ITP: Investigation and Management

Key points

• ITP: immune-mediated platelet destruction — autoantibodies (usually IgG) against platelet glycoprotein IIb/IIIa or Ib complex, plus impaired platelet production.
• A bone marrow examination is only needed if there are atypical features; when done it shows normal or increased megakaryocytes. Treat based on bleeding and very low counts, not the platelet number alone.
• First-line: a short course of corticosteroids (prednisolone), with IV immunoglobulin (IVIG) added if a rapid rise is needed (active bleeding or urgent surgery).
• Second-line (now favoured over splenectomy): a thrombopoietin receptor agonist — eltrombopag, romiplostim or avatrombopag. Rituximab is an alternative; fostamatinib (a SYK inhibitor) is an option in refractory ITP.
• Splenectomy is reserved for later-line/refractory disease and avoided within the first year (chance of spontaneous remission). Life-threatening bleeding: IV methylprednisolone + IVIG, platelet transfusion, and a TPO-RA/rituximab as rescue.

Decision points in this pathway

• Platelets < 30 after 3 months of steroids?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.