Primary immune thrombocytopenia in children and young adults - Leeds Children’s Hospital Guidance

Publication: 30/09/2020  
Next review: 30/09/2023  
Clinical Guideline
CURRENT 
ID: 6737 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Leeds Children’s Hospital Guidance to diagnosis and management of primary immune thrombocytopenia in children and young adults

 
LTHT Paediatric Prescribing and Monitoring Guide Eltrombopag for ITP 
LTHT Paediatric Prescribing and Monitoring Guide Romiplostim for ITP 

Diagnosis

A presumptive diagnosis of ITP is made when the history, physical examination, complete blood count (CBC), and examination of the peripheral blood smear do not suggest other thrombocytopenia aetiologies.

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Assessment at initial presentation

History

Key elements are acquired not congenital presentation and absence of differential diagnoses see appendix.

Document bleeding severity

Grade

Bleeding

Management approach

Grade 1 (minor

Minor bleeding, few petechiae (≤100 total) and/or ≤5 small bruises (≤3 cm in diameter), no mucosal bleeding

Consent for observation

Grade 2 (mild)

Mild bleeding, many petechiae (100 total) and/or >5 large bruises (>3 cm in diameter), no mucosal bleeding

Consent for observation

Grade 3 (moderate)

Moderate bleeding, overt mucosal bleeding, troublesome lifestyle

Intervention to reach grade 1 or 2

Grade 4 (severe)

Severe bleeding, mucosal bleeding leading to decrease in Hb >2 g/dL or suspected internal haemorrhage

Intervention

Examination

Exclude signs of alternative diagnoses including splenomegaly.

Investigations

Full blood count and expert medical analysis of the peripheral blood smear.

Bone marrow aspiration, biopsy, and cytogenetics should be performed if abnormal or potentially malignant cells are visualized on smear and carefully considered if there are other abnormalities of the haemoglobin and/or white cell count (with the exception of microcytic anaemia) or if there is hepatosplenomegaly and/or adenopathy.

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Review

 

Provide open access to Paediatric Haematology Oncology wards and 24/7 telephone numbers.
Outpatient review appointments timings:

  • 1 week and 3 weeks then alternate months for 6 months.
  • 6 months to one year each three months.6 monthly if stable thereafter.
  • Medical review and FBC 1 week, 3 week, 3 months, 6 months, 1 year and 6 monthly thereafter
  • Nursing review other visits – no FBC needed
    • Each appointment assess severity of bleeding quality of life
    • Advise re activities
    • Medical review examination of lymph nodes and spleen and as appropriate

Parents need to be reassured that is generally a benign transient disorder and given the Parent Information Sheet.  They must be explicitly told what to watch for and when they should bring their child.  There is no need to admit or treat if the child is well.

Avoid NSAIDS.

Indications for return include:

  1. any clinical deterioration
  2. wet mucosal bleeding
  3. persistent prolonged epistaxis
  4. any uncontrolled bleeding
  5. significant head injury.

This is generally a self-limiting illness and the platelet count should recover in ~3 months in >90% of cases. 

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Assessment of patients diagnosed with ITP who have no improvement in platelet count after 3 to 6 months and require treatment.

ITP may be classified as primary or secondary to other medical conditions present at diagnosis. Furthermore, it may be further classified as newly diagnosed (0-3 months), persistent (3-12 months), or chronic (12 months).

Differential diagnoses to consider if persistent or chronic are:

Previously diagnosed or possible high risk for conditions that may be associated with immune thrombocytopenia (eg, infections [COVID, HIV, HCV, HBV]),

Autoimmune/immunodeficiency disorders (CVID, systemic lupus erythematosus, or APS), and malignancy (eg, lymphoproliferative disorders)

Liver disease (including cirrhosis or portal hypertension)

Splenomegaly

Drugs (prescription or nonprescription), including heparin, alemtuzumab, PD-1 inhibitors, abciximab, valproate, alcohol abuse, consumption of quinine (tonic water), exposure to environmental toxins, or chemotherapy

Bone marrow diseases, including myelodysplastic syndromes, leukaemias, other malignancies, metastatic disease, myelofibrosis, aplastic anaemia, megaloblastic anaemia and Gaucher disease

Recent transfusions (rare possibility of posttransfusion purpura) and recent vaccinations

