Immune Thrombocytopenia (ITP)


Immune thrombocytopenia (ITP) is an autoimmune hematologic disorder in which autoantibodies target antigens on the surface membranes of normal platelets. The platelets are then destroyed by macrophages via phagocytosis, so that the number of functional platelets in the circulation is decreased.1 

Decreased platelet counts increase the risk for episodes of abnormal bleeding. Some patients with ITP may remain asymptomatic despite lower platelet counts, although occasional severe complications, such as intracranial hemorrhaging, may be fatal. Given the widely ranging severity of the symptoms, patients with ITP require individualized treatment plans developed by experienced healthcare providers who specialize in the management of this disease.1,2 

Patients with ITP may require care from a multidisciplinary team of healthcare providers, depending on their age, the severity of their symptoms, their comorbidities, and the body regions affected by bleeding. The multidisciplinary team may include primary care physicians, pediatricians, hematologists, rheumatologists, gastroenterologists, neurologists, obstetricians, emergency care physicians and staff, radiologists, general and pediatric surgeons, nurses, and pharmacologists.   

Emergency Care Physicians/Staff

Patients with ITP experiencing episodes of severe bleeding may require inpatient emergency care at a hospital. Emergency care physicians and staff perform hemostasis, request and analyze imaging to determine the source and severity of the bleeding, prescribe specific pharmaceutical treatments such as corticosteroids and intravenous immunoglobulin (IVIG), and decide whether blood transfusions or emergency surgery is necessary in cases of life-threatening bleeding.10

Read more about ITP therapies

Gastroenterologists

Gastroenterologists may treat patients with ITP, particular older adults, who experience gastrointestinal bleeding. Gastroenterologists must be especially careful when performing upper gastrointestinal endoscopic procedures or colonoscopies to locate the source of bleeding because of these patients’ increased risk for bleeding. Prophylactic blood transfusions before endoscopic procedures must be used with caution.7

Hematologists

Hematologists specialize in the treatment of ITP, which is a blood disorder. The primary goal of the hematologist is to increase the number of circulating platelets with careful medical and pharmacological management and monitoring.2,4 

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Neurologists

In the rare case that intracranial hemorrhage develops in a patient with ITP, a vascular neurologist or neurosurgical team may be required to determine the steps necessary to decrease the intracranial pressure and protect the brain. Blood pressure management is one of the main focuses of treatment after a patient develops intracranial hemorrhage per the INTERACT-II clinical trial. Surgical procedures may be required.8 

Read more about ITP complications

Nurses

Patients with ITP may require transfusions of blood or platelets if the platelet levels become too low. Typically, trained members of the nursing staff administer transfusions. The nurse who performs the transfusion periodically monitors the patient’s vital signs during a blood transfusion.15

Obstetricians

Pregnant women with ITP require the care of an obstetrician with expertise in the management of patients with bleeding disorders. These specialists work to prevent maternal and neonatal complications of ITP and determine the safest mode of delivery according to the obstetrical indications.3,9

Read more about ITP risk factors

Pediatricians

Pediatricians may observe frequent bruising, easy bleeding, or the initial appearance of rash-like skin lesions in children with ITP and confirm the diagnosis with appropriate laboratory testing. Like primary care providers, pediatricians should refer children with suspected ITP and their caregivers to hematologists and a multidisciplinary team that specializes in the management of pediatric ITP.3

Read more about ITP diagnosis

Pharmacists

Pharmacists provide necessary pharmaceutical support for patients with ITP who require prescription medications such as corticosteroids, immunosuppressants, or other recommended drugs.16 

Primary Care Physicians

Primary care physicians are often the first healthcare providers to notice thrombocytopenia on routine laboratory testing in adult patients with ITP. Platelet counts below 100,000/µL may indicate ITP, and the primary care physician should refer the patient to an experienced hematologist to confirm the diagnosis and provide specialized care.3

