History Isolated bleeding symptoms with low platelet No constitutional symptoms like weight loss, bone pain, night

sweat

Physical examination Bleeding w/o hepatosplenomegaly, lymphadenopathy or stigmata of congenital conditions

Complete blood count Isolated thrombocytopenia ( plt < 100). Anaemia significant blood loss. Normal RBC index, WBC and differential
Peripheral blood smear Platelets normal to large in size. RBC and WBC morphology normal

Bone marrow exam- Unnecessary In patients with typical features of ITP prior to treatment with steroid, splenectomy or patient who fail I.V Ig therapy
Bone marrow exam Necessary Abnormal history, physical exam, FBC or Peripheral blood film

All adult patients with newly diagnosed ITP should test for HIV and HCV. Insufficient evidence routine use of antiplatelet, antiphospholipid and ANA, thrombopoietin levels or platelet parameters

Treatment strategies in ITP - A platelet count for adequate hemostatis RATHER than normal platelet count - Discussion with patient - Severity of bleeding - Anticipated surgical procedures - Medication side effect - Health- related Quality of life

1. Assessment of Disease Status a)Bleeding timing, loacation, severity Risk factor for bleeding use of antithrombotic agents or high-risk occupations b) Anticipated surgical procedures c) Compliance with recommended treatment d) Bleeding interfer with daily activities/ cause anxiety

2. General consideration a) Majority pt with no bleeding/mild bleeding observation alone regards of platelet count b) First line treatment observation, corticosteroid, IV Ig or anti-D Immunoglobulin( Anti-D) c) Anti- D use with caution . FDA severe hemolysis. Not for pt with low Hb or evidence of autoimmune hemolysis

a) Treat patient with plt < 30 b) Longer course of corticosteroid over shorter course c) IV Ig used with corticosteroid when rapid increase of platelet needed d) Either IV Ig or Anti- D maybe used as first line if corticosteroids contraindicated.

1. Assessment of Disease Status a) Bleeding timing, loaction, severity b) Any change in history/ physical diagnosis - ? another diagnosis causing thrombocytopenia c) Any contraindication to splenectomy d) Effect of ITP on patients work/school/ participation in activities e) Respond intermittently to current drug treatment f) Side effects from current treatment g) How patient cope psychological with low platelet count?

2. General consideration a) Pt with plt > 30 and asymptomatic after splenectomy do not require further therapy b) If previous treatment with corticosteroid , IV Ig or Anti- D has been successful, these options maybe used as needed to prevent bleeding c) If previous treatment with corticosteroid, IV Ig or Anti- D unsuccessful, subsequent management may include splenectomy, rituximab, thrombopoietin receptor agonists or more potent immunosuppresion

3. Special consideration for Adult a) Splenectomy failed corticosteroid, similar efficacy with open or laparoscopic procedures b) Rituximab Risk of bleeding, failed corticosteroid, IV Ig or splenectomy c) Thrombopoietin Receptor Agonists at risk of bleeding and relapse after splenectomy/ contraindication to splenectomy and failed 1 other therapy. Also for risk of bleeding after failed 1 line of therapy such as corticosteroid/IV Ig and not undergone splenectomy d) High dose Dexamethasone no comment in current guideline e) Immunosuppression Insufficient data for specific recommendations