Diagnosis and management of chronic ITP: comments from an ICIS expert group

Abstract

Immune thrombocytopenia (ITP) is a common disorder in children and adults. In a patient with newly diagnosed ITP, the treatment strategy is relatively well defined. Second-line treatments are more controversial, and the management of chronic ITP is even more so. During the 3rd ICIS Expert Meeting on Consensus and Development of Strategies in ITP, held in Basel on September 3-5, 2009, a group of experts were tasked with reaching a consensus on some frequently asked questions relating to diagnosis and management of children and adults with chronic ITP. The content of this article is designed to provide a practical support to trained haematologists in their care of patients with chronic ITP.

Was sind die Indikationen für Rescue-Verfahren?

“…Die Gabe von IVIG kann in Analogie zur idiopathischen Immunthrombozytopenie (ITP) auch bei Patienten mit schwerer und therapierefraktärer Autoimmunthrombozytopenie im Rahmen eines SLE erwogen werden. Die Gabe von IVIG wird in Kombination mit GC bei akuten Blutungskomplikationen im Rahmen einer ITP empfohlen [23,49] und ist in dieser Indikation auch zugelassen. Auch vor operativen Eingriffen oder bei Schwangeren mit ITP kann ein Einsatz von IVIG erwogen werden, wenn GC nicht ausreichend wirksam waren oder vermieden werden müssen [73].…”

Risk of Thromboembolism in Patients with Immune Thrombocytopenia

“…However, prophylactic anticoagulation with low doses of low-molecular weight heparins (LMWH) perioperatively has not eliminated the appearance of portal vein thrombosis [84]. The Intercontinental Cooperative ITP Study Group (ICIS) expert group recommended that prophylactic dose LMWH should be administered as usual in ITP patients with high-risk surgery such as orthopedic or cancer surgery, if platelet counts are above 30,000/μL [85]. On the other hand, there have been conflicting reports regarding thromboprophylaxis of aspirin in aPLpositive patients [86][87][88].…”

“…For the treatment of thrombosis in patients with ITP, ICIS expert group recommend that treatment of thrombosis should be started with unfractionated heparin (UFH) at half-therapeutic dose while increasing the platelet count in patients with low platelet counts [85]. If the patient tolerates half-therapeutic UFH for a few days, the dose should be increased to the therapeutic level, and later UFH should be replaced by LMWH or warfarin.…”

“…In -patients with ITP with atrial fibrillation, initial anticoagulation with LMWH is preferred, and subsequent continuation of anticoagulation only, if no bleeding occurs. Initial target international normalized ratio (INR) should be in the lower range (e.g., 1.5-2.0) and increased to the regular level (INR 2.0-2.5), only if this has been shown to be safe [85].…”

“…Coated coronary stents should not be used because they require more intensive anticoagulation [85]. UFH (70-100 IU/kg) or fondaparinux (2.5 mg) + half dose UFH during PCI and acetylsalicylic acid (ASA) (300 mg) plus clopidogrel (300-600 mg) after stent placement is recommended [93].…”