Immune Thrombocytopenia (ITP): Treatment

Immune Thrombocytopenia (ITP): overview

This algorithm outlines treatment of newly diagnosed immune thrombocytopenia (ITP), organized by line of therapy.

First-line treatment is corticosteroids, either dexamethasone or prednisone. When a rapid platelet rise is needed because of bleeding, IVIG is added to steroids. In the second line, the chart lists three classes. Thrombopoietin receptor agonists (eltrombopag, romiplostim or avatrombopag) stimulate platelet production. Rituximab, an anti-CD20 antibody, produces durable responses in a subset of patients. Fostamatinib, a SYK inhibitor, is supported by the FIT trials. For refractory disease, splenectomy offers durable remission in about 60% of patients, and immunosuppression or combination therapy is individualized. The sequence moves from short-term corticosteroids, with IVIG reserved for bleeding, to longer-term second-line agents and finally to surgical or combination approaches for refractory cases.

Trials behind this algorithm

Cheng 2003 (HD-Dex ITP) Cheng Y et al, NEJM, 2003; PMID: 12944568
RAISE Cheng G et al, Lancet, 2011; PMID: 20739054
FIT Bussel J et al, Am J Hematol, 2018; PMID: 29696684

Background reading: Immune thrombocytopenia (ITP) board review notes.

Immune Thrombocytopenia (ITP): the algorithm in words

Starting point: Immune thrombocytopenia (newly diagnosed). Full background: Immune thrombocytopenia (ITP) notes.

First-line (first-line): Corticosteroids (dexamethasone or prednisone); Rapid rise: IVIG (if bleeding) (+ steroids).
Second-line (second-line): TPO-RA: Eltrombopag / romiplostim / avatrombopag (thrombopoietin receptor agonist); Anti-CD20: Rituximab (durable response in subset); SYK: Fostamatinib (FIT trials).
Refractory (later-line): Surgical: Splenectomy (durable remission ~60%); Combination: Immunosuppression / combination (individualized).