Inherited thrombocytopenia: TAR syndrome, radioulnar synostosis, congenital amegakaryocytic thrombocytopenia, Wiskott-Aldrich syndrome, MYH9-related disease, Bernard-Soulier syndrome, type IIB VWD, or platelet-type VWD

Other thrombocytopenic disorders (DIC, TTP, HUS, Evans syndrome)

Clinical reassessment

Repeat history, physical examination

Repeat investigations

  1. Full blood count, blood film, renal function, liver function, serum B12 and folate levels
  2. Direct Antiglobulin Test to exclude coexistent autoimmune haemolytic anaemia
  3. Baseline Immunoglobulin levels and lymphocyte subsets to exclude coexisting immunodeficiency
  4. Autoantibody screen including anti-phospholipid antibodies
  5. Hepatitis A,B,C and HIV serology;  PCR for cytomegalovirus, EBV; stool sample for H pylori antigen
  6. Coagulation screen, D Dimer, Clauss fibrinogen, lupus anticoagulant, von Willebrand disease screen including Ristocetin Induced Platelet Aggregation (RIPA), platelet glycoproteins for Bernard Soulier (Call coagulation laboratory on 65620 a week before to book)
  7. Bone marrow aspiration, biopsy, and cytogenetics
  8. Genetic screening for inherited thrombocytopenia and bone marrow failure syndromes

Recommendations:

  1. An EDTA sample for DNA extraction and sequencing for panels R90 and R91 should be sent to Yorkshire & North East Genomic Laboratory Hub, Central Lab Genomic Specimen Reception (Histopathology Department) Bexley Wing, Level 5, St James’s University Hospital  (https://www.leedsth.nhs.uk/assets/Genetics-Laboratory/Referral-forms/5032e4ab10/LGSR017-Genetics-Referral-Form-Editable-2020-07-03.pdf).
    Details of available panels can be found at: https://nhsgms-panelapp.genomicsengland.co.uk/panels
  2. If there are additional cytopenias or clinical concern regarding Fanconi anaemia, a Lihep sample should be sent to Sheffield for chromosomal breakage analysis as well as requesting the R229 panel (with EDTA sample sent for R90/R91). Consideration should also be made for telomere length testing if indicated by the history or presence of other cytopenias.
  3. If there is a family history of malignancy or bone marrow failure, panels R92/R347 should also be requested.
  4. The presence of other cytopenias (e.g. AIHA), abnormal lymphocyte subsets or immunoglobulins, or marrow findings (e.g. increased megakaryopoiesis suggestive of peripheral destruction) may also be indicate a primary immunodeficiency/immune dysregulation and a request for the R15 panel should be considered.
  5. Families should be counselled regarding the possible implications of a genetic diagnosis for both the patient and other family members.
  6. Additional testing may also be indicated and this may be guided by further discussion with clinical genetics and/or immunology. For cases where genetics will have more urgent management implications there is the additional option for trio exomes (R14, EDTA samples from patient and both parents) could be considered.

Rationale: The choice of genetic testing will depend in part on clinical features (including blood film findings, presence of other cytopenias, bone marrow results and family history). Genetic causes include syndromes presenting with isolated thrombocytopenia due to defects in megakaryopoiesis (including mutations of MPL, MECOM, RBM8A, HOXA11), thrombocytopenia with associated increased risk of haematological malignancy (RUNX1, ETV6, ANKRD26, GATA2), macrothrombocytopenias (including Bernard-Soulier, MYH9-associated disorders), other disorders associated with morphologically abnormal or dysfunctional platelets (e.g. Grey platelet syndrome, Wiskott-Aldrich syndrome, type 2B vWD) or thrombocytopenia as part of an inherited bone marrow failure syndrome (including Fanconi anaemia and telomeropathies).

The relevant genes are covered by a number of panels (total 175 genes, although these panels may change in future):

R229 (18 genes) -Fanconi anaemia and Bloom syndrome

R91 (56 genes) - Other inherited bone marrow failure syndromes

R90 (105 genes) - Inherited bleeding disorders, which includes macrothrombocytopenias, platelet function disorders, and vWF but also RUNX1 which is not on the above two panels.

R92 (33 genes)  - Rare anaemias, which includes a small number of genes not included in the above 3 panels such as NBN (associated with Nijmegen breakage syndrome) and DDX41 (associated with predisposition to MDS/AML).

