Immune Thrombocytopenia (ITP)

📋 Key Information Summary

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Immune thrombocytopenia (ITP) is an autoimmune condition characterised by isolated thrombocytopenia (platelets <100×10⁹/L) in the absence of another identifiable cause — it remains a diagnosis of exclusion.
In adults, ITP is typically chronic with insidious onset; in children it is usually acute and self-limiting following a viral illness, resolving within 6 months in >80%.
A peripheral blood film must be reviewed to exclude pseudothrombocytopenia, spurious counts, schistocytes (TTP/HUS), or leukaemic blasts before diagnosing ITP.
Bone marrow biopsy is NOT routinely required in typical presentations but should be considered before second-line therapy or if there are atypical features (age >60, refractory disease, or abnormal blood film).
Observation without treatment is appropriate if platelets >30×10⁹/L AND there is no clinically significant bleeding, regardless of patient age.
First-line treatment for significant bleeding or counts <30×10⁹/L with bleeding risk includes corticosteroids (prednisolone 1 mg/kg/day PO for 1–2 weeks then taper) or high-dose dexamethasone (40 mg/day PO for 4 days).
IV immunoglobulin (IVIG 1 g/kg) or anti-D immunoglobulin (WinRho® 50 µg/kg IV, Rh-D positive non-splenectomised patients only) provide rapid platelet response in emergencies or pre-procedural settings.
Tranexamic acid (1 g PO/IV TDS) is a useful adjunct for mucosal bleeding; avoid NSAIDs and antiplatelet agents in all ITP patients.
Avoid intramuscular injections, rectal examinations, and contact sports in patients with platelets <50×10⁹/L; counsel on trauma and bleeding risk.
Splenectomy remains a durable second-line option with ~60–70% long-term response; thrombopoietin receptor agonists (romiplostim, eltrombopag) and rituximab are increasingly used as second-line alternatives.
All patients should receive pneumococcal, Haemophilus influenzae type b, and meningococcal vaccinations at least 2 weeks before elective splenectomy.
Aboriginal and Torres Strait Islander Australians may present later with more severe disease; ensure culturally safe communication, appropriate health-literacy resources, and link with Indigenous health services.
Urgent haematology referral is recommended for all new suspected ITP cases, platelets <20×10⁹/L, active clinically significant bleeding, or failure of first-line therapy.
Emergency treatment with IVIG + corticosteroids ± platelet transfusion is required for life-threatening bleeding (intracranial, gastrointestinal, or genitourinary haemorrhage).

Introduction & Australian Epidemiology

Immune thrombocytopenia (ITP), formerly termed idiopathic thrombocytopenic purpura, is an acquired autoimmune disorder in which antibody- and cell-mediated destruction of platelets, together with impaired megakaryopoiesis, results in isolated thrombocytopenia. The condition affects both children and adults, though the clinical course differs markedly between these populations.

In Australia, the estimated incidence of adult ITP is approximately 3.3 per 100,000 person-years, with a prevalence of 9–12 per 100,000. Paediatric ITP is more common, with an incidence of approximately 5 per 100,000 children per year. The condition shows a bimodal age distribution, with a peak in childhood (2–6 years) and a second peak in adults aged 20–50 years, with a slight female preponderance in adults.

In children, over 80% of cases resolve spontaneously within 6 months (acute ITP). In contrast, adult ITP is more frequently chronic, with approximately 60–70% of patients requiring ongoing treatment beyond 12 months. Mortality in adult ITP is modestly increased compared with the general population (standardised mortality ratio ~1.3–2.0), primarily due to bleeding and infection-related complications.

ITP may occur in isolation (primary ITP) or in association with other conditions including systemic lupus erythematosus (SLE), antiphospholipid syndrome, common variable immunodeficiency (CVID), hepatitis C virus (HCV) infection, Helicobacter pylori infection, HIV, and chronic lymphocytic leukaemia (CLL). Identifying and treating secondary causes is an essential component of management.

