Immune thrombocytopenic purpura (ITP) is an acquired autoimmune disorder where platelets are destroyed by the immune system. It presents with bruising and low platelet counts. Treatment depends on severity but includes corticosteroids, intravenous immunoglobulin, anti-D immunoglobulin, splenectomy, thrombopoietin receptor agonists, and rituximab. Management involves raising platelet counts to prevent bleeding while considering the underlying cause, risk of side effects, and the chronicity of ITP in selecting treatments.

1. Immune Thrombocytopenic Purpura
Dr. SUNIL KUMAR

2. INTRODUCTION
• Immune thrombocytopenic purpura (ITP; also termed idiopathic thrombocytopenic purpura) is an acquired
disorder in which there is immune-mediated destruction of platelets and possibly inhibition of platelet release
from the megakaryocyte.
• In children, it is usually an acute disease, most commonly following an infection, and with a self-limited
course.
• In adults, it is a more chronic disease, although in some adults, spontaneous remission occurs, usually within
months of diagnosis.
• ITP is termed secondary if it is associated with an underlying disorder like-
- autoimmune disorders, particularly SLE
- infections, such as HIV and hepatitis C, are common causes.
- The association of ITP with Helicobacter pylori infection is unclear but appears to have a geographic
distribution.
• ITP is characterized by mucocutaneous bleeding and a low, often very low, platelet count, with an otherwise
normal peripheral blood cells and smear.
• Patients usually present either with ecchymoses and petechiae, or with thrombocytopenia incidentally found
on a routine CBC.
• Mucocutaneous bleeding, such as oral mucosa, gastrointestinal, or heavy menstrual bleeding, may be
present. Rarely, life-threatening, including central nervous system, bleeding can occur. Wet purpura (blood
blisters in the mouth) and retinal hemorrhages may herald life-threatening bleeding.

3. ..
• Antibodies directed against platelet membrane glycoproteins IIb/IIIa
or Ib/IX complexes can be detected in roughly 80% of cases of
chronic ITP.
• The spleen is an important site of anti-platelet antibody production
and the major site of destruction of the IgG-coated platelets
• The diagnosis rests on the clinical features, the presence of
thrombocytopenia, examination of the marrow, and the exclusion of
secondary ITP. Reliable clinical tests for anti-platelet antibodies are not
available

4. LABORATORY TESTING IN ITP
• Laboratory testing for antibodies (serologic testing) is usually not helpful due to the low
sensitivity and specificity of the current tests.
• Bone marrow examination can be reserved for those who have other signs or
laboratory abnormalities not explained by ITP or in patients who do not respond to
initial therapy.
• The peripheral blood smear may show large platelets, with otherwise normal
morphology.
• Iron-deficiency anemia may be present due to bleeding.
• Laboratory testing is performed to evaluate for secondary causes of ITP and should
include testing for HIV infection and hepatitis C.
• Serologic testing for SLE, serum protein electrophoresis, immunoglobulin levels to
potentially detect hypogammaglobulinemia, selective testing for IgA deficiency or
monoclonal gammopathies, and testing for H. pylori infection should be considered,
depending on the clinical circumstance.
• If anemia is present, direct antiglobulin testing (Coombs’ test) should be performed to
rule out combined autoimmune hemolytic anemia with ITP (Evans’ syndrome).

5. TREATMENT
The treatment of ITP uses drugs that-
1. Decrease reticuloendothelial uptake of the antibody-bound
platelet
2. Decrease antibody production
3. Increase platelet production.
• The diagnosis of ITP does not necessarily mean that treatment
must be instituted. Patients with platelet counts >30,000/μL
appear not to have increased mortality related to the
thrombocytopenia

6. ..
• Initial treatment in patients without significant bleeding symptoms, severe thrombocytopenia
(<5000/μL), or signs of impending bleeding (such as retinal hemorrhage or large oral mucosal
hemorrhages) can be instituted as an outpatient using single agents.
• Prednisone at 1 mg/kg,
• Rh0(D) immune globulin therapy (WinRho SDF), at 50–75 μg/kg, is also being used in this setting.
Rh0(D) immune globulin must be used only in Rh-positive patients because the mechanism of
action is production of limited hemolysis, with antibody-coated cells “saturating” the Fc receptors,
inhibiting Fc receptor function. Rare complication of severe intravascular hemolysis.
• Intravenous gamma globulin (IVIgG), which is pooled, primarily IgG antibodies, also blocks the Fc
receptor system, but appears to work primarily through different mechanism(s).
• IVIgG has more efficacy than anti-Rh0(D) in postsplenectomized patients.
• IVIgG is dosed at 1–2 g/kg total, given over 1–5 days. Side effects are usually related to the volume
of infusion and infrequently include aseptic meningitis and renal failure.
• For patients with severe ITP and/or symptoms of bleeding, hospital admission and combined-
modality therapy is given using high-dose glucocorticoids with IVIgG or anti-Rh0(D) therapy and, as
needed, additional immunosuppressive agents.
• Rituximab, an anti-CD20 (B cell) antibody, has shown efficacy in the treatment of refractory ITP,
although long-lasting remission only occurs in ∼30% of patients.

7. ..
• Splenectomy has been used for treatment of patients who relapse
after glucocorticoids are tapered.
• Splenectomy remains an important treatment option; however, more
patients than previously thought will go into a remission over time.
• Vaccination against encapsulated organisms (especially pneumococcus,
but also meningococcus and Haemophilus influenzae, depending on
patient age and potential exposure) is recommended before
splenectomy
• Observation, if the platelet count is high enough, or intermittent
treatment with anti-Rh0(D) or IVIgG, or initiation of treatment with a
TPO receptor agonist.

8. ..
• TPO receptor agonists are available for the treatment of ITP.
• Two agents
1. Romiplostim administered subcutaneously
2. Eltrombopag orally
• Effective in raising platelet counts in patients with ITP and are recommended
for adults at risk of bleeding who relapse after splenectomy or who have
been unresponsive to at least one other therapy, particularly in those who
have a contraindication to splenectomy
• With the recognition that ITP will resolve spontaneously in some adult
patients, short-term treatment with a TPO agonist can be considered before
splenectomy in patients who need therapy.
• Eltrombopag is FDA approved for use in children over 1 year of age.
• Romiplostim is not yet FDA approved in children but a randomized trial
supports efficacy.

10. ..
• The Syk inhibitor fostamatinib represents a novel mechanism of action
to treat ITP patients who do not respond to corticosteroids, TPO-
mimetics, or rituximab.
• The goals of management of pregnancy-associated ITP are a platelet
count of 10,000–30,000/mcL in the first trimester, greater than
30,000/mcL during the second or third trimester, and greater than
50,000/mcL prior to cesarean section or vaginal delivery. Moderate-
dose oral prednisone or intermittent IVIG infusions are standard.
• Splenectomy is reserved for failure to respond to these therapies and
may be performed in the first or second trimester

11. …
• For thrombocytopenia associated with HIV or hepatitis C virus,
effective treatment of either infection leads to an amelioration of
thrombocytopenia in most cases
• Refractory thrombocytopenia may be treated with infusion of IVIG or
anti-D (HIV andhepatitis C virus), splenectomy (HIV), or interferon-
alpha or eltrombopag (hepatitis Cvirus, including eradication).
• Treatment with corticosteroids is not recommended in hepatitis C
virus infection.
• Occasionally, ITP treatment response is impaired due to H pylori
infection, which should be ruled out in the appropriate situation.