Immune thrombocytopenia Management (adults) Laboratory evaluation (adult patients) Obtain HCV infection and human immunodeficiency virus serologies in all adult patients with ITP. B Obtain further hematological investigations if there are abnormalities other than thrombocytopenia (and perhaps findings of iron deficiency) on CBC or peripheral blood smear. B H. pylori testing Test for H. pylori infection in adult patients with ITP. B Bone marrow biopsy Adult patients Q Does the patient have a clinical features that are atypical for immune thrombocytopenia? Q Does the patient have significant abnormalities other than thrombocytopenia on CBC or peripheral blood smear? Yes to any Consider performing a bone marrow biopsy in patients in whom CBC or peripheral blood smear shows abnormalities other than thrombocytopenia (and perhaps findings of iron deficiency). C No to all Consider not routinely performing a bone marrow biopsy in patients with a clinical presentation that is typical of ITP. D Indications for admission Adult patients Q Does the patient have a platelet count < 20 10 /L? Yes Consider hospital admission in adults patients with newly diagnosed ITP and a platelet count of < 20 10 /L. C No Consider providing outpatient management, rather than hospital admission, in adults with a platelet count of 20 10 /L who are asymptomatic or have minor mucocutaneous bleeding. C Indications for treatment Adult patients Q Does the patient have a platelet count < 30 10 /L? Yes Consider initiating treatment in adults with newly diagnosed ITP and a platelet count of < 30 10 /L who are asymptomatic or have minor mucocutaneous bleeding. C No Avoid initiating treatment, and provide clinical observation only, in adults with newly diagnosed ITP and a platelet count of 30 10 /L who are asymptomatic or have minor mucocutaneous bleeding. D Patients with HIV-associated ITP Q Does the patient have human immunodeficiency virus infection? Yes Use IVIG if treatment for ITP is required in patients with HCV infection. B Consider initiating antiviral therapy in patients with secondary ITP due to hepatitis C. Closely monitor the platelet in patients treated with interferon, owing to a risk of worsening thrombocytopenia. C Patients with H. pylori-associated ITP ASH Q Does the patient have H. pylori infection? Yes Administer H. pylori eradication therapy in patients with ITP who are found to have H. pylori infection on the basis of urea breath tests, stool antigen tests, or endoscopic biopsies. B No First-line therapy (adult patients) Initiate a short course of corticosteroids ( 6 weeks, including treatment and taper), rather than a prolonged course (> 6 weeks) of corticosteroids. B Consider using either prednisone (0.5-2.0 mg/kg per day) or dexamethasone (40 mg per day for 4 days) as the first-line corticosteroid agent. C Consider using corticosteroids alone in preference to the combination of rituximab and corticosteroids. C Second-line therapy Adult patients Q Is the patient corticosteroid-dependent? Q Is the patient corticosteroid-unresponsive? Yes to any Consider initiating a thrombopoietin receptor agonist in preference to initiating rituximab. C Consider initiating rituximab in preference to performing splenectomy. C Consider using either eltrombopag or romiplostim as the thrombopoietin receptor agonist of choice. C No to all Management of corticosteroid side effects Monitor patients who are treated with corticosteroids for potential side effects, regardless of the duration or type of corticosteroid selected. This includes close monitoring for hypertension, hyperglycemia, sleep and mood disturbances, gastric irritation or ulcer formation, glaucoma, myopathy, and osteoporosis. E Assess health-related quality of life (HRQoL) (depression, fatigue, mental status, etc) in patients patients who are treated with corticosteroids, given the potential impact of these agents on mental health. E