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I.
OVERVIEW:
*The following definitions of acute, persistent and chronic as well as primary and
secondary ITP were recently formulated and adopted by the International Working
Group on ITP1.*
Immune thrombocytopenia (ITP) is an acquired generally benign disorder in which
antibodies are generated against platelet antigens resulting in accelerated platelet
destruction and a platelet count less than 100,000/mm3. In children ITP is most
frequently an acute, self-resolving condition; however, a minority of patients will
develop either persistent ITP, defined as thrombocytopenia lasting longer than 3
months but resolving by 12 months, or chronic ITP, defined as thrombocytopenia lasting
longer than 12 months, and will require ongoing care.
II.
III.
SCOPE: This document is intended to provide evidence-based guidelines for the initial
care of pediatric patients presenting with concern for newly diagnosed immune
thrombocytopenia. Additionally, management of patients with persistent or chronic ITP
requiring additional treatment is briefly covered.
IV.
NEW REFERRALS:
A. Any patient referred to our department (via page, M-Line call or faxed outpatient
referral) should be triaged through the on-call PHO fellow (when available) and
discussed with the on-service pediatric hematology/oncology attending. Patients with a
new presentation concerning for ITP but with an incomplete work up will generally
require evaluation in the UM ED. Direct admissions may be arranged at the discretion
of the on-service PHO attending for asymptomatic patients who MUST have been seen
by a physician and had labs drawn on the day of referral. For full details regarding the
direct admission criteria, please refer to the Mott direct admit policy found at the web
address: http://www.med.umich.edu/i/policies/pediatric/pdfs/admissions.pdf.
Chapter 1.2
1
Effective April 2011
The goal of these guidelines is to assist in the care of patients in coordination with referring physicians, hematology/oncology
physicians, and other caregivers. These guidelines do not replace the expertise and clinical judgment of the treating physician.
Each patients situation must be evaluated individually. These guidelines are updated annually. To ensure that you have the most
up-to-date version of the guidelines, contact the University of Michigan Pediatric Hematology/Oncology Program.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
INITIAL EVALUATION:
Primary ITP remains a clinical diagnosis based on the acute onset of isolated
thrombocytopenia, with a platelet count less than 100,000/mm3, frequently concurrent
with the sudden onset of bruising, petechiae and/or mucous membrane bleeding in an
otherwise healthy child in the absence of alternative causes of thrombocytopenia such
as immunodeficiency, infection, medication exposure, bone marrow failure syndromes,
malignancies and genetic thrombocytopenia syndromes. Secondary ITP includes all
forms of immune-mediated thrombocytopenia except for primary ITP, e.g
thrombocytopenia due to SLE or medication exposures.
The classical presentation of a pediatric patient with ITP is a child between the ages of 210 years presenting with an acute onset of bruising/petechiae and a platelet count <
20,000 with a history of an antecedent viral infection.
.
A. History and Physical: The clinical manifestations of ITP are directly related to
thrombocytopenia.
Important items to query on history of presenting illness:
- Onset of bleeding symptoms (bruising, gum bleeding, petechiae,
nosebleeds, heavy menses, hematuria, etc.).
- Presence of an antecedent viral infection.
- Any associated symptoms concerning for other diagnoses, e.g.
lymphadenopathy, weight loss, fatigue, rash, joint swelling, headache,
etc.
- Personal history of autoimmune disease.
- Any previous blood counts drawn (especially helpful with platelet
counts in the 50-100k range to raise concern for platelet defect or
vWD).
- Any recent immunizations in the past 8 weeks, specifically MMR,
varicella or other live-attenuated vaccines (e.g. influenza).
Chapter 1.2
2
Effective April 2011
The goal of these guidelines is to assist in the care of patients in coordination with referring physicians, hematology/oncology
physicians, and other caregivers. These guidelines do not replace the expertise and clinical judgment of the treating physician.
Each patients situation must be evaluated individually. These guidelines are updated annually. To ensure that you have the most
up-to-date version of the guidelines, contact the University of Michigan Pediatric Hematology/Oncology Program.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
VI.
VII.