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Secondary causes must be excluded: Always test for HIV, hepatitis C, H. pylori, autoimmune markers (ANA, dsDNA, antiphospholipid antibodies), and immunoglobulin levels before concluding that ITP is primary. Treatment of an underlying condition may resolve the thrombocytopenia.

Diagnosis of Exclusion

ITP is defined as isolated thrombocytopenia (platelet count <100×10⁹/L) with normal white cell count, haemoglobin (unless bleeding-related), and coagulation profile (PT/APTT/INR normal), in the absence of another identifiable cause. There is no single confirmatory test; the diagnosis is established by excluding alternative aetiologies.

Essential Diagnostic Criteria

Platelet count <100×10⁹/L on at least two occasions, separated by >24 hours (to exclude transient post-viral thrombocytopenia in children).
Peripheral blood film reviewed by an experienced haematologist or haematology scientist — excludes pseudothrombocytopenia (EDTA-dependent clumping), dysplasia, schistocytes (thrombotic thrombocytopenic purpura / haemolytic uraemic syndrome), leukaemic blasts, and giant platelets (MYH9-related disorders).
Full blood count with differential showing no anaemia (unless attributable to bleeding) and normal white cell morphology.
Coagulation studies (PT, APTT, fibrinogen) within normal limits.
No palpable splenomegaly on examination (if present, consider hypersplenism, lymphoproliferative disease, or chronic liver disease).

Recommended Baseline Investigations

Essential Full blood count with film Confirm isolated thrombocytopenia; exclude morphological abnormalities. MBS Item 66551.

Essential Coagulation screen (PT, APTT, fibrinogen) Rule out DIC, coagulopathy. MBS Item 66569.

Essential Blood group and direct antiglobulin test (DAT) If transfusion may be needed; exclude Evans syndrome (ITP + autoimmune haemolytic anaemia).

Essential HIV serology Mandatory in all new ITP patients per ASH 2019 guidelines. MBS Item 69317.

Essential Hepatitis C antibody / PCR HCV-associated ITP is treatable by eradicating HCV. MBS Item 69365.

Available H. pylori testing (stool antigen or urea breath test) Eradication may improve platelet counts in 30–50% of seropositive patients. MBS Item 69319 / 69320.

Available Immunoglobulin levels (IgG, IgA, IgM) Low levels may indicate CVID; important before rituximab or splenectomy.

Available ANA, dsDNA, antiphospholipid antibodies Screen for SLE / antiphospholipid syndrome, particularly in women of childbearing age.

Available Hepatitis B serology Required before rituximab or immunosuppressive therapy (risk of reactivation).

Referral Bone marrow aspirate and trephine biopsy NOT routine for typical presentations. Indicated before second-line therapy, age >60 years (to exclude MDS), or atypical features.

Referral Thrombopoietin (TPO) level Not routinely required; may help distinguish ITP from marrow failure in complex cases. Available through reference laboratories.

Specialist Anti-platelet antibody testing (MAIPA, direct/indirect) Low sensitivity and specificity; NOT recommended for routine diagnosis. Available at select tertiary centres only.

Differential Diagnosis of Thrombocytopenia

Category	Condition	Key Distinguishing Features
Pseudothrombocytopenia	EDTA-dependent platelet clumping	Platelet count normalises on citrate sample; film shows clumps
Spurious	Giant platelets counted as RBCs (MYH9 disorders)	Large platelets on film; normal platelet mass
Consumptive	TTP / HUS	Schistocytes, anaemia, ↑LDH, neurological or renal features; medical emergency
Consumptive	DIC	Prolonged PT/APTT, low fibrinogen, elevated D-dimer
Drug-induced	Heparin-induced thrombocytopenia (HIT)	Onset 5–14 days after heparin exposure; thrombosis paradox; PF4 antibody positive
Drug-induced	Other drugs (valproate, quinine, sulfonamides, linezolid)	Temporal relationship with drug exposure; resolves on withdrawal
Hypersplenism	Chronic liver disease, portal hypertension	Palpable splenomegaly, deranged LFTs, signs of chronic liver disease
Bone marrow failure	MDS, aplastic anaemia, leukaemia infiltration	Cytopenias in multiple lineages; dysplasia; abnormal marrow
Infection-related	Viral (EBV, CMV, dengue), sepsis	Systemic features; self-limiting if viral; positive cultures if bacterial
Pregnancy-specific	Gestational thrombocytopenia, pre-eclampsia/HELLP	Usually late pregnancy; platelets typically >70×10⁹/L in gestational; HELLP has elevated transaminases