Radiologists

Radiologists interpret the imaging requested by physicians caring for patients with ITP. Magnetic resonance imaging (MRI) or computed tomography (CT) may be needed to identify potential intracranial hemorrhaging and sources of internal bleeding. Radiographic imaging may also be used to identify hepatosplenomegaly in patients with ITP.11

Read more about ITP testing

Rheumatologists

ITP is an autoimmune disorder in which the body attacks platelets. ITP may occur along with another autoimmune disorder, such as systemic lupus erythematosus or rheumatoid arthritis.5,6 Rheumatologists specialize in treating diseases of the immune system, including autoimmune disorders such as lupus, rheumatoid arthritis, and ITP. A rheumatologist may also be the provider who first identifies a patient presenting with concomitant lupus and ITP. 

Read more about ITP comorbidities

Surgeons

General surgeons, surgical oncologists, hepatobiliary and pancreatic surgeons, or pediatric surgeons who specialize in laparoscopic splenectomy may become involved in the care of patients with ITP when this procedure is indicated. However, physicians try to avoid splenectomy within the first 12 months after a diagnosis of ITP.12-14

Read more about ITP surgical management

References

  1. Kessler CM. Immune thrombocytopenia (ITP): practice essentials. Medscape. Updated January 7, 2021. Accessed October 7, 2022.
  2. Find an ITP doctor. Platelet Disorder Support Association. Accessed October 7, 2022.
  3. Pietras NM, Pearson-Shaver AL. Immune thrombocytopenic purpura. StatPearls [Internet]. Updated May 10, 2022. Accessed October 7, 2022.
  4. Kessler CM. Immune thrombocytopenia treatment & management: medical care. Medscape. Updated January 7, 2021. Accessed October 7, 2022.
  5. Roussotte M, Gerfaud-Valentin M, Hot A, et al. Immune thrombocytopenia with clinical significance in systemic lupus erythematosus: a retrospective cohort study of 90 patients. Rheumatology. 2022;61(9):3627-3639. doi:10.1093/rheumatology/keab925
  6. Ichikawa N, Harigai M, Nakajima A, Hara M, Kamatani N. Immune thrombocytopenic purpura associated with rheumatoid arthritis – a report of five cases and review of the literature. Mod Rheumatol. 2001;11(3):246-250. doi:10.3109/s101650170013
  7. Laine L. Treatment of thrombocytopenic patients with GI bleeding. Gastrointest Endosc. 2018;88(1):62-65. doi:10.1016/j.gie.2018.03.003
  8. Intracranial hemorrhage: advancing medical & surgical treatment options. Cleveland Clinic. December 1, 2021. Accessed October 7, 2022.
  9. Neunert C, Terrell DR, Arnold DM, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019;3(23):3829-3866. doi:10.1182/bloodadvances.2019000966
  10. Bavunoğlu I, Eşkazan AE, Ar MC, et al. Treatment of patients with immune thrombocytopenia admitted to the emergency room. Int J Hematol. 2016;104(2):216-222. doi:10.1007/s12185-016-2003-5
  11. Greinacher A, Selleng S. How I evaluate and treat thrombocytopenia in the intensive care unit patient. Blood. 2016;128(26):3032-3042. doi:10.1182/blood-2016-09-693655
  12. Chaturvedi S, Arnold DM, McCrae KR. Splenectomy for immune thrombocytopenia: down but not out. Blood. 2018;131(11):1172-1182. doi:10.1182/blood-2017-09-742353
  13. Kessler CM. Immune thrombocytopenia treatment & management: surgical care. Medscape. Updated January 7, 2021. Accessed October 7, 2022.
  14. Splenectomy: departments and specialties. Mayo Clinic. Accessed October 7, 2022.
  15. Jordan A. Step-by-step master’s guide to blood transfusions. Brookline College. July 13, 2022. Accessed October 7, 2022.
  16. Immune thrombocytopenia: the role of current and emerging therapies and navigating patient care opportunities for pharmacists. Pharmacy Times Continuing Education . Accessed October 7, 2022. 

Reviewed by Debjyoti Talukdar, MD, on 10/19/2022.

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