Immune Thrombocytopenic Purpura (ITP) Medication
- Author: Craig M Kessler, MD; Chief Editor: Srikanth Nagalla, MBBS, MS, FACP more...
The treatment of acute immune thrombocytopenic purpura (ITP) requires considerable individualization. General approaches for children with acute ITP and adults with chronic ITP are discussed below.
Recommended general approach for children with acute immune thrombocytopenic purpura
For initial (induction) treatment, in patients with a platelet count of 20-30 × 109/L [20-30 × 103/µL] and/or mucocutaneous bleeding), one regimen is prednisone 4-8 mg/kg/d with the intent of a rapid and complete taper after 7-10 days or when the platelet count reaches 50 × 109/L (50 × 103/µL), whichever occurs first. In critical situations, an IV infusion of a corticosteroid may be preferable.
Second-line (maintenance) treatment is IV Rh immune globulin (IG), 75/µg/kg (off-label dose) for the Rh-positive patient or IVIG 1.0 g/kg for the Rh-negative patient. If the patient has clinically significant purpura or bleeding at presentation, consider infusing the first dose of IV RhIG or IVIG at the time of initial therapy with corticosteroids.
Repeat the infusions at 3- to 4-week intervals (maintenance) until a satisfactory platelet count is achieved. If the platelet count is not maintained after 3-4 infusions, the case might be refractory, and a different treatment should be considered. Conditions refractory to IV RhIG may respond to IVIG, and vice versa. If the patient's hemoglobulin level decreases to 8.0 g/dL during treatment with IV RhIG, temporarily switch to IVIG until the level recovers. In this situation, the patient's condition should not be considered refractory to IV RhIG.
Conventional third-line treatment is splenectomy. However, recognizing the life-long potential adverse effects of splenectomy and the promising reports of responses to rituximab,[76, 77] the authors consider a course of rituximab 375 mg/m2 per week for four doses (off-label indication) before splenectomy (which becomes fourth-line therapy). Rituximab at a standard dose of 375 mg/m2 per week for 4 weeks appears to be safe and effective, allowing nearly 40% of patients with ITP to achieve a long-term response and splenectomy-sparing effect in one study.
Recommended general approach for adults with chronic immune thrombocytopenic purpura
Adults whose disease is not controlled with a prednisone-induced increase in platelet count that is maintained by IV RhIG or IVIG and whose conditions do not respond to four weekly infusions of rituximab are candidates for splenectomy. After these serial experiences, such patients are likely to have had thrombocytopenia for at least 6 months and, therefore, are categorized as having chronic ITP. Eltrombopag or romiplostim offer potential maintenance of safe levels of platelet counts for adults who qualify by having ITP for at least 6 months and whose conditions are refractory to conventional medical management (prednisone, IV RhIG, IVIG, rituximab), and whose platelet count is not maintained in a satisfactory range after splenectomy.
The treatment of chronic, refractory ITP may introduce risks of toxicity from medications that are comparable in severity to the risks of untreated thrombocytopenia. These treatments also may impact adversely on the patient's quality of life.
For patients with chronic refractory ITP who have access to investigational programs, the authors encourage them to participate in controlled clinical trials to support the development of effective treatments for this category.
Most conventional treatments for ITP act by decreasing destruction of autoantibody-coated circulating platelets. In contrast, thrombopoietin mimetics increase platelet counts in persons with ITP by increasing the number of platelets produced and released by the bone marrow. Agents in this class include the thrombopoietin peptide mimetic romiplostim (Nplate) and the nonpeptide mimetic eltrombopag (Promacta).[82, 83]
Romiplostim was approved by the US Food and Drug Administration (FDA) in August 2008. It is a thrombopoiesis-stimulating protein Fc-peptide fusion protein ("peptibody") that increases platelet counts in patients with acute and chronic ITP without reports of significant toxicity.[84, 33, 85]
Eltrombopag is indicated for treatment of thrombocytopenia in patients with chronic ITP who have shown insufficient response to corticosteroids, immunoglobulins, or splenectomy. This drug was also approved by the FDA in 2008.[86, 87] In August 2015, the FDA expanded the indication for eltrombopag to include treatment of chronic ITP in patients 1 year of age and older who have not achieved an appropriate response with other medical therapy or splenectomy.