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TTP is a medical emergency: If schistocytes are present on the blood film, or if there is microangiopathic haemolytic anaemia (anaemia, elevated LDH, elevated reticulocytes, low haptoglobin) with neurological or renal features, initiate plasma exchange immediately and contact haematology — do NOT wait for ADAMTS13 results.

Initial Management Thresholds

The decision to treat ITP depends on the platelet count AND the clinical bleeding status. Many patients with counts above 30×10⁹/L and no bleeding can be safely observed without treatment.

Severity Stratification & Treatment Thresholds

Observation

Platelets >30×10⁹/L, No Bleeding

Asymptomatic or minor petechiae only. No mucosal bleeding. No procedures planned. Platelet count stable or trending upward.

Setting: Primary care with haematology oversight; monitor FBC every 1–4 weeks initially

First-Line Treatment

Platelets <30×10⁹/L OR Clinically Significant Bleeding

Mucosal bleeding (epistaxis, gingival, menorrhagia), extensive purpura, wet purpura (oral blood blisters — ominous sign), or counts <30×10⁹/L with additional risk factors (hypertension, anticoagulant use, age >60).

Setting: Haematology outpatient or short-stay unit; may require admission

Emergency

Life-Threatening Bleeding

Intracranial haemorrhage, significant gastrointestinal haemorrhage, genitourinary bleeding, or any haemodynamic instability. Requires immediate multi-modal treatment.

Setting: Emergency department → ICU/haematology; immediate treatment

First-Line Pharmacological Therapy

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Prednisolone

Panafcortelone® · Generic · Corticosteroid

Adult dose 1 mg/kg/day PO (max 80 mg/day) for 1–2 weeks, then taper over 4–6 weeks. Avoid prolonged courses (>6 weeks) due to steroid toxicity.

Paediatric dose 1–2 mg/kg/day PO for 2–4 weeks then taper (evidence for benefit in acute childhood ITP is limited; may be used if significant bleeding).

Onset of response 2–7 days (slower than IVIG)

Key considerations Gastric protection with PPI; monitor BSL; check for latent TB before prolonged courses; rarely provides sustained remission as monotherapy (only ~20–30% long-term response).

PBS status ✔ PBS General Benefit

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Dexamethasone (high-dose pulsed)

Generic · Corticosteroid

Adult dose 40 mg/day PO for 4 consecutive days (single pulse). May repeat for 1–2 additional cycles at 2–4-week intervals if initial response is suboptimal. Used as alternative to prednisolone.

Paediatric dose Not routinely recommended in children; use prednisolone instead.

Onset of response 2–5 days; durable response in ~40–50% after multiple pulses.

Key considerations Monitor blood glucose closely (risk of steroid-induced hyperglycaemia); insomnia; gastric protection recommended; may cause mood disturbance.

PBS status ✔ PBS General Benefit

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IV Immunoglobulin (IVIG)

Intragam® P / Flebogamma® · Immunoglobulin

Adult dose 1 g/kg as single infusion (max 70 g) over 6–12 hours. Can repeat at 24–48 hours if no response. Alternatively 0.4 g/kg/day for 5 days (older regimen).

Paediatric dose 0.8–1 g/kg as single dose; may repeat once.

Onset of response 24–48 hours (most rapid non-surgical option)

Key considerations Pre-medicate with paracetamol and antihistamine. Risk of aseptic meningitis, haemolysis (especially in non-O blood groups), thrombosis, and renal impairment. Response is transient (2–4 weeks). Supply may be limited — consult haematology.