R347 (9 genes) - Inherited predisposition to AML panel.  This includes genes covered by other panels associated with thrombocytopenia (ANKRD26, ETV6, RUNX1 and GATA2), telomeropathies and MDS (DDX41, TERTC, TERT) but also TP53 and CEBPA, which may be relevant if there is a family history of haematological malignancies.

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Recommendations for initial treatment of children with ITP when required

(Please refer to table 1 for indications to start therapy, consider consultation with regional paediatric haematologist)

  1. Prednisolone should be given at 4 mg/kg per day in 3 or 4 divided doses for 4 days with no taper, with a maximum daily dose of 200 mg. Corticosteroids are relatively contraindicated in the presence of severe infection or recent varicella contact.
  2. 2.If there is a need for more rapid escalation of the platelet count, IVIg often increases the platelet count to haemostatic levels (>50 x 109 /L) within 24 to 48 hours. IVIg is effective when given as a single dose of 0.8 to 1.0 g/kg (Grade A recommendation, evidence level Ib). 

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Recommendations for treatment of persistent or chronic ITP in children

  1. Most children can be managed with watchful waiting.
  2. Rescue therapy with corticosteroids, IVIg can be used in children on watchful monitoring to treat acute bleeding episodes if/when they occur.
  3. Multiple paediatric studies support the use of TPO receptor agonists (TPO-RAs) in children with persistent/chronic ITP, demonstrating good response and reduction in bleeding frequency with an absence of side effects in the majority of patients.

    TPO-RAs. The lowest dose required to achieve and maintain a platelet count >50 x 109 /L should be used for eltrombopag and romiplostim. A retrospective study of TPO-RAs in children with ITP (primary/ secondary and newly diagnosed/chronic) reported a stable response rate of 40% and no significant difference in response pattern between romiplostim and eltrombopag. If there is no response to one TPO-RA or there is a response that is lost and a TPO-RA is the best option for treatment, switch to the alternative TPO-RA and/or consider combining it with mycophenolate mofetil  or another immunosuppressant (evidence level IV). If a TPO-RA is initiated and effective, optimal duration of treatment is unknown. Consensus recommendation is to consider tapering the dose after 6 to 12 months of a stable response with a platelet count >50 x 109 /L to determine whether it can be discontinued. Tapering can be tried again if it fails initially. Median time to eltrombopag response is 12 to 20 days, depending on the age of the patients. There are few data on the administration of eltrombopag for longer than 1 year in children.

    Studies of romiplostim in children with ITP (newly diagnosed and chronic) have reported overall response rates of 71% to 88%, and a median time to response of 4 to 5 weeks.

    TPO-RAs can be used in patients who fulfil the following criteria following completion of a Blueteq form;

Either:

  • chronic ITP refractory to standard active treatments and rescue therapies or;
  • chronic ITP with severe disease and high risk of bleeding and needs frequent courses of rescue therapies.  

And:

  • Over 1 year of age
  • MDT discussion regarding TPO-RA initiation

Patients who do not fit these criteria would require an individual non-formulary request. Note eltrombopag is only available as tablets which cannot be crushed.

See Appendix for dosing schedule and monitoring requirements.

  1. In those who fail TPO-RAs, especially adolescent females, rituximab and dexamethasone should be considered (evidence level III; Grade C recommendation).

    Rituximab. Rituximab is not approved for the treatment of ITP. However, studies report that it may induce responses in children with chronic ITP. Overall response rates to rituximab in this population are reported at 23% to 69%. Use would require an individual non-formulary request.

    Mycophenolate mofetil . In 30 children with primary ITP (newly diagnosed, persistent, or chronic), treatment with mycophenolate mofetil achieved a response rate of 56%, and 29% of patients relapsed (evidence level IIb). Limited toxicity (asthenia, vomiting, and skin effects in 1 patient each) was observed. Doses were not specified but a  suggested dose for different indications is 10-20mg/kg bd however discuss with pharmacy before starting

    Fostamatinib. Fostamatinib is not licensed for the treatment of children with ITP and there are no data on its use in children.