Corticosteroids are the treatment of choice for initial management of acute ITP. These agents increase the platelet count by decreasing splenic uptake of autoantibody-coated platelets and by decreasing synthesis of autoantibody. Dosages must be tapered after a safe platelet count is achieved, and the drug is replaced with IV RhIG or IVIG to avoid serious complications of long-term steroid use.
Oral corticosteroid that is used most frequently because of its relatively low cost, known adverse effects, and long-term clinical record. DOC for initial treatment of ITP in children and adults. For aggressive treatment, may be combined with IV RhIG or IVIG. In emergency, replace PO prednisone with IV methylprednisolone.
DOC for the initial management of severe bleeding tendency in ITP. IV is recommended when the most rapid and reliable treatment of ITP is required. In this situation, combine with IV RhIG in qualified Rh(D)-positive patients or IVIG in Rh(D)-negative patients or unqualified Rh(D)-positive patients.
Blood products are used to improve clinical and immunologic aspects of ITP. These products may decrease autoantibody production and increase solubilization and removal of immune complexes.
Specialized immunoglobulin product manufactured from pools of plasma from Rh(D)-negative persons and alloimmunized to D blood group antigen. Subjected to anion-exchange column chromatography to permit IV infusion and solvent-detergent treatment and nanofiltration to reduce infectivity by lipid-enveloped viruses. Induces immune RBC hemolysis in Rh(D)-positive recipients, decreasing function of mononuclear macrophages (reticuloendothelial blockade) and sparing immunoglobulin-coated platelets from splenic destruction.
Large dose of 1 g/kg induces decreased function of mononuclear macrophages (reticuloendothelial blockade), sparing immunoglobulin-coated platelets from splenic destruction. Used with IV methylprednisolone to manage acute ITP in children. Decreased time to an increased platelet count compared with IV RhIG, but the difference does not appear to be clinically significant. Compared with IV RhIG, associated with more adverse effects, longer infusions, and increased cost, causing many hematologists to prefer IV RhIG as a supplement to corticosteroids, at least for Rh(D)-positive patients.
Immunosuppressive antimetabolites are used in patients with ITP to reduce production of abnormal autoantibodies.
May be effective in some patients with ITP whose conditions do not or no longer have response to corticosteroids, IV RhIG, or IVIG. May be used with prednisone to reduce dose of prednisone or as another PO medication to delay splenectomy.
Synthetic Antineoplastic Drugs
Synthetic antineoplastic drugs are chemically related to nitrogen mustards. These agents inhibit cell growth and proliferation.
May be useful in some patients whose conditions do not or no longer have a response to corticosteroids, IV RhIG, IVIG, or splenectomy. Induces less of a decrease in platelet count than other immunosuppressive alkylating agents.
The steroidogenic properties of androgens may modulate the immune system.
May impair the clearance of immunoglobulin-coated platelets and decreases autoantibody production. Increased platelet counts in 40-50% of patients, particularly postmenopausal women.
Monoclonal antibodies are chimeric murine-human monoclonal antibodies directed against CD20 on B lymphocytes.
Chimeric monoclonal antibody directed against the CD20 antigen on the surface of normal and malignant B lymphocytes. Antibody is IgG kappa immunoglobulin with murine light- and heavy-chain variable sequences and human constant region sequences.
These new agents directly stimulate production of platelets by the bone marrow.
An Fc-peptide fusion protein (peptibody) that increases platelet production through binding and activation of the thrombopoietin (TPO) receptor, a mechanism similar to endogenous TPO. Indicated for chronic immune (idiopathic) thrombocytopenic purpura in patients who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy.