PBS status ✖ Authority Required — Specialist

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Anti-D Immunoglobulin

WinRho® · Rh immunoglobulin

Adult dose 50 µg/kg IV as single dose (equivalent to 2,500 IU for a 70 kg patient).

Eligibility Rh-D positive, non-splenectomised patients only.

Key considerations Risk of severe intravascular haemolysis — must observe for ≥8 hours post-infusion; check haemoglobin and haptoglobin post-infusion. Rarely used since FDA safety alert; consult haematology.

PBS status ✖ Authority Required — Specialist

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Tranexamic Acid

Cyklokapron® · Generic · Antifibrinolytic

Adult dose 1 g PO/IV TDS (or 15 mg/kg TDS). Mouthwash: 500 mg in 5 mL water, swill and spit TDS for oral/mucosal bleeding.

Paediatric dose 15–25 mg/kg PO/IV TDS (max 1 g per dose).

Key considerations Useful adjunct for mucosal bleeding. Contraindicated in upper urinary tract bleeding (risk of ureteric obstruction). Reduce dose if eGFR <30 mL/min. Avoid in DIC (unless specific expert guidance).

PBS status ✔ PBS General Benefit

Emergency Management of Life-Threatening Bleeding

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Life-threatening ITP bleed — initiate ALL simultaneously:

Platelet transfusion (1 adult dose, can repeat) — response will be poor but is necessary in emergency
IVIG 1 g/kg IV (Intragam® P)
IV methylprednisolone 1 g/day for 3 days OR dexamethasone 40 mg IV
Tranexamic acid 1 g IV stat then 1 g IV TDS
Recombinant factor VIIa (NovoSeven®) — haematology-guided only in refractory cases
Urgent emergency splenectomy may be required if medical therapy fails

Contact on-call haematology immediately. Arrange ICU admission if haemodynamically unstable or intracranial bleeding suspected.

Second-Line Therapies (for chronic/refractory ITP — Haematologist-directed)

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Eltrombopag

Revolade® · Thrombopoietin receptor agonist (TPO-RA)

Adult dose 50 mg PO daily (range 25–75 mg/day). Start 25 mg if East Asian ancestry or hepatic impairment. Titrate to maintain platelets 50–150×10⁹/L.

Paediatric dose ≥1 year: 25 mg PO daily (50 mg if ≥6 years and ≥30 kg); titrate upward.

Key considerations Take on empty stomach (≥2 hours after food, ≥1 hour before food — calcium-rich foods impair absorption). Monitor LFTs fortnightly initially, then monthly. Risk of hepatotoxicity and reticulin bone marrow fibrosis with prolonged use. Requires PBS Authority application.

PBS status ✖ Authority Required — Specialist; ≥2 prior therapies failed

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Romiplostim

Nplate® · Thrombopoietin receptor agonist (TPO-RA)

Adult dose 1 µg/kg SC once weekly, titrate by 1 µg/kg increments weekly to target platelets 50–200×10⁹/L (max 10 µg/kg).

Paediatric dose ≥1 year: same as adult weight-based dosing.

Key considerations Administered by injection (home or clinic). No food interactions. Monitor for reticulin fibrosis with periodic marrow biopsies if on therapy >1 year. Platelet counts may rebound rapidly if doses missed — do not stop abruptly.

PBS status ✖ Authority Required — Specialist; ≥2 prior therapies failed

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Rituximab

MabThera® / Riximyo® · Anti-CD20 monoclonal antibody

Adult dose 375 mg/m² IV weekly for 4 weeks, OR 1,000 mg IV on days 1 and 15. Pre-medicate with hydrocortisone, paracetamol, and promethazine.

Key considerations Response rate ~60% but sustained long-term response only ~20–30%. Risk of hepatitis B reactivation (screen and treat before starting). Risk of hypogammaglobulinaemia with repeated courses. Late-onset neutropenia possible.

