From the Guidelines
Platelet transfusions are generally not recommended for immune thrombocytopenia (ITP) except in cases of life-threatening bleeding or before urgent procedures. In ITP, the problem is increased platelet destruction rather than decreased production, so transfused platelets are rapidly destroyed by the same autoimmune mechanism 1. The effect of platelet transfusions on the platelet count does appear to be short-lived, as reported in the American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia 1.
Some key points to consider in the management of ITP include:
- First-line treatments for ITP include corticosteroids, intravenous immunoglobulin (IVIG), or anti-D immunoglobulin (for Rh-positive non-splenectomized patients)
- If platelet transfusions are absolutely necessary in emergency situations, they should be given along with IVIG to help prolong the survival of transfused platelets
- The goal of ITP management is to increase the patient's own platelet production and decrease immune-mediated destruction
- For refractory cases, second-line therapies include thrombopoietin receptor agonists, rituximab, or splenectomy
- Patients should be monitored for bleeding symptoms rather than focusing solely on platelet counts, as many patients with low counts may not have significant bleeding
In cases of life-threatening bleeding, other treatment options such as recombinant factor VIIa (rfVIIa) or antifibrinolytic agents (aminocaproic acid and tranexamic acid) may be considered, but their efficacy is unproved and they carry significant risks, including thrombosis 1. Emergent splenectomy may also be considered in truly life-threatening bleeding, but this treatment should be regarded as heroic given the dangers of unplanned surgery, lack of immunization, risk of surgical bleeding, and risk of managing bleeding while preparing a patient for major abdominal surgery 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 platelet transfusions as a rescue therapy is mentioned in the context of managing bleeding or immediate risk of hemorrhage in patients with ITP.
- Key points:
- Platelet transfusions are allowed as a rescue therapy.
- The decision to use platelet transfusions should be based on the clinical judgment of the healthcare provider, taking into account the patient's risk of bleeding or hemorrhage. 2
From the Research
ITP and Platelet Transfusion
- Immune thrombocytopenia (ITP) is characterized by a platelet count less than 100 × 10^9/L without anemia or leukopenia 3.
- Patients with ITP may be asymptomatic, or they may have mild bleeding like petechiae, purpura, or epistaxis, and in rare cases, they may present with life-threatening bleeding 3.
- Platelet transfusions are recommended for patients with ITP who present with critical hemorrhage, and the treatment should be initiated as soon as possible, along with corticosteroids and intravenous immune globulin (IVIG) 3, 4.
- For less severe bleeding, platelet transfusions are not recommended, and the treatment consists of corticosteroids by themselves or in conjunction with IVIG 3.
- The use of concurrent intravenous immunoglobulin and platelet transfusion has been shown to be effective in controlling bleeding and increasing platelet counts in patients with ITP 4.
- The management of adult patients with ITP involves the use of various treatments, including corticosteroids, intravenous immunoglobulin, and anti-RhD immune globulin, as well as thrombopoietin receptor agonists, rituximab, and splenectomy 5, 6.
- Platelet transfusions are also recommended for patients with thrombocytopenia who have active hemorrhage or platelet counts less than 10 × 10^3 per μL, in addition to treatment of underlying causative conditions 7.
Indications for Platelet Transfusion
- Critical hemorrhage 3
- Active hemorrhage 7
- Platelet counts less than 10 × 10^3 per μL 7
- Need for invasive procedures with platelet counts less than 50 × 10^3 per μL 7