Current ASH Guidelines on ITP Management 2019 – Recommendations for Newly Diagnosed ITP in Children
At the end of 2019, the American Society of Hematology (ASH) published current guidelines for immune thrombocytopenia (ITP), in which a panel of experts attempted to define evidence-based recommendations for the care management of these patients.
Strong and Conditional Recommendations
Strong recommendations: May be used as a standard in most situations. They are supported by meaningful research.
Conditional (appropriate) recommendations: Are based on the fact that there are various options, and recommendations can be useful in decision-making for specific patients depending on individual risks, values, and preferences. They will likely need to be supported by further research in the future.
Currently, there is a lack of sufficient evidence to support strong recommendations. Strategies that use medications with minimal side effects are preferred.
Recommended Practices for Specific Patient Groups
This article brings the basic points concerning newly diagnosed ITP in pediatric patients as a specific group for diagnosis and treatment. In the cited guidelines, these recommendations are summarized under points 10−20:
10a: In children with newly diagnosed ITP and a platelet count < 20×109/l, who have no or mild bleeding (skin manifestations), the expert panel does not recommend hospitalization and prefers outpatient monitoring (conditional recommendation). However, in patients with diagnostic uncertainty, in families in socially difficult situations, or living far from the hospital, or where it is not reliable that the family will bring the child for follow-up, hospitalization is the preferred option.
10b: In children with newly diagnosed ITP and a platelet count ≥ 20×109/l, who have no or mild bleeding (skin manifestations), the panel does not recommend admission for hospitalization and prefers outpatient monitoring (conditional recommendation). However, the note in recommendation 10a applies.
The referring physician must ensure that the patient will have a follow-up within 24−72 hours.
11: In children with newly diagnosed ITP, who have no or mild bleeding, the panel recommends observation rather than corticosteroid administration (conditional recommendation).
12: In children with newly diagnosed ITP, who have no or mild bleeding, the panel recommends observation rather than the administration of intravenous immunoglobulins (IVIG) (strong recommendation).
13: In children with newly diagnosed ITP, who have no or mild bleeding, the panel recommends observation rather than the administration of anti-D immunoglobulins (strong recommendation).
14: In children with newly diagnosed ITP, who have mucosal bleeding that is not life-threatening or impairs their quality of life, the panel does not recommend corticosteroid administration for more than 7 days and prefers administration for ≤ 7 days (strong recommendation).
15: In children with newly diagnosed ITP, who have mucosal bleeding that is not life-threatening or impairs their quality of life, the panel recommends prednisone (2−4 mg/kg/day with a maximum of 120 mg daily for 5−7 days) rather than dexamethasone (0.6 mg/kg/day with a maximum of 40 mg/day for 4 days) (conditional recommendation).
16−18: In children with newly diagnosed ITP, who have bleeding that is not life-threatening or impairs their quality of life, the panel recommends corticosteroids rather than anti-D immunoglobulin or IVIG (conditional recommendation).
19: In children with ITP, who have bleeding that is not life-threatening or impairs their quality of life and did not respond to 1st line treatment, the panel recommends the administration of thrombopoietin receptor agonists (TPO-RA) rather than rituximab (conditional recommendation).
20: In children with ITP, who have bleeding that is not life-threatening or impairs their quality of life and did not respond to 1st line treatment, the panel recommends the administration of thrombopoietin receptor agonists (TPO-RA) rather than splenectomy (conditional recommendation).
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Source: Neunert C., Terrell D. R., Arnold D. M. et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv 2019 Dec 10; 3 (23): 3829−3866, doi: 10.1182/bloodadvances.2019000966.
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