PBS status ✖ Authority Required — Specialist

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Mycophenolate Mofetil

CellCept® · Immunosuppressant

Adult dose 500–1,000 mg PO BD, titrate to 1,500 mg BD. Response may take 4–8 weeks.

Key considerations Monitor FBC and LFTs. Teratogenic — contraindicated in pregnancy. GI side effects common. Increasingly used as steroid-sparing agent.

PBS status ⚠ PBS Authority Required — Specialist

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Azathioprine

Imuran® · Immunosuppressant / thiopurine

Adult dose 1–2 mg/kg/day PO (typically 100–150 mg/day). Response in 2–6 months.

Key considerations Check TPMT genotype/phenotype before starting (risk of severe myelotoxicity in TPMT-deficient patients). Monitor FBC and LFTs. Teratogenic. Long steroid-sparing alternative.

PBS status ✔ PBS General Benefit

Splenectomy

Laparoscopic splenectomy offers a durable complete response in approximately 60–70% of patients with chronic ITP. It is generally considered after failure of at least one medical second-line agent (TPO-RA or rituximab) or if TPO-RAs and rituximab are not suitable. Key considerations include:

Vaccinate against Streptococcus pneumoniae (2 vaccines: Prevenar 13® then Pneumovax 23® at least 2 weeks pre-splenectomy), Neisseria meningitidis (Menactra® or Nimenrix® — ACWY + B), and Haemophilus influenzae type b (Hib) at least 2 weeks before surgery.
Ensure lifelong post-splenectomy antibiotic prophylaxis (phenoxymethylpenicillin 250 mg PO BD or erythromycin 250 mg PO BD if penicillin-allergic) — patient must carry a MedicAlert bracelet.
Thromboprophylaxis post-operatively (LMWH) as per surgical protocol.
Risk of overwhelming post-splenectomy infection (OPSI), particularly with encapsulated organisms — annual influenza vaccination and revaccination schedule per ATAGI guidelines.

Monitoring During Treatment

Week 1–2 FBC twice weekly during initial steroid or IVIG therapy to assess response. Daily platelet count if inpatient with significant bleeding.

Week 2–4 Weekly FBC during steroid taper. Assess for steroid side effects (hyperglycaemia, mood disturbance, insomnia).

Month 1–3 FBC every 2–4 weeks. Determine if remission is sustained. Initiate second-line if still treatment-dependent.

Month 3–12 FBC monthly for chronic ITP. Monitor for treatment side effects of second-line agents.

Long-term (>12 months) FBC every 2–3 months if stable. Annual review with haematology. Reassess need for ongoing therapy annually. Annual vaccination updates for asplenic patients.

Primary-Care Role

General practitioners play a critical role in the long-term management and supportive care of patients with ITP, even when haematology is directing therapy. The following practical measures are essential in the primary-care setting.

Medications to Avoid

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Key medication restrictions in ITP:

NSAIDs (ibuprofen, naproxen, diclofenac, celecoxib) — impair platelet function AND increase GI bleeding risk. Use paracetamol for analgesia; if inadequate, discuss with haematology.
Aspirin and antiplatelet agents (clopidogrel, ticagrelor, prasugrel) — contraindicated unless specifically indicated under haematology guidance (e.g., post-coronary stent with dual-discussion).
Intramuscular (IM) injections — avoid when platelets <50×10⁹/L due to risk of deep muscle haematoma. Vaccinations should be given subcutaneously where possible.
Anticoagulants (warfarin, DOACs, heparin) — use with extreme caution and haematology co-management if indicated.
Rectal examinations and suppositories — avoid when platelets <50×10⁹/L.

