Our approach to the initial treatment of pediatric patients with newly diagnosed immune thrombocytopenia (ITP) based on severity of bleeding symptoms and other risk factors

ITP: immune thrombocytopenia; PLT: platelet; IV: intravenous; IVIG: intravenous immune globulin; anti-D: anti-D immune globulin (also known as anti-Rho immune globulin); NSAID: nonsteroidal antiinflammatory drug; DAT: direct antiglobulin test.

* Anti-D may be used instead of or in addition to IVIG in Rh-positive, DAT-negative, non-splenectomized patients. Anti-D should not be given if the patient's DAT status is unknown, which is often the case in emergency situations. If DAT is negative and Rh is positive, our practice is to include anti-D as part of combination therapy in patients with life-threatening bleeding. IV anti-D can be a useful component of therapy even in splenectomized patients despite its relative lack of efficacy when used as the sole agent in these patients. Other experts may not use ant-D in this setting. In non-emergency situations, anti-D is generally used as an alternative to IVIG rather than an additive therapy.

¶ Additional interventions that have been used patients with severe or life-threatening bleeding based upon limited data include: recombinant human factor VIIa, vincristine, adjunctive antifibrinolytic agents (eg, epsilon aminocaproic acid or tranexamic acid), and emergency splenectomy. For patients with severe menorrhagia, hormonal therapy may be warranted. In addition, we often administer a high dose of a thrombopoietin receptor agonist (eg, romiplostim) in patients with severe bleeding. This practice is not standardized. PLT transfusions are generally reserved for patients with active, life-threatening bleeding. However, PLT transfusions may be necessary for patients with non-life-threatening bleeding who require surgery and for those who do not achieve an adequate response with other treatments (eg, if the response is too slow or if the PLT count does not increase to an acceptable level). Refer to separate UpToDate content on ITP for additional details regarding these therapies.

Δ For severe bleeding that is not life-threatening (gastrointestinal bleeding without hemodynamic instability, pulmonary hemorrhage without cardiopulmonary compromise, severe prolonged epistaxis, muscle or joint hemorrhage), the components of treatment are similar to those used for life-threatening bleeding; however, rather than giving all 3 agents (IVIG, IV anti-D, and methylprednisolone) for up to 4 days, a measured approach using only 1 or 2 of these agents for fewer days may be sufficient. The choice of agents can be guided by the patient's previous treatment response if such experience exists. The choice and duration of therapy also depends upon the response to treatment.

◊ Target platelet counts for patients undergoing surgery or invasive procedures are higher than thresholds to prevent spontaneous bleeding and depend on the nature of the procedure. Refer to UpToDate topics on ITP and platelet transfusion therapy for further details.

§ For children with substantially impaired quality of life due to symptoms (especially fatigue) or anxiety about bleeding risks, pharmacologic therapy may be a reasonable option (after discussing with the patient and/or caregivers and carefully weighing the potential risks and benefits).