ITP: Where Does Treatment Begin?
Before starting treatment for immune thrombocytopenia (ITP), two key questions must be answered:
Is it really ITP?
Does it really require treatment?
ITP is a diagnosis of exclusion. It has no unique features, and all other possible causes of low platelet count must be ruled out before confirming the diagnosis.
Treatment is required when platelets fall below 20–30,000/µL and there is clinical bleeding.
If it is ITP and treatment is necessary, the most common initial therapy is corticosteroids (prednisone, less often dexamethasone). Intravenous immunoglobulin (IVIG) can also be used, but despite its very high cost, its effect is usually no longer-lasting than that of corticosteroids.
If there is no effect (persistent bleeding), therapy moves to second-line options:
Splenectomy,
Rituximab,
Thrombopoietin receptor agonists (e.g., eltrombopag),
Immunosuppressive therapy (azathioprine, cyclosporine, cyclophosphamide, etc.).
The Key Question in Treatment
When to switch from first-line to subsequent lines of therapy.
In acute situations, corticosteroids are prescribed immediately in high doses (pulse therapy).
Another option is oral prednisone 0.5–2 mg/kg (most often 1 mg/kg) for 1–2 weeks, followed by gradual tapering over no more than 6 weeks.
Long-term prednisone therapy for 6 months or more is no longer used.
Patients whose platelet counts do not rise on glucocorticoids, or who experience rapid relapse of thrombocytopenia after tapering or discontinuing steroids, should be monitored closely or transitioned to alternative treatments, rather than continuing corticosteroids.