INITIAL MANAGEMENT
A. Patients with ITP and life threatening bleeding.
Although ICH is rare occurring in less than 1% of patients with ITP, the consequences of
ICH are severe with a 25% mortality rate and another 25% of patients suffering
permanent neurologic sequelae2. It is estimated that of children who develop ICH,
~25% have ICH as their presenting symptom of ITP, with the highest risk in patients less
than 3 years old with platelet counts less than 20x 10 9/L and with antecedent head
Chapter 1.2
4
Effective April 2011
The goal of these guidelines is to assist in the care of patients in coordination with referring physicians, hematology/oncology
physicians, and other caregivers. These guidelines do not replace the expertise and clinical judgment of the treating physician.
Each patients situation must be evaluated individually. These guidelines are updated annually. To ensure that you have the most
up-to-date version of the guidelines, contact the University of Michigan Pediatric Hematology/Oncology Program.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
VIII.
IX.
PLATELET TRANSFUSION
A. Only indicated for life threatening active bleeding.
B. Refer to Transfusion CPG.
X.
Chapter 1.2
6
Effective April 2011
The goal of these guidelines is to assist in the care of patients in coordination with referring physicians, hematology/oncology
physicians, and other caregivers. These guidelines do not replace the expertise and clinical judgment of the treating physician.
Each patients situation must be evaluated individually. These guidelines are updated annually. To ensure that you have the most
up-to-date version of the guidelines, contact the University of Michigan Pediatric Hematology/Oncology Program.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
XI.
Chapter 1.2
7
Effective April 2011
The goal of these guidelines is to assist in the care of patients in coordination with referring physicians, hematology/oncology
physicians, and other caregivers. These guidelines do not replace the expertise and clinical judgment of the treating physician.
Each patients situation must be evaluated individually. These guidelines are updated annually. To ensure that you have the most
up-to-date version of the guidelines, contact the University of Michigan Pediatric Hematology/Oncology Program.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
XII.
XII.
PERSISTENT/CHRONIC ITP
Unlike adult ITP, most pediatric ITP patients will have an acute self-resolving course of
thrombocytopenia. For the minority of pediatric patients who develop persistent or
chronic ITP, the treatments below can be considered. Treatment should be tailored on
an individual basis.
A. Indications for treatment of persistent/chronic ITP:
i. Clinical bleeding.
ii. Need for temporary improvement in platelet counts, e.g. surgery.
iii. Risk of serious bleeding due to extremely low platelet counts or patient
participation sports or other high-risk endeavors.
C. Standard or First-Line Treatment Options to Consider:
i. IVIG7,9,10
a. If previously responded to IVIG or has not had IVIG, may give as
above in section VII.
ii. Rh0 (D) Immunoglobulin (WinRho)7,9
Chapter 1.2
8
Effective April 2011
The goal of these guidelines is to assist in the care of patients in coordination with referring physicians, hematology/oncology
physicians, and other caregivers. These guidelines do not replace the expertise and clinical judgment of the treating physician.
Each patients situation must be evaluated individually. These guidelines are updated annually. To ensure that you have the most
up-to-date version of the guidelines, contact the University of Michigan Pediatric Hematology/Oncology Program.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.
Document Origin April 2010: Kelly Walkovich (Pediatric Hematology/Oncology), Erika Howle
(Pharmacy), Jacob Bilhartz (Pediatrics)
Document Review March 2011: Kelly Walkovich (Pediatric Hematology/Oncology), Erika
Howle (Pharmacy), George Hucks (Pediatric Hematology/Oncology)
Document Editor: Kelly Walkovich (Pediatric Hematology/Oncology)
APPROVALS
APPROVALS
______________________________________________
Clinical Director, Raymond Hutchinson
Date: 3/18/2011
Date
Date: 4/4/2011
__________________
Date
Date: 3/9/2011
Date
Chapter 1.2
11
Effective April 2011
The goal of these guidelines is to assist in the care of patients in coordination with referring physicians, hematology/oncology
physicians, and other caregivers. These guidelines do not replace the expertise and clinical judgment of the treating physician.
Each patients situation must be evaluated individually. These guidelines are updated annually. To ensure that you have the most
up-to-date version of the guidelines, contact the University of Michigan Pediatric Hematology/Oncology Program.
Copyright 2011 by the Regents of the University of Michigan. All Rights Reserved.