIG 4.
• The effectiveness of platelet transfusion in reducing post-procedure bleeding risk in patients with ITP is controversial, and bleeding risk is primarily determined by procedural risk and patient condition, rather than platelet transfusion 5.

Treatment Options

• First-line treatments for ITP include oral corticosteroids, intravenous immunoglobulin, and anti-D immunoglobulin 6.
• Second-line therapies include rituximab, thrombopoietin receptor agonists (such as eltrombopag), and splenectomy 3, 6, 7.
• Eltrombopag has been shown to be effective as a second-line treatment for patients with primary immune thrombocytopenia, with an overall response rate of 94% 7.

Bleeding Risk Stratification

• Bleeding risk in patients with ITP is influenced by factors such as platelet transfusion amount, high-risk procedure, anticoagulant use, anemia, age, and ITP treatment 5.
• Minimizing unnecessary platelet transfusions and addressing bleeding risk factors pre-procedure is crucial to reduce bleeding risk in patients with ITP 5.