Coach’s Corner

Dexamethasone 40 mg daily x 4 is my treatment of choice for essentially all patients with newly diagnosed ITP because it “concentrates the pain” of steroids into a short duration and (based upon one small RCT) has slightly better outcomes. Continued here.

Generally, I prefer dexamethasone for 4 days given less steroid exposure and at least equal efficacy.

I prefer dexamethasone because it consolidates treatment into 4 days (vs. 6 weeks or more with prednisone) and precludes the need for carefully monitored prednisone taper.

I do not have a strong preference over either in clinical practice. I will often end up using prednisone, as it allows me to more flexibility to taper and the dosing. Moreover in the outpatient setting, practically I  can use dose adjustments as second reason to justify the frequent and close laboratory monitoring.

I prefer a schedule of daily prednisone as the steroid regimen for newly diagnosed ITP, but I believe 6 weeks is far too short, as many patients who are steroid-responsive will “relapse” with rapid tapers. Continued here.

Dexamethasone, because available literature, while small, suggests better responses, but more importantly lower adverse events (personal experience with high dose steroids).

I prefer dexamethasone pulse rather than expose to steroids for prolonged period. Steroids alone often do not induce prolonged response in adults and I tend to abandon rather quickly and this way I can minimize toxicities.

Preferred treatment: Dex 40 mg daily x 4

I rule out hemolysis if any anemia, even if mild. I check HBV in case I want to use rituximab later. I check PT/PTT and liver function tests on everyone. I don’t do quantitative immunoglobulins without a suggestive history. I don’t do H. pylori unless GI symptoms since I’m not convinced by the data that treating it helps ITP in unselected populations. Continued here.

I typically order H. pylori IgG in addition to HCV and HIV. I have identified several patients with active H. pylori. I don’t order quantitative immunoglobulins.

I have rarely encountered cases where testing for H. pylori or immunoglobulin levels in an otherwise healthy patient with suspected ITP changes management, so I keep things simple and stick with careful examination of the peripheral smear and HIV/HCV serology.

I usually also test for Hepatitis B (but mostly because I will often reach for rituximab after steroids). I tend to test for H pylori in certain populations (like people that have spent time in high risk parts of the world). Since H pylori is a stool based test at my institution, I use it less and less. I do not routinely send immune globulin levels.

I’ve given up on H. pylori antibody testing, and I do not check quantitative immunoglobulin levels routinely.

I order H. pylori studies in a patient from an endemic region. I also check IgG levels since CVID and immune dysfunction syndromes are common and may have prognostic and even therapeutic value .

I tend to check H. pylori in patients of Asian origin.

Our local protocol says no other tests.

I admit patients with platelets<20 or bleeding, if they are newly diagnosed (therefore I don’t know yet what treatment they will respond to or how quickly). I would admit patient 1. I would likely admit patient 2. especially if it’s an older adult with other major medical issues or risk to fall. Continued here.

I would admit patient patients with platelet count < 10K (such as patient 1). I would treat a patient with platelet count > 20K as an outpatient. A patient with platelet count 10-20K (patient 2) is borderline. If patient is reliable I may keep outpatient.

I generally admit patients with a platelet count < 10K whether or not they are bleeding (e.g., patient 1), though I might increase that threshold to 20K if the patient is at higher risk for bleeding (e.g., taking anticoagulant, or elderly and at risk for fall). I feel strongly about the importance of shared decision making in these cases.

I am generally comfortable managing someone as an outpatient with newly diagnosed ITP with a platelet count of >20K as long as I can ensure laboratory studies multiple times a week. If there is concern for bleeding, platelets <20K, or if its not feasible to ensure very close follow up I would prefer admitting.

I certainly have a low threshold for unfit, frail, unreliable patients. I would admit patient 1, and my decision to admit patient 2 would depends on the age of the patient, comorbidities, general fitness, etc.

Only new diagnosed patient with platelet < 10K, not knowing whether they are a ‘bleeder’ or not.

As a general rule, my threshold for admission is platelet count <10K, wet purpura, comorbidities and/or past history of response to therapy.

Patient 1: No admission; Patient 2: No admission. We would only admit patients with active bleeding.

• Patient 1: Does not qualify, but if platelets <5K (i.e., undetectable in our lab) I might give IVIG with steroids (no platelets).
• Patient 2: Yes, qualifies for emergency treatment, though I might try IVIG and steroids without  platelet transfusion.
• Patient 3: Yes, qualifies. I would administer the kitchen sink with IVIG, platelet transfusions and steroids.

I would treat Patients 2 and 3 as emergencies. Patient 2 would get steroids and IVIG. Patient 3 would get steroids, IVIG, and platelets.

• Patient 1, non-emergency, treatable with corticosteroids alone.
• Patient 2, I would administer corticosteroids and IVIG.
• Patient 3 qualifies for emergency treatment with corticosteroids, IVIG and platelets.

I would use platelet transfusions only when there is active serious bleeding. Of the three options I would therefore restrict to option C. Option B is a maybe for me, but in my practice I have usually managed patients in the first two categories with IVIG and steroids.

• Patient 1: Does not qualify. I would give steroids alone, with IVIG and platelets in reserve.
• Patient 2: Does qualify. I would administer all three agents.
• Patient 3: Does qualify. I would administer all three agents.

Patient 1: Steroids +/- IVIG; Patient 2: Steroids +/- IVIG; Patient 3: Steroids + IVIG. Platelet transfusions do not work. Only consider if life-threating bleeding. IV/infusional tranexamic acid may be more useful.

• Patient 1 does not meet indications for emergency bleed. I would treat with steroids alone.
• For patient 2, I would consider steroids/IVIG +/-Nplate
• Patient 3 qualifies for emergency treatment with steroids, IVIG, and platelet transfusions.

• Patient 1 –  NO
• Patient 2 – NO (can often be managed with tranexamic acid)
• Patient 3 –  YES

Consistently above 50K.

I try to keep patients > 50K if on an anticoagulant or antiplatelet agent.

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> 50K

For full dose anticoagulation I would be comfortable with a platelet count of over 50K. It will depend on some patient specific factors of course, including the indication for anticoagulation and the stability of the counts.

• Absent a bleeding history, I’d accept 30-40 K/uL in a young, fit patient, perhaps 40-50 K/uL in an older, less fit patient, and I’d favor apixaban over rivaroxaban and consider whether or not the apixaban dosing might be 2.5 mg twice daily as opposed to 5 mg twice daily.

>30K

Would target above 50k.

Not a lot of evidence, but we would try to keep platelets > 20K.