Back Back
FAQs: Management of ITP
FAQs: Practical Guidance in the Management of ITP

Released: October 22, 2024

Expiration: October 21, 2025

Tara Azizi
Tara Azizi, MSN, AGPCNP-BC, CRNP
Lucus W. Enslin
Lucus W. Enslin, MSN, FNP-BC
Jennifer Mead
Jennifer Mead, PA-C
Activity Information

Activity

Progress
1
Course Completed
Continue
Key Takeaways
  • Watchful waiting may be an option for patients with immune thrombocytopenia (ITP) with a history of stable platelet counts above 20,000/µL and who tolerate low platelet counts without experiencing bleeding events.
  • Infection with the COVID-19 virus and vaccination against the virus may trigger ITP flares in individuals with ITP.
  • Thrombopoietin receptor agonists are all effective in ITP, with patient preferences, dosing schedule, route of administration, and coverage being important considerations guiding choice.

In this commentary adapted from a discussion at a live webinar titled “Practical Guidance on Modern Chronic ITP Therapeutics: A Blueprint to Improve Patient Outcomes and Quality of Life,” Lucus W. Enslin, MSN, FNP-BC; Tara Azizi, MSN, AGPCNP-BC, CRNP; and Jennifer Mead, PA-C discuss practical considerations in the management of patients with immune thrombocytopenia (ITP).

When is the watchful waiting approach appropriate for patients who are newly diagnosed with ITP?

Lucus W. Enslin, MSN, FNP-BC: The watchful waiting approach will be appropriate in situations where the patient is not experiencing any bleeding event and the platelet counts are above 20,000/µL. However, if the platelet counts are below 20,000/µL, it usually signals that the patient is in need of treatment, as there is a risk of catastrophic bleeding when the platelet counts are below 20,000/µL. Of note, for patients with ITP, the prevention of bleeding is the ultimate goal. Ideally, when the platelet counts are already very low, treatment should ensue.

Tara Azizi, MSN, AGPCNP-BC, CRNP: We do not utilize watchful waiting for our patients who are newly diagnosed with ITP unless we have closely monitored the patient for many months, and we know that the patient’s platelet count is not going to drop below 20,000/µL and are confident that the patient will be able to tolerate platelet counts in the 20,000-30,000/µL range without experiencing any bleeding event.

Jennifer Mead, PA-C: Yes, I agree. Watchful waiting is an option for patients for whom we already have a history of their tolerance of low platelet counts.

Does infection with the COVID-19 virus complicate the quality of life of patients living with ITP?

Lucus W. Enslin, MSN, FNP-BC: I think infection with the COVID-19 virus complicates the quality of life of any individual. So, for patients with ITP, infection with the COVID-19 virus would add some complications to their quality of life. If the patient is undergoing treatment with an immunosuppressant such as mycophenolate mofetil, sirolimus, or rituximab, recovery from the infection may be delayed. At my institution, we encourage our patients with ITP to be up-to-date with the approved vaccines and to avoid infection.

Tara Azizi, MSN, AGPCNP-BC, CRNP: At my institution, there are no specific prophylactic measures we take regarding our patients with ITP who are newly diagnosed with the COVID-19 infection. Of note, we worry about viral infections being a trigger for ITP flares; so, we encourage patients to report any symptoms such as petechiae or bleeding.

Jennifer Mead, PA-C: At my institution, we encourage routine vaccinations against the virus. However, it is possible for vaccines to induce ITP flares. Therefore, we have our patients obtain a complete blood count (CBC) within 2 weeks of receiving the vaccine to monitor the platelet trend. If the platelet count shows a visible downward trend, we start weekly CBC monitoring. Another complication to note is that treatment using heavy immunosuppression will lower the response to any vaccine; so, it is best to discuss with the provider when to receive the vaccines.

Based on the differences among the available thrombopoietin receptor agonists (TPO-RAs), which category of patients with ITP stand to benefit most from taking the orally available TPO-RAs.

Lucus W. Enslin, MSN, FNP-BC: The orally available TPO-RAs, specifically eltrombopag and avatrombopag, offer significant advantages in the management of chronic ITP, particularly for patients who prioritize convenience, require long-term therapy, or have specific preferences against injectable treatments. The choice of TPO-RA should be individualized based on patient preferences, lifestyle, comorbidities, and specific clinical considerations. It is important for advanced practice providers to consult the drug’s reference guide, prescribing information, and/or pharmacist for further information.

Jennifer Mead, PA-C: The main difference among the 3 approved TPO-RAs lies in how they are taken. Romiplostim is administered once weekly in the clinic via subcutaneous injection, but eltrombopag and avatrombopag are orally available and can be taken daily at home. The choice of one over the others relies on patient’s convenience and insurance coverage. Patients who are able to fully adhere to and comply with taking their medications daily benefit the most from the orally available options.

Tara Azizi, MSN, AGPCNP-BC, CRNP: In the second-line setting, a TPO-RA is a great option, especially for a patient for whom immunosuppression is of concern, and/or for a patient who needs to achieve a durable platelet response. Eltrombopag is associated with the risk of hepatotoxicity and dietary restrictions with regard to avoiding administration with polyvalent cations, but avatrombopag is not. A patient who would likely benefit most from an oral TPO-RA is one who is not able to visit the clinic weekly to receive the injectable form.

Your Thoughts?
What challenges do you experience in your practice when it comes to using TPO-RAs in the management of your patients with ITP? Answer the polling question and join the conversation in the discussion box below.

Continue

Poll

1.

How often do you ask your patients with chronic ITP about signs and symptoms of treatment-related adverse events?

Submit