Patient Counselling

Explain that ITP is an autoimmune condition — the immune system is destroying platelets, not cancer.
Counsel on signs of significant bleeding: persistent nosebleeds (>20 minutes), blood in urine or stools, heavy menstrual bleeding, unexplained bruising spreading rapidly, wet purpura (blood blisters inside the mouth).
Advise to present immediately to the emergency department if severe headache occurs (risk of intracranial haemorrhage) or if significant trauma occurs.
Avoid contact sports, activities with high injury risk, and use of sharp objects when platelets are <50×10⁹/L.
Wear a medical alert identification (bracelet or necklace) if platelets are chronically low or if splenectomised.
Dental procedures — inform the dentist of ITP status; platelet count >30×10⁹/L is generally safe for dental extractions with local measures (tranexamic acid mouthwash, gelatin sponge). Discuss with haematology for counts <30×10⁹/L.
Menorrhagia management — refer to gynaecology if heavy menstrual bleeding is impacting quality of life; tranexamic acid and hormonal therapies (combined OCP, LNG-IUS) can be used with haematology guidance.

Pre-Splenectomy Vaccination Protocol

When splenectomy is planned, the following vaccines should be administered at least 2 weeks before surgery. If urgent splenectomy is required, vaccinate as soon as possible post-operatively (but note reduced immunogenicity).

Vaccine	Product	Schedule	PBS / NIP Status
Pneumococcal conjugate (PCV13)	Prevenar 13®	Single dose SC	Funded for asplenic patients under NIP
Pneumococcal polysaccharide (PPV23)	Pneumovax 23®	Single dose SC ≥8 weeks after PCV13, then repeat every 5 years	Funded for asplenic patients under NIP
Meningococcal ACWY	Menactra® / Nimenrix®	Single dose SC; booster every 5 years	Funded for asplenic patients under NIP
Meningococcal B	Bexsero®	2 doses SC, ≥4 weeks apart	Not NIP-funded for adults; private purchase (~$130–150/dose)
Haemophilus influenzae type b (Hib)	ActHIB®	Single dose SC (if not previously vaccinated as adult)	Funded for asplenic patients under NIP
Influenza (annual)	Flu vaccine (quadrivalent)	Annual, before winter season	NIP-funded annually for all Australians
COVID-19	Per current ATAGI recommendations	As per current booster schedule	NIP-funded

Routine Monitoring in Primary Care (Stable Chronic ITP)

FBC every 2–3 months if stable and on no active treatment.
Annual review of bleeding symptoms, quality of life, and medication review.
Monitor for complications of chronic steroid use (osteoporosis screening with DEXA if >3 months cumulative use; diabetes screening; cataracts; adrenal suppression).
Bone protection: calcium + vitamin D supplementation; consider bisphosphonate if prolonged steroid use expected.
Mental health screening — chronic ITP and its treatments are associated with anxiety, depression, and fatigue.

When to Refer

Most patients with newly diagnosed ITP should be referred to haematology for confirmation of diagnosis, risk stratification, and treatment planning. The urgency and level of referral depend on the clinical scenario.

1

Urgent Referral (Same Day / ED)

Platelets <20×10⁹/L regardless of symptoms; any active clinically significant bleeding (wet purpura, mucosal haemorrhage, GI/GU bleeding); suspected intracranial haemorrhage (severe headache, neurological signs); haemodynamic instability. Send to nearest ED and contact on-call haematology.

2

Semi-Urgent Referral (Within 1–2 Weeks)

All new suspected ITP — even if asymptomatic with counts >30×10⁹/L. Haematology should confirm diagnosis, exclude secondary causes, determine need for treatment, and establish a monitoring plan.

3

Routine Referral (Within 4–6 Weeks)

Stable chronic ITP with change in clinical status (increasing bleeding symptoms, declining platelet trend); need for second-line therapy decision; pre-conception counselling for women of childbearing age; prior to elective surgery requiring platelet optimisation.

4

Not Requiring Haematology Referral

Isolated mild thrombocytopenia (platelets 100–150×10⁹/L) without clinical significance — may represent a normal variant (ethnic thrombocytopenia, constitutional). Recheck FBC in 4–8 weeks and refer if declining or symptomatic. Pseudothrombocytopenia on blood film — repeat with citrate tube.

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GP-initiated investigations while awaiting haematology: It is reasonable for the GP to order the essential baseline investigations (FBC and film, coagulation, HIV, hepatitis C, H. pylori stool antigen) while awaiting the haematology appointment to expedite the diagnostic workup.

