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![Idiopathic (Immune) Thrombocytopenic Purpura Thrombocytopenia in the absence of other](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-1.jpg)
Idiopathic (Immune) Thrombocytopenic Purpura
Thrombocytopenia in the absence of other blood cell
abnormalities (normal RBC & WBC, normal peripheral smear)
No clinically apparent conditions or medications that can account for thrombocytopenia
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![Statistics of ITP Incidence of 22 million/year in one study](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-2.jpg)
Statistics of ITP
Incidence of 22 million/year in one study
Prevalence greater as
often chronic
*Segal et al ?100 million/year
*age-adjusted prevalence 9.5/100,000
*1.9 :1 females / males
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![](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-3.jpg)
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![Clinical Manifestations May be acute or insidious onset Mucocutaneous Bleeding](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-4.jpg)
Clinical Manifestations
May be acute or insidious onset
Mucocutaneous Bleeding
*petechiae, purpura, ecchymosis
*epistaxis, gum bleeding
*menorrhagia
*GI bleed, CNS bleed = RARE
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![](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-5.jpg)
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![](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-6.jpg)
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![Etiology of ITP : Children Often after infection (viral or](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-7.jpg)
Etiology of ITP : Children
Often after infection (viral or bacterial)
Theories:
*antibody
cross-reactivity
*H. pylori
*bacterial lipopolysaccharides
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![Diagnosis (of Exclusion) Rule out other causes: *lab error /](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-8.jpg)
Diagnosis (of Exclusion)
Rule out other causes:
*lab error / PLT clumping
*drug / medication interaction
*infections (HIV, Hepatitis C)
*thyroid / autoimmune disease
*destructive / consumptive processes (TTP/HUS)
*bone marrow disease (leukemias, MDS)
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![Diagnosis (of Exclusion) Rule out other causes: *lab error /](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-9.jpg)
Diagnosis (of Exclusion)
Rule out other causes:
*lab error / PLT clumping
*drug / medication interaction
*infections (HIV, Hepatitis C)
*thyroid / autoimmune disease
*destructive / consumptive processes (TTP/HUS)
*bone marrow disease (leukemias, MDS)
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![To Marrow or Not to Marrow? Bone marrow aspiration &](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-10.jpg)
To Marrow or Not to Marrow?
Bone marrow aspiration & biopsy if…
Patient
60 yrs. or older
Poorly responsive to tx
Unclear clinical picture
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![Anti-Platelet Antibody Testing NOT recommended by ASH Practice Guidelines Poor](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-11.jpg)
Anti-Platelet Antibody Testing
NOT recommended by ASH Practice Guidelines
Poor positive/negative predictive values,
poor sensitivity with all current testing methods…
…and doesn’t change the management!
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![Management of ITP Goal = prevention of bleeding, NOT cure!](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-12.jpg)
Management of ITP
Goal = prevention of bleeding, NOT cure!
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![General Principles of Therapy Major bleeding rare if PLT >](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-13.jpg)
General Principles of Therapy
Major bleeding rare if PLT > 10,000
Goal =
get PLT count to safe level to prevent bleeding…
…not to specifically cure the ITP!
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![“Safe” Platelet Counts “moderately” t-penic = 30-50,000 Probably safe if asymptomatic Caution with elderly (CNS bleeds)](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-14.jpg)
“Safe” Platelet Counts
“moderately” t-penic = 30-50,000
Probably safe if asymptomatic
Caution with elderly
(CNS bleeds)
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![When Planning Therapy… Tailor therapy and decision to treat to](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-15.jpg)
When Planning Therapy…
Tailor therapy and decision to treat to the individual
patient
Weigh bleeding vs. therapy risks
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![Initial Therapy Prednisone 1 mg/kg/day *usually response within 2 weeks](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-16.jpg)
Initial Therapy
Prednisone 1 mg/kg/day
*usually response within 2 weeks
Taper off after
PLT response
Duration of use = controversial
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![Second-Line Therapy IV Immune Globulin (IVIg) 1 gram/kg/day x 2](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-17.jpg)
Second-Line Therapy
IV Immune Globulin (IVIg)
1 gram/kg/day x 2 days
WinRho (anti-D)
– if pt is Rh+
50-75 mcg/kg/day
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![Treatment Side-Effects Steroids *bone density loss *GI effects *muscle weakness](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-18.jpg)
Treatment Side-Effects
Steroids
*bone density loss *GI effects
*muscle weakness *weight gain
IVIG/anti-D
*hypersensitivity *headache
*renal failure *nausea/vomiting
*alloimmune hemolysis
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![Splenectomy Usually reserved for treatment failure Consider risk of bleeding,](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-19.jpg)
Splenectomy
Usually reserved for treatment failure
Consider risk of bleeding, pt lifestyle
RISKS
*surgical
procedure
*loss of immune function ? vaccinations
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![Data from George, JN, Woolf, SH, Raskob, GE, et al.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-20.jpg)
Data from George, JN, Woolf, SH, Raskob, GE, et al. Blood
1996; 88:3.
When to do Splenectomy?
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![Response Post-Splenectomy Usually normalized PLTs within 2 weeks (often immediately)](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-21.jpg)
Response Post-Splenectomy
Usually normalized PLTs within 2 weeks (often immediately)
Younger pts do
better
Kojouri et al (Blood 2004) ? 65% CR
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![Data from Fabris, F, et al. Br J Haematol 2001; 112:637.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-22.jpg)
Data from Fabris, F, et al. Br J Haematol 2001; 112:637.
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![Chronic Refractory ITP Persistent > 3 months PLT Failure to respond to splenectomy](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-23.jpg)
Chronic Refractory ITP
Persistent > 3 months
PLT < 50,000
Failure to respond to
splenectomy
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![When all else fails… Steroids IVIg / anti-D Rituximab (anti-CD20)](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-24.jpg)
When all else fails…
Steroids
IVIg / anti-D
Rituximab (anti-CD20)
Cyclophosphamide
Danazol
Accessory splenectomy
H. pylori eradication
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![Wrapping it up… ITP is often a chronic disease in](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-25.jpg)
Wrapping it up…
ITP is often a chronic disease in adults
Multiple therapies
may be needed over time
Goal = prevention of complications
Therapy needs to be tailored to the individual patient
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![](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/62315/slide-26.jpg)