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Recommendations for school and participation in sporting activities for children with ITP

  1. Children and adolescents 5 to 18 years old need ≥60 minutes of physical activity per day, ≥3 d/wk. This should include exercises or sports to promote strong muscles and bones.
  2. Normal attendance and play at nursery, school, or college, depending on age, is essential. The risk of bleeding and information about ITP should be provided to the school in a way that facilitates inclusion, not isolation.
  3. Active participation in low-risk activities should be maintained, irrespective of platelet count and treatment.
  4. Participation in non low-risk activities must be discussed with the family, school, and coach. A number of factors must be considered prior to participation, including age of the child, platelet count, bleeding history, and physical nature of the activity
  5. Participation in high-risk activities (including BMX racing, boxing, American football, ice hockey, lacrosse, motorcycle riding, motocross racing, power lifting, outdoor rock climbing, rodeo, rugby, snowmobiling, trampoline, and wrestling) should be discouraged unless the patient has a near-normal platelet count on a consistent and stable basis. Alternatively, treatment should be administered to provide a safe platelet count during the activity.

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Recommendations for splenectomy in children with chronic ITP

  1. Splenectomy should only be considered in children who have failed all available medical therapies, are having thrombocytopenia-related bleeding, and whose life is at risk or whose HRQoL is substantially impaired.
  2. Splenectomy should be avoided if at all possible before 5 years of age and within 1 year of disease onset.
  3. Before considering splenectomy, reassess the diagnosis of ITP by excluding alternative diagnoses, including inherited thrombocytopenia, bone marrow failure, drug induced thrombocytopenia, subclinical viral infections, immunodeficiency syndromes (eg, CVID, autoimmune lymphoproliferative syndrome), and myelodysplastic syndrome.
  4. Prior to splenectomy, ensure that vaccinations are up to date according to national policy. Vaccination, as a minimum, should include pneumococcal 13-valent conjugate vaccine, followed by pneumococcal 23-valent vaccine 8 weeks later; H influenzae type B; and both meningococcal vaccines to cover all 5 species subtypes.
  5. If there is any concern for an immunodeficiency-related ITP, even if undocumented, reducing the risk for post-splenectomy sepsis by assessing response to pneumococcal vaccines pre-procedure is advisable.

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Recommendations for emergency treatment in children at any stage of their ITP

  1. Combination therapy, including a two- to threefold higher dose of platelets transfusion should be infused, IV corticosteroids, and IVIg, with or without anti-D, is recommended. Platelet transfusions should be administered as a bolus, followed by continuous infusion in combination with IV high-dose steroids (eg, IV methylprednisolone, 30 mg/kg per day). IVIg (0.8-1.0 g/kg per day, with or without single-dose IV anti-D (75 microgram/kg), should be given for ICH or other life-threatening or serious bleeding. A second dose of IVIg and IV steroids may be required if a platelet response is not seen within 24 hours of the initial dose (Grade C recommendation).
  2. Antifibrinolytics may be given if bleeding continues despite therapy if no haematuria
  3. If there is an ICH, emergency splenectomy and/or neurosurgical control of bleeding should be considered in conjunction with emergency platelet-raising therapy, but medical treatment should never be delayed because of surgical or radiologic intervention if at all
  4. TPO-RAs should be considered; they may aid the acute response in patients and prevent a decrease in platelet count if initial response to emergency therapy is lost.

The risk of bleeding following ICH may necessitate long-term treatment. There is no role for emergency splenectomy unless patients have failed multiple other treatments. Studies have only supported the use of recombinant factor VIIa in patients with massive bleeding after trauma

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Recommendations for management of neonates born to women with ITP

  1. Umbilical cord platelet count should be obtained at the time of delivery or as soon as possible.
  2. Repeat the platelet count as needed depending on platelet levels, trends in the count, and response to treatment (if any). If cord platelet count is <100 x 109 /L, repeat the platelet count daily until stable. The incidence of pseudothrombocytopenia is high in neonates because of the difficulties encountered in obtaining unclotted blood with blood draws.
  3. If platelet count is <50 x 109 /L at birth, perform a cranial ultrasound. A magnetic resonance imaging for confirmation or clarification can be performed without anaesthesia using the sleep and swaddle approach 30 to 60 minutes prior.
  4. In the case of ICH, give IVIg and a course of corticosteroids (dose to be discussed with neonatal consulatant as no specific dose guidance available) to maintain platelet count >100 x 109 /L for 1 week if possible and >50 x 109 /L for another week. The use of platelet transfusion may increase neonatal risk.
  5. If there is symptomatic bleeding or if platelet count is <30 x 109 /L, with or without platelet transfusion, give IVIg.
  6. If severe thrombocytopenia continues for >1 week in a breast-fed infant, consider pausing breastfeeding for a few days to see whether platelet count increases.
  7. Women who had a splenectomy may have a thrombocytopenic newborn, even if their platelet count is normal.
  8. The only currently reliable predictor of whether a baby will be thrombocytopenic is if a previous sibling was thrombocytopenic.