Special Populations

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Pregnancy

Incidence: ITP affects 1–2 in 1,000 pregnancies. Must distinguish from gestational thrombocytopenia (platelets usually >70×10⁹/L, resolves postpartum) and pre-eclampsia/HELLP.

Treatment thresholds: Treat if platelets <30×10⁹/L in first/second trimester, <50×10⁹/L in third trimester, or before delivery/neuraxial anaesthesia. Target ≥50×10⁹/L for vaginal delivery and ≥80×10⁹/L for caesarean section.

Safe medications: Prednisolone (preferred steroid), IVIG (no teratogenicity), azathioprine (low risk with monitoring).

Contraindicated: Mycophenolate (teratogenic), eltrombopag and romiplostim (teratogenic in animal studies — discontinue ≥2 weeks before conception), rituximab (crosses placenta — avoid, especially in first trimester), methotrexate.

Neonatal risk: 10–15% of neonates born to mothers with ITP will have neonatal thrombocytopenia. Cord blood platelet count at delivery. Cranial ultrasound if neonatal count <50×10⁹/L. Severe neonatal thrombocytopenia (<20×10⁹/L) is rare (<5%).

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Paediatrics

Prognosis: >80% of childhood ITP is acute and self-limiting (resolves within 6 months). Chronic ITP is more likely in adolescents and those with insidious onset.

Treatment approach: Observation is first-line if no significant bleeding, even with very low counts. Treat for clinically significant bleeding only. IVIG (1 g/kg) or prednisolone (1–2 mg/kg/day) for 2 weeks if treatment required.

Activity restriction: Avoid contact sports, trampolining, and high-risk activities when platelets <50×10⁹/L. Most children can attend school normally.

Second-line: Chronic ITP in children may require TPO-RAs (eltrombopag approved from age 1, romiplostim from age 1). Splenectomy generally deferred until >5 years old if possible.

Parental education: Provide written action plan for when to present to ED (head injury, prolonged bleeding, mouth blood blisters, severe headache). Avoid aspirin/NSAIDs — use paracetamol for fever/pain.

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Elderly (≥65 years)

Higher risk: Older adults with ITP have higher bleeding risk, more treatment resistance, and higher mortality. Falls prevention is critical — home safety assessment, medication review for sedating drugs.

Bone marrow biopsy: Recommended before initiating second-line therapy in patients >60 years to exclude myelodysplastic syndrome (MDS) which can mimic or coexist with ITP.

Steroid caution: Increased risk of steroid-related complications: hyperglycaemia, osteoporotic fracture, delirium, infection. Use shorter courses, PPI cover, and consider early transition to steroid-sparing agents.

Treatment thresholds: Consider treating at higher platelet counts (e.g., <50×10⁹/L rather than <30×10⁹/L) due to increased fall risk and comorbidities.

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Renal Impairment

Tranexamic acid: Reduce dose if eGFR <30 mL/min (risk of accumulation and seizures). Avoid in severe renal impairment.

IVIG: Risk of osmotic nephropathy and acute kidney injury — use sucrose-free formulations, adequate hydration, and slower infusion rates. Monitor renal function.

Eltrombopag: No dose adjustment required for renal impairment. Preferred TPO-RA in CKD patients.

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Hepatic Impairment

Caution: Corticosteroids may worsen hepatic encephalopathy in advanced liver disease. Consider hepatology co-management.

Eltrombopag: Start at 25 mg/day in hepatic impairment (Child-Pugh A–C). Monitor LFTs weekly initially — risk of hepatotoxicity. Contraindicated if ALT >5× ULN.

Diagnostic consideration: Thrombocytopenia in chronic liver disease may be due to hypersplenism, decreased thrombopoietin production, or alcohol toxicity — distinguish from ITP before treating.

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Immunocompromised

HIV-associated ITP: Treat underlying HIV with antiretroviral therapy (ART) — platelet count often improves with immune reconstitution. First-line: corticosteroids + ART. Second-line: TPO-RAs, rituximab (with caution).

