Adult ITP

The foremost goal of management of adult patients with ITP is to prevent major bleeding by maintaining a hemostatic platelet count. Recent published guidelines state that, because randomized clinical trials are lacking, treatment must be tailored to the individual patient.¹ However, some general principles may be outlined.

In most cases, a “normal” platelet count is not needed for hemostasis. Risk of spontaneous bleeding is minimal if the platelet count is maintained between 30,000/µL and 50,000/µL in a person without other risk factors.² Therefore, patients with platelet counts exceeding 30,000/µL generally require no treatment unless they are symptomatic (have significant mucosal bleeding) or are likely to experience blood loss due to a procedure or another medical condition.^1,3

Factors that can increase the risk of bleeding include:⁴

• Age greater than 60 years
• Various lifestyle issues (from very active to frail and/or prone to falls)
• Associated platelet dysfunction or coagulation defects
• Surgery or trauma
• Uncontrolled hypertension
• Infection
• Peptic ulcer disease

In these situations, the maintenance of a platelet count at a higher level (= 50,000/µL) should be considered.⁴ These factors should be considered in light of potential side effects of treatment.

Childhood ITP

As a result of the high rate of spontaneous resolution, observation is a common management strategy for childhood ITP. Treatment is typically pursued for children with very low platelet counts (eg, under 10,000/µL) or platelet counts less than 20,000/µL with significant mucosal bleeding.³ As outlined below, potential therapies include glucocorticoid therapy, IVIg, anti-D, platelet transfusions, and splenectomy (in rare cases) depending on the platelet count and the symptoms.³

Given the likelihood of spontaneous resolution, the benefits of treating childhood ITP are not clear. Although treatment has been shown to shorten the duration of very low platelet counts (< 20,000/µL), it is still debatable whether the effects of treatment alter the (already low) odds of intracranial hemorrhage.²

References

1. British Committee for Standards in Haematology General Haematology Task Force. Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Br J Haematol. 2003;120(4):574-596.
2. Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med. 2002;346(13):995-1008.
3. George JN, Woolf SH, Raskob GE, et al. Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology. Blood. 1996;88(1):3-40.
4. Chong BH, Ho S-J. Autoimmune thrombocytopenia. J Thromb Haemost. 2005;3(8):1763-1772.