Oral thrombopoietin (TPO) receptor agonist. Interacts with transmembrane domain of human TPO receptor and induces megakaryocyte proliferation and differentiation from bone marrow progenitor cells. Indicated for thrombocytopenia associated with chronic idiopathic thrombocytopenic purpura in patients experiencing inadequate response to corticosteroids, immunoglobulins, or splenectomy. Not for use to normalize platelet counts, but used when clinical condition increases bleeding risk.
Butros LJ, Bussel JB. Intracranial hemorrhage in immune thrombocytopenic purpura: a retrospective analysis. J Pediatr Hematol Oncol. 2003 Aug. 25(8):660-4. [Medline].
Fogarty PF, Segal JB. The epidemiology of immune thrombocytopenic purpura. Curr Opin Hematol. 2007 Sep. 14(5):515-9. [Medline].
Nilsson T, Norberg B. Thrombocytopenia and pseudothrombocytopenia: a clinical and laboratory problem. Scand J Haematol. 1986 Oct. 37(4):341-6. [Medline].
Jubelirer SJ, Harpold R. The role of the bone marrow examination in the diagnosis of immune thrombocytopenic purpura: case series and literature review. Clin Appl Thromb Hemost. 2002 Jan. 8(1):73-6. [Medline].
Calpin C, Dick P, Poon A, Feldman W. Is bone marrow aspiration needed in acute childhood idiopathic thrombocytopenic purpura to rule out leukemia?. Arch Pediatr Adolesc Med. 1998 Apr. 152(4):345-7. [Medline]. [Full Text].
Sandler SG, Tutuncuoglu SO. Immune thrombocytopenic purpura - current management practices. Expert Opin Pharmacother. 2004 Dec. 5(12):2515-27. [Medline].
Tarantino MD, Buchanan GR. The pros and cons of drug therapy for immune thrombocytopenic purpura in children. Hematol Oncol Clin North Am. 2004 Dec. 18(6):1301-14, viii. [Medline].
[Guideline] Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr, Crowther MA. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 Apr 21. 117(16):4190-207. [Medline]. [Full Text].
Mazzucconi MG, Fazi P, Bernasconi S, et al. Therapy with high-dose dexamethasone (HD-DXM) in previously untreated patients affected by idiopathic thrombocytopenic purpura: a GIMEMA experience. Blood. 2007 Feb 15. 109(4):1401-7. [Medline]. [Full Text].
Borst F, Keuning JJ, van Hulsteijn H, Sinnige H, Vreugdenhil G. High-dose dexamethasone as a first- and second-line treatment of idiopathic thrombocytopenic purpura in adults. Ann Hematol. 2004 Dec. 83(12):764-8. [Medline].
Imbach P, Barandun S, d'Apuzzo V, et al. High-dose intravenous gammaglobulin for idiopathic thrombocytopenic purpura in childhood. Lancet. 1981 Jun 6. 1(8232):1228-31. [Medline].
Anderson D, Ali K, Blanchette V, et al. Guidelines on the use of intravenous immune globulin for hematologic conditions. Transfus Med Rev. 2007 Apr. 21(2 suppl 1):S9-56. [Medline].
Sandler SG. Treating immune thrombocytopenic purpura and preventing Rh alloimmunization using intravenous rho (D) immune globulin. Transfus Med Rev. 2001 Jan. 15(1):67-76. [Medline].
Sandler SG, Novak SC, Roland B. The cost of treating immune thrombocytopenic purpura using intravenous Rh immune globulin versus intravenous immune globulin. Am J Hematol. 2000 Mar. 63(3):156-8. [Medline]. [Full Text].
Gaines AR. Acute onset hemoglobinemia and/or hemoglobinuria and sequelae following Rh(o)(D) immune globulin intravenous administration in immune thrombocytopenic purpura patients. Blood. 2000 Apr 15. 95(8):2523-9. [Medline]. [Full Text].
Chun NS, Savani B, Seder RH, Taplin ME. Acute renal failure after intravenous anti-D immune globulin in an adult with immune thrombocytopenic purpura. Am J Hematol. 2003 Dec. 74(4):276-9. [Medline]. [Full Text].