CVID: ITP is a recognised complication of CVID. Treat with IVIG replacement therapy + ITP-specific treatment. Avoid rituximab if possible (further B-cell depletion).

Post-transplant: Drug-induced thrombocytopenia must be excluded. Tacrolimus and mycophenolate can both cause thrombocytopenia. Requires transplant team and haematology co-management.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Later presentation

Aboriginal and Torres Strait Islander Australians may present later with lower platelet counts and more severe bleeding due to delayed access to healthcare, particularly in remote and very remote communities. A lower threshold for urgent haematology referral should be considered.

Remote and rural access

Specialist haematology services are concentrated in major cities and regional centres. Telehealth consultations (Medicare Items 99–111) are essential for remote communities. Royal Flying Doctor Service (RFDS) should be engaged early for urgent transfers. Ensure IVIG and emergency treatments are available at the nearest regional hospital.

Secondary causes

Higher prevalence of conditions associated with secondary ITP: hepatitis C (particularly in some remote communities), HIV, H. pylori, and autoimmune disease. Ensure thorough screening for secondary causes at diagnosis. HCV treatment with direct-acting antivirals (DAAs) on the PBS may resolve HCV-associated ITP.

Infection burden

Higher background rates of bacterial and viral infections in remote communities may confound the diagnosis of ITP (infection-related thrombocytopenia) and complicate immunosuppressive treatment. Careful clinical assessment is required to distinguish ITP from infection-related cytopenias.

Post-splenectomy care

Splenectomised patients in remote communities require robust primary-care follow-up for lifelong antibiotic prophylaxis, vaccination boosters, and education about OPSI. Ensure prescriptions for phenoxymethylpenicillin are maintained through local Aboriginal Medical Services (AMS) or remote health clinics.

Cultural safety

Provide culturally appropriate health education in the patient's preferred language where possible. Use Aboriginal Health Workers (AHWs) and Aboriginal Health Practitioners (AHPs) as key members of the care team. Respect cultural obligations regarding gender-concordant care, sorry business, and connection to country. Avoid assumptions — ask the patient about their preferences.

Medication access

Ensure medications (prednisolone, tranexamic acid, eltrombopag) are available through the local health service or Remote Area Aboriginal Health Services (RAAHS). PBS Close the Gap co-payment ($7.70 per script) applies to Aboriginal and Torres Strait Islander patients with a CTG marker — ensure this is recorded on the PBS claim.

Follow-up adherence

Mobility between communities, seasonal movement, and social determinants of health may affect follow-up attendance. Flexible recall systems, outreach clinics, and coordination with AMS and Indigenous liaison officers improve continuity of care. AIHW data shows Aboriginal and Torres Strait Islander Australians have higher rates of avoidable hospitalisation for blood disorders — proactive community-based care can reduce this gap.

📚 References

1. Neunert C, Terrell DR, Arnold DM, et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Advances. 2019;3(23):3829–3866. doi:10.1182/bloodadvances.2019000966.
2. Provan D, Arnold DM, Bussel JB, et al. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Advances. 2019;3(22):3780–3817. doi:10.1182/bloodadvances.2019000812.
3. Matzdorff A, Meyer O, Ostermann H, et al. Immune thrombocytopenia — current diagnostics and therapy: recommendations of a joint working group of DGHO, OGHO, SGH, GPOH, and DGTI. Annals of Hematology. 2018;97(9):1583–1604.
4. Miltiadous O, Hou M, Bussel JB. Identifying and treating refractory ITP: difficulty in diagnosis and role of combination treatment. Blood. 2020;135(7):472–490. doi:10.1182/blood.2019003599.
5. Royal College of Pathologists of Australasia (RCPA). Peripheral blood film — recommendations. RCPA Manual. 10th ed. Surry Hills, NSW: RCPA; 2023.
6. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Blood and blood-forming organ diseases. Cat. no. IHW 256. Canberra: AIHW; 2023.
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