Current ASH Guidelines for Management of ITP 2019 − Recommendations for Newly Diagnosed ITP in Adults
The American Society of Hematology (ASH) published current guidelines for immune thrombocytopenia (ITP) at the end of 2019, where a panel of experts attempted to define evidence-based recommendations for the management of these patients.
Strong and Conditional Recommendations
Strong recommendations: These can be used as a standard in most situations. They are supported by meaningful research.
Conditional (suitable) recommendations: These are based on the fact that there are various options to choose from, and the recommendation may be useful in decision-making for specific patients depending on their individual risks, values, and preferences. In the future, these recommendations should likely be supported by further research.
Currently, there is a lack of sufficient evidence to support strong recommendations. Preferred strategies use medications with minimal side effects.
Recommended Procedures for Specific Patient Groups
This article provides key points regarding newly diagnosed ITP or corticosteroid-dependent or corticosteroid-refractory ITP in adult patients.
1a: In adults with newly diagnosed ITP and platelet count < 30×109/l, who are asymptomatic or have minimal mucocutaneous bleeding, the panel recommends corticosteroid treatment over a watch-and-wait strategy (conditional recommendation).
1b: In adults with newly diagnosed ITP and platelet count ≥ 30×109/l, who are asymptomatic or have minimal mucocutaneous bleeding, the panel recommends a watch-and-wait strategy over corticosteroid treatment (strong recommendation).
2a: In adults with newly diagnosed ITP and platelet count < 20×109/l, who are asymptomatic or have minimal mucocutaneous bleeding, the panel recommends hospitalization (conditional recommendation). In adults with known ITP and platelet count < 20×109/l, who are asymptomatic or have minimal mucocutaneous bleeding, the panel recommends outpatient monitoring (conditional recommendation).
2b: In adults with newly diagnosed ITP and platelet count ≥ 20×109/l, who are asymptomatic or have minimal mucocutaneous bleeding, the panel recommends outpatient monitoring (conditional recommendation).
3: In adults with newly diagnosed ITP, the panel does not recommend prolonged treatment with prednisone (> 6 weeks including tapering), supporting a shorter duration of treatment (strong recommendation).
4: For initial treatment in adults with newly diagnosed ITP, the panel recommends corticosteroids: either prednisone (0.5−2.0 mg/kg/day) or dexamethasone (40 mg/day for 4 days) (conditional recommendation).
5: In adults with newly diagnosed ITP, the panel recommends corticosteroid monotherapy over combination with rituximab (conditional recommendation).
6: In adults with ITP persisting ≥ 3 months, who are corticosteroid-dependent or refractory to corticosteroid treatment and for whom TPO receptor agonists (TPO-RA) are considered, the panel recommends eltrombopag or romiplostim (conditional recommendation).
7: In adults with ITP persisting ≥ 3 months, who are corticosteroid-dependent or refractory to corticosteroid treatment, the panel recommends either splenectomy or TPO-RA (conditional recommendation).
8: In adults with ITP persisting ≥ 3 months, who are corticosteroid-dependent or refractory to corticosteroid treatment, the panel recommends rituximab over splenectomy (conditional recommendation).
9: In adults with ITP persisting ≥ 3 months, who are corticosteroid-dependent or refractory to corticosteroid treatment, the panel recommends TPO-RA over rituximab (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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