American Society of Hematology 2019 guidelines for immune thrombocytopenia

Abstract

Background: Despite an increase in the number of therapies available to treat patients with immune thrombocytopenia (ITP), there are minimal data from randomized trials to assist physicians with the management of patients. Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the management of ITP. Methods: In 2015, ASH formed a multidisciplinary guideline panel that included 8 adult clinical experts, 5 pediatric clinical experts, 2 methodologists with expertise in ITP, and 2 patient representatives. The panel was balanced to minimize potential bias from conflicts of interest. The panel reviewed the ASH 2011 guideline recommendations and prioritized questions. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence (up to May 2017) and formulate recommendations. Results: The panel agreed on 21 recommendations covering management of ITP in adults and children with newly diagnosed, persistent, and chronic disease refractory to first-line therapy who have non–life-threatening bleeding. Management approaches included: observation, corticosteroids, IV immunoglobulin, anti-D immunoglobulin, rituximab, splenectomy, and thrombopoietin receptor agonists. Conclusions: There was a lack of evidence to support strong recommendations for various management approaches. In general, strategies that avoided medication side effects were favored. A large focus was placed on shared decision-making, especially with regard to second-line therapy. Future research should apply standard corticosteroid-dosing regimens, report patient-reported outcomes, and include cost-analysis evaluations.

Severe Pediatric COVID-19 Presenting With Respiratory Failure and Severe Thrombocytopenia

“…ITP is a diagnosis of exclusion and while the other causes of thrombocytopenia could not be ruled out with complete certainty, the clinical and laboratory findings were not supportive of these alternative diagnoses. Therefore, her thrombocytopenia was treated as ITP with standard first-line treatments, IVIG and corticosteroids 9 , with good recovery of her platelets. While mild thrombocytopenia has been reported in older patients with COVID-19 4 , our patient's presentation with profound thrombocytopenia was atypical.…”

Immune Thrombocytopenic Purpura (ITP) as an Uncommon Extraintestinal Complication of Crohn’s Disease: Case Vignette and Systematic Literature Review

“…e 2019 American Society of Hematology (ASH) guidelines on management of immune thrombocytopenic purpura recommend first-line therapy with corticosteroids, IVIG, or anti-D immunoglobulin as they have the quickest initial response [20]. Despite treatment with both corticosteroids and IVIG, our patient had no response and continued to be transfusion-dependent.…”

“…Despite treatment with both corticosteroids and IVIG, our patient had no response and continued to be transfusion-dependent. In a typical patient with ITP unresponsive to initial corticosteroid therapy, ASH guidelines recommend thrombopoietin receptor agonists (TPO-RA), rituximab, and splenectomy as subsequent treatment options [20].…”

Severe immune thrombocytopenic purpura in critical COVID-19: a case report

“…This relative lag may be caused by the underlying disease severity and its associated high antibody load but may also be related to the ongoing bleeding that may have contributed to platelet consumption and loss of the administered IVIG. Although it is not unusual for ITP to start to improve after 7 to 10 days of treatment, such a late response is not common [4].…”