Chronic immune thrombocytopenic purpura (ITP) is characterized by easy bruising and petechiae that persists for more than 6-12 months. The spleen plays a key role in the pathophysiology by destroying antibody-coated platelets. Treatment options include wait and watch if platelets are above 50,000, intravenous immunoglobulins, corticosteroids, intravenous anti-D therapy, splenectomy, rituximab, and thrombopoietin receptor agonists like romiplostim and eltrombopag. The choice of treatment depends on the severity of symptoms, platelet count, and prior treatment history.

1. CHRONIC ITP
By DR Falak abro

2. • chronic ITP persists for more than 6-
12 months.
• Chronic ITP has more insidious onset
with easy bruising and petechiae
•Age 8-14 years.
• male : female ratio is 1:2

4. PATHOPHYSIOLOGY
• Increased platelet destruction .
• Spleen is key organ in Pathophysiology
.platelet autoantibodies formed in white pulp
. Macrophages in red pulp destroy immunoglobulin
coated platelets.

5. PATHOPHYSIOLOGY
•Autoantibody coated platelets induce
Fc receptor-mediated phagocytosis by
mononuclear macrophages

6. Clinical
Signs and
symptoms

7. *Bruise

8. Petechiae

10. PurPura

12. Gingival
bleeding

13. Epistaxsis

14. INVESTIGATION

15. PERIPHERAL BLOOD FILM
• ITP with low platelet count usually
(<100,000 usually) with normal hemoglobin
and WBC count
• thrombocytopenia with platelet count
<20 x 109/L is common and platelet size
may be normal or increased

16. Bone Marrow
Examination

17. •The bone marrow in patients with ITP
contains normal or increased number of
megakaryocytes indicates that :
a: plateletes production is normal
b: thrombocytpenia is due to increased
platelet destruction.

20. TREATMENT

21. • Wait and Watch if platelets are
below 50,000 or there is no signs of
bleeding.

22. INTRAVENOUS IMMUNOGLOBULINS
•Mechanism:
blocking FC receptors of RE
(reticuloendothelial) phagocytes.
• preventing them from binding and
destroying IgG antibody-coated platelets.

24. LNH PHARMACY
1 vial= 250 mg
Price= approx Rs: 1500

25. Dose : safe dose is 400mg/kg/day using
5 days continuously or 1g/kg/day for 2
days.
Merits: IVIG is preferable to steroids because
it causes faster elevation of platelete count
greater than 20,000 within 24 hours.

26. Demerits :
• Its expensive
• Long infusion time of 6-8 hours
• Headache
• vomiting

27. Corticosteroids:
Mechanism
• inhibit platelet destruction.
•Rapid action that reduces RE
destruction of antibody coated platelet.

28. Dose:
•Oral prednisone 1-2mg/kg/day for two
weeks then tapered over third week
• In chronic ITP with recurrent bleeding
intravenous methyl predinisolone
20-30mg/kg/day for 3 days can be given.

29. Intravenous Anti D therapy :
MECHANISM:
• Specific red blood cell antibodies coat red
blood cells, which are taken by RE system
in place of antibody coated platelets.
•Anti Rh-D immunoglobulin produces mild
hemolytic anemia that saturates Fc receptors of
phagocytic elements of RE system.

30. •Dose I/V 50ug -75ug/kg for two days
platelet rise within 48 hours to 72 hours.
•Merits: Lower side effects than IVIG
doesnot cause headach or vomiting
•Demerit: causes hemolysis.

31. LNH PHARMACY
1 vial= 300 ug
Price = RS: 5500

32. SPLEENECTOMY:
•Indicated in chronic, symptomatic ITP
when other options fail.
•About 64-88% of patient with chronic Itp
achieve complete remission.

33. It is done because It removes:
• primary site of platelete destruction and
 site of antiplatelete-antibody production

34. RITUXIMAB:
MECHANISM:
• it is monoclonal antibody which depletes
B-cells by binding to the CD-20 antigen surface
•Therapy effect remains for 6-12 months as it
prevents activity of autoreactive cells specially
against gp-IIb/IIIa.

35. Dose : 375mg/m2 per dose weekly for 4
weeks.
Price : 100mg vial approx RS: 17000
500mg vial approx RS: 85000

36. Time to respond therapy : 1-7 weeks
Side-effects: fever, chills, allergy reactions
which can be prevented by slow infusion and
premedication with antihistamine or steroids.

37. (Thrombopoeitin) TPO receptor agonists
•Mechanism of action
•Endogenous TPO made in liver which regulates platelet
production by increasing the number and maturation of
bone marrow megakaryocytes.
•2 TPO receptor agonists :
a: romiplostim with dose 1-10ug/kg/dose
subcutanously weekly.
b: Eltrombopag with dose is 50mg orally.

38. •ROMIPLOSTIM is a subcutaneous
thrombopoiesis stimulating FC-peptide fusion
protein.
•ELTROMBOPAG is orally active non peptide
agonist, it acts by stimulating platelet
production.

39. Side effects
• Romiplostim : headache, phyrangitis, fatigue
•Eltrombopag : nausea and vomiting, hepatic
toxicity

41. THANKYOU…