What are the ASH recommendations for treatment of immune thrombocytopenia (ITP) in adults?

Updated: Jan 11, 2020
  • Author: Craig M Kessler, MD, MACP; Chief Editor: Srikanth Nagalla, MBBS, MS, FACP  more...
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Answer

The 2019 ASH guidelines recommend against treatment of patients with a platelet count ≥30×109/L who are asymptomatic or have mild mucocutaneous bleeding. For newly diagnosed adult patients with a platelet count < 30×109/L, the guidelines suggest treatment with corticosterioids. For adults with a platelet count < 20×109/L who are asymptomatic or have minor mucocutaneous bleeding, the guidelines suggest hospital admission for newly diagnosed patients but outpatient treatment for those with an established diagnosis of ITP. In addition, Also, those patients who are not admitted to the hospital should receive education and expedited follow-up with a hematologist within 24 to 72 hours of the diagnosis or disease relapse. [8]

For first-line treatment, the guidelines recommend a short course (≤6 weeks) of steroids over a prolonged course (> 6 weeks, including treatment and taper). Additional first-line treatment suggestions include the following [8] :

  • Either prednisone (0.5-2.0 mg/kg per day) or dexamethasone (40 mg per day for 4 days) as the type of corticosteroid 
  • Corticosteroids alone rather than rituximab and corticosteroids

The following 2011 ASH treatment suggestions remain unchanged [42] :

  • IVIG may be used with corticosteroids when a more rapid increase in platelet count is required
  • Either IVIG or anti-D (in appropriate patients) may be used if corticosteroids are contraindicated
  • If used, IVIG should be administered in a single dose of 1 g/kg; the dose may be repeated if necessary

For adults with ITP for ≥3 months who are corticosteroid dependent or unresponsive to corticosteroids, the 2019 second-line treatment suggestions include the following, depending on preference [8] :

  • A TPO-RA (either eltrombopag or romiplostim)
  • Rituximab, for those who value avoiding surgery and long-term medication
  • Splenectomy, for those who value avoiding long-term medication and gaining a durable response

The ASH guidelines recommend delaying splenectomy for at least 1 year after diagnosis, if possible, because of the potential for spontaneous remission in the first year. The 2011 recommendation that for medically suitable patients, laparoscopic and open splenectomy offer similar efficacy, also remains unchanged. [8]

In summary, the 2019 ASH guidelines suggest tailoring second-line therapy based on the patient's values and preferences. For those who value avoiding surgery or are not surgical candidates, a TPO-RA is preferred. Rituximab is preferred for those who value avoiding surgery and long-term medication. Finally, splenectomy should only be considered after at least 1 year has elapsed since diagnosis, given the risks of morbidity and mortality with a surgical procedure. Splenectomy should be reserved for those who value avoiding long-term medication and gaining a durable response.

While no ASH recommendations were made regarding the association of Helicobacter pylori in adult ITP, every adult with gastrointestinal symptoms with ITP or with chronic unresponsive ITP may benefit from H pylori diagnostic testing, and triple therapy should be administered to all those who test positive for H pylori infection. [86] Remissions after treatment of H Pylori were observed more frequently in reports from Japan and Italy (28%-100%) than in the US and other European countries (< 13%).   


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