DESCRIPTION IMMUNE THROMBOCYTOPENIC PURPURA (ITP) 

A common bleeding disorder due to immune destruction of platelets. To diagnose ITP, isolated thrombocytopenia is present (rest of the complete blood count, including an examination of the peripheral blood smear, is entirely normal). Clinically apparent associated conditions, drugs (e.g. penicillins, cephalosporins, quinine, rifampicin and heparin), or other agents that may cause thrombocytopenia are NOT present. Patients with suspected ITP should be tested for SLE and for HIV infection.

Investigations

Thrombocytopenia with normal white cell count and red cell series. Anaemia may be present due to blood loss.

Peripheral blood smear to exclude RBC fragments. Smear may show large platelets.

Do INR and aPTT, which should be normal in ITP.

If there is a poor response to treatment do a bone marrow biopsy.

GENERAL MEASURES

Avoid:

»     medication that affects platelet function, e.g. NSAIDs and aspirin,

»  platelet transfusions unless life-threatening bleeds,

»   dental procedures in acute phase, and

»   IM injections.

Reassure the patient that resolution usually occurs in acute ITP.

Medic alert bracelet.

Platelet transfusions may be given if surgery is required or in life-threatening bleeding.

MEDICINE TREATMENT

Acute ITP 

• Prednisone, oral, 2 mg/kg daily.
• Taper dose once response is achieved, usually within 10–14 days.
• Therapy may be required for a few months before prednisone is eventually discontinued.
• Also indicated for HIV-associated immune thrombocytopenia. Also start combination antiretroviral therapy urgently in these patients.

Platelet transfusions

Platelet transfusions are only indicated in acute active bleeding uncontrolled by other means or before procedures. In an adult, 1 mega-unit of single donor, leucocyte depleted platelets is usually sufficient to control the bleeding initially. Platelet transfusions have limited benefit in this condition as platelets are rapidly destroyed by the immune system.

 

REFERRAL

» All cases not responding to steroids and, in the case of HIV patients, not responding to ART – discuss with haematologist.

Reference and further reading

Standard Treatment Guidelines and Essential Medicines List for South Africa 2012 Edition

ACKNOWLEDGEMENTS

Our heartfelt thanks go to the National Essential Drugs List Committee and, in particular, the Expert Review Committee for the Hospital Level EDL (Adult) for their continued dedication and commitment to the process. Without your passion and technical expertise, this publication would not have been possible. We would also like to thank the many doctors, pharmacists, professional societies and other health care professionals who contributed by way of comment, remarks and the supply of appropriate evidence. Your
involvement in the consultative process is an integral part of the review and has undoubtedly contributed to the excellence of this edition.

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