Second line therapy for immunethrombocytopenia (ITP) in adults

Second line therapies include splenectomy, rituximab, TPO-RAs and fostamatinib. Immunosuppressive medications such as mycophenolate mofetil may also be used. Use of a second line therapy is appropriate when glucocorticoids cannot be used and/or are ineffective, provided the diagnosis is confirmed and secondary causes of ITP have been reviewed and treated if present. Selection of second-line therapy in adults with ITP should be individualized based on duration of disease and patient values and preferences, which may change over time. Splenectomy is often deferred for 12 months to allow time for a spontaneous remission to occur. Other factors that may influence treatment decisions include frequency of bleeding sufficient to require hospitalization or rescue medication, comorbidities, adherence to daily therapies, medical and social support networks, cost, and availability of treatments. Patients may benefit from additional time, discussions and support while making decisions about treatment.