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Appendix 1

‘Updated international consensus report on the investigation and management of primary immune thrombocytopenia’ Blood 26 NOVEMBER 2019 x VOLUME 3, NUMBER 22

Useful information

Diagnosis

A presumptive diagnosis of ITP is made when the history, physical examination, complete blood count (CBC), and examination of the peripheral blood smear do not suggest other thrombocytopenia aetiologies. No “gold standard” test exists to reliably establish the diagnosis. Response to ITP-specific therapy (eg, IVIg, IV anti-D Ig [anti-D], or steroids) supports the diagnosis but does not exclude secondary ITP, because many secondary ITPs respond to IVIg.

Differential diagnoses of thrombocytopenia

Other autoimmune diseases associated with thrombocytopenia, including SLE, CVID, autoimmune lymphoproliferative syndrome, and chronic viral infections, should be considered in difficult, persistent, and chronic cases and in those with multiple autoimmune cytopenias (eg, Evans syndrome). Older children and those with slow evolution of disease (evidence level Ib-III) may be more likely to develop chronic disease.

Liver disease (including cirrhosis or portal hypertension)

Splenomegaly

Drugs (prescription or nonprescription), including heparin, alemtuzumab, PD-1 inhibitors, abciximab, valproate, alcohol abuse, consumption of quinine (tonic water), exposure to environmental toxins, or chemotherapy

Bone marrow diseases, including myelodysplastic syndromes, leukaemia, other malignancies, metastatic disease, myelofibrosis, aplastic anaemia, megaloblastic anaemia, marrow infiltration, and Gaucher disease

Recent transfusions (rare possibility of post-transfusion purpura) and recent vaccinations

Inherited thrombocytopenia: TAR syndrome, radioulnar synostosis, congenital amegakaryocytic thrombocytopenia, Wiskott-Aldrich syndrome, MYH9-related disease, Bernard-Soulier syndrome, type IIB VWD, or platelet-type VWD

Other thrombocytopenic disorders (DIC, TTP, HUS, Evans syndrome)

Severe vitamin B12 and folate deficiency can result in thrombocytopenia

Salient points in patient history

Recent infections/ vaccinations (an increased ITP risk was associated with measles-mumps-rubella vaccination in children)

Drugs, liver disease, and primary haematological disorders, ethanol abuse, foreign travel

Historical patient information should include establishing timing of bleeding symptoms onset- infancy / early life or later

Bleeding after previous surgery, dentistry or trauma, menstrual bleeding, prior blood counts, drug and toxin exposure, recent foreign travel and vaccinations, recent infections, needle stick accidents, and prior transfusions with blood products.

Incidence and degree of bleeding (eg, menstrual bleeding) is important.

Family history of thrombocytopenia or bleeding disorders.

Features atypical of ITP (orthopaedic abnormalities, learning difficulties, renal disease, hearing disorders, or malignancy). Constitutional symptoms (eg, fever or weight loss, hepatomegaly, splenomegaly, or lymphadenopathy) might indicate an underlying disorder (HIV, chronic liver disease, systemic lupus erythematosus [SLE], lysosomal storage disease, or a lymphoproliferative disease).

The possibility of physical abuse must be considered.

Fatigue may be part of the ITP syndrome.

Management

From registry and cohort data, 0% to 4% of children with newly diagnosed ITP have severe (grade 4) bleeding requiring immediate intervention, bleeding that may require treatment is reported in 30% to 56% of newly diagnosed children. The incidence of ICH in children with ITP is 0% to 1% (evidence level III). Spontaneous remission may occur at any time, even >3 years from diagnosis.

TPO-RAs.

