Recommended management of ITP

What is the recommended management of immune thrombocytopenia (ITP)?

Bertrand Godeau, MD, PhD: The first-line treatment is well codified. It is steroids, either oral prednisone or dexamethasone. There are pros and cons of dexamethasone and prednisone. In some countries a lot of physicians prefer to use prednisone, but dexamethasone can be an option.

My message is that you must give steroids for a short period. You should avoid prolonged treatment with steroids, because you will not modify the natural history of the disease and you will expose your patients to very severe side effects. You should use immunoglobulin only for patients with severe hemorrhagic complications, and ITP is a rare disease in which we have tests for different doses of intravenous immunoglobulin (IVIG). We demonstrated 15 years ago that if you use 1 g/kg of body weight of IVIG, you have a response in 60% of patients. It is not necessary to use systematically 2 g/kg of body weight of IVIG because 1 g can be sufficient in 60% of patients. We reserve 2 g/kg of body weight of IVIG for life-threatening situations. And we reserve IVIG only for patients with very severe complications and not for low platelet counts. A low platelet count is not an indication for IVIG. It should be reserved for very severe situations. The same is true for platelet transfusion.

With regards to the second-line treatment, as I mentioned during the congress [see MIRCIM 2018], it is very difficult to answer your question because there is no consensus between dapsone, thrombopoietin (TPO) mimetics, rituximab, and splenectomy. It depends on your country. In some countries it is difficult to obtain some drugs because they are not licensed or the costs are high. But if you practice medicine in a country in which there are no restrictions, I think that the second-line treatment should be personalized according to the age of the patient, presence of comorbidities, history of thrombosis, and history of infection.

In France in my group the second-line treatment is dapsone. If the patient fails to respond to dapsone, we test rituximab. If the patient fails to respond to rituximab, we give a short course of TPO mimetics for 3 to 6 months. After 1 year of treatment, we discuss splenectomy. It is clear that today it is less frequent to propose splenectomy in ITP, but if you practice medicine in a country where it is difficult to obtain rituximab or TPO mimetics, splenectomy remains a very good treatment for ITP.