Splenectomy in steroid-unresponsive ITP

Do you perform splenectomy in patients with immune thrombocytopenic purpura (ITP) who do not respond to steroid treatment?

Mark Crowther: In the 2011 American Society of Hematology (ASH) guidelines which I chaired on ITP, we reviewed the evidence carefully and found that although rituximab is used widely in the treatment of ITP, there is very little evidence that it produces sustained remissions in a significant fraction of patients. Since then there has been even more information published showing that the rate of sustained remission with rituximab is really low. That means, in my mind, that if a patient has a sufficiently low platelet count and you feel it needs to be increased, splenectomy is the second-line treatment of choice.

The first part of that, though, is the most important, which is many patients can travel around with very low platelet counts for a long time and be completely asymptomatic. It is only in patients who have demonstrated complications or who are at high risk of complications that we would do that.