Eltrombopag and romiplostim have been studied extensively in children, leading to FDA and European Medicines Agency licenses in children ≥1 year old with ITP for >6 months’ duration with insufficient response to corticosteroids, Igs, or splenectomy. In general, TPO-RAs should be used as preferred treatment in patients with ITP in whom alleviating the thrombocytopenia is likely to provide a clear clinical benefit, including reducing the risk of bleeding and/or improving the HRQoL. The lowest dose required to achieve and maintain a platelet count >50 x 109 /L should be used for eltrombopag and romiplostim. A retrospective study of TPO-RAs in children with ITP (primary/ secondary and newly diagnosed/chronic) reported a stable response rate of 40% and no significant difference in response pattern between romiplostim and eltrombopag (evidence level IIb).

If there is no response to 1 TPO-RA or there is a response that is lost and a TPO-RA is the best option for treatment, switch to the alternative TPO-RA and/or consider combining it with mycophenolate mofetil  or another immunosuppressant (evidence level IV). If a TPO-RA is initiated and effective, optimal duration of treatment is unknown. Consensus recommendation is to consider tapering the dose after 6 to 12 months of a stable response with a platelet count. >50 x 109 /L to determine whether it can be discontinued. Tapering can be tried again if it fails initially. Switching to another treatment, such as rituximab, immunosuppressants, or splenectomy, requires extensive discussion with the patient and/or family.

Eltrombopag

The PETIT and PETIT2 studies of eltrombopag in children with chronic ITP reported a platelet count ≥50 x 109 /L at least once in 80% of patients (evidence level Ib) in PETIT2, 40% of patients had a platelet count ≥50 x 109 /L for≥6 weeks without rescue. No World Health Organization grade 3 or 4 bleeding in patients on eltrombopag was reported in either trial. In the PETIT trial, 30% of children received the maximum dose of eltrombopag (75 mg/d); 89% of patients required >1 dose modification. Median time to response was 12 to 20 days, depending on the age of the patients. There are few data on the administration of eltrombopag for longer than 1 year in children.

Romiplostim.

In children, the recommended initial dose is 1 microgram/kg per week, administered subcutaneously; the dose can be adjusted depending on platelet count (see prescribing information for full details). A 24-week phase 3 study reported a median average dose of 3.9 microgram/kg (interquartile range, 2.4-7.3) and a median most frequent dose during the final 8 weeks of 5.5 microgram /kg (interquartile range, 3-10). In the absence of thrombotic risk, the authors use an initial dose of 3 microgram /kg per week. Studies of romiplostim in children with ITP (newly diagnosed and chronic) have reported overall response rates of 71% to 88%, and a median time to response of 4 to 5 weeks (evidence levels Ib-III). A study of long-term romiplostim treatment in children found AEs and platelet responses similar to those seen in adult patients and maintenance of effect over 4 years. However, another study with 24 weeks of romiplostim treatment reported no sustained response (platelet count ≥50 x 109 /L /L for ≥6 months with no ITP medication) following romiplostim discontinuation (evidence level Ib).

RITUXIMAB. Rituximab is not approved for the treatment of ITP. However, studies report that it may induce responses in children with chronic ITP. Overall response rates to rituximab in this population are reported at 23% to 69% (evidence levels IIbIII). Relapse rates vary from 14% to 42% of responding patients, within ≈1 year (evidence levels IIb-III). In 1 study, 66 children with ITP were treated with rituximab; 57% had a response, but by 5 years only 26% maintained that response. These results are identical to those in adults, with the exception that 2 years after treatment, no children, but some adults, relapsed.

One study combined rituximab with dexamethasone and demonstrated an initial response rate of 45% and a relapse rate of 40% after 60 months (evidence level III). In adolescent female patients with ITP duration < 24 months, 47% maintained long-term remission without further therapy.

Mycophenolate Mofetil . In 30 children with primary ITP (newly diagnosed, persistent, or chronic), treatment with mycophenolate mofetil achieved a response rate of 56%, and 29% of patients relapsed (evidence level IIb). Limited toxicity (asthenia, vomiting, and skin effects in 1 patient each) was observed. Doses were not specified.

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Provenance

Record: 6737
Objective:

Guidance on diagnosis and management of primary immune thrombocytopenia

Clinical condition:

Primary immune thrombocytopenia

Target patient group: Children with ITP
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

‘Updated international consensus report on the investigation and management of primary immune thrombocytopenia’ Blood 26 NOVEMBER 2019 x VOLUME 3, NUMBER 22

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.3

Related information

Not supplied

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