[Guideline] Rajasekhar A, Gernsheimer T, Stasi R, James AH. 2013 Clinical Practice Guide on Thrombocytopenia in Pregnancy. American Society of Hematology. Available at Rajasekhar A, Gernsheimer T, Stasi R, James AH. Accessed: September 24, 2015.
Gottlieb P, Axelsson O, Bakos O, Rastad J. Splenectomy during pregnancy: an option in the treatment of autoimmune thrombocytopenic purpura. Br J Obstet Gynaecol. 1999 Apr. 106(4):373-5. [Medline].
McMillan R. The pathogenesis of chronic immune thrombocytopenic purpura. Semin Hematol. 2007 Oct. 44(4 suppl 5):S3-S11. [Medline].
Chan H, Moore JC, Finch CN, Warkentin TE, Kelton JG. The IgG subclasses of platelet-associated autoantibodies directed against platelet glycoproteins IIb/IIIa in patients with idiopathic thrombocytopenic purpura. Br J Haematol. 2003 Sep. 122(5):818-24. [Medline].
Crow AR, Lazarus AH. Role of Fcgamma receptors in the pathogenesis and treatment of idiopathic thrombocytopenic purpura. J Pediatr Hematol Oncol. 2003 Dec. 25 suppl 1:S14-8. [Medline].
Sandler SG. The spleen and splenectomy in immune (idiopathic) thrombocytopenic purpura. Semin Hematol. 2000 Jan. 37(1 suppl 1):10-2. [Medline].
Moulis G, Palmaro A, Montastruc JL, Godeau B, Lapeyre-Mestre M, Sailler L. Epidemiology of incident immune thrombocytopenia: a nationwide population-based study in France. Blood. 2014 Nov 20. 124(22):3308-15. [Medline].
Danese MD, Lindquist K, Gleeson M, Deuson R, Mikhael J. Cost and mortality associated with hospitalizations in patients with immune thrombocytopenic purpura. Am J Hematol. 2009 Jul 16. [Medline].
Medeiros D, Buchanan GR. Major hemorrhage in children with idiopathic thrombocytopenic purpura: immediate response to therapy and long-term outcome. J Pediatr. 1998 Sep. 133(3):334-9. [Medline].
Arnold DM. Bleeding complications in immune thrombocytopenia. Hematology Am Soc Hematol Educ Program. 2015 Dec 5. 2015 (1):237-42. [Medline].
KUhne T, Imbach P, Bolton-Maggs PH, et al, for the Intercontinental Childhood ITP Study Group. Newly diagnosed idiopathic thrombocytopenic purpura in childhood: an observational study. Lancet. 2001 Dec 22-29. 358(9299):2122-5. [Medline].
Michel M, Rauzy OB, Thoraval FR, et al. Characteristics and outcome of immune thrombocytopenia in elderly: results from a single center case-controlled study. Am J Hematol. 2011 Dec. 86(12):980-4. [Medline].
Heitink-Pollé KM, Nijsten J, Boonacker CW, de Haas M, Bruin MC. Clinical and laboratory predictors of chronic immune thrombocytopenia in children: a systematic review and meta-analysis. Blood. 2014 Nov 20. 124(22):3295-307. [Medline].
Kuter DJ, Bussel JB, Lyons RM, et al. Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet. 2008 Feb 2. 371(9610):395-403. [Medline].
Zheng T, Chunlei L, Zhen W, Ping L, Haitao Z, Weixin H, et al. Clinical-Pathological Features and Prognosis of Thrombotic Thrombocytopenic Purpura in Patients With Lupus Nephritis. Am J Med Sci. 2009 Sep 9. [Medline].
Rajantie J, Zeller B, Treutiger I, Rosthöj S. Vaccination associated thrombocytopenic purpura in children. Vaccine. 2007 Feb 26. 25(10):1838-40. [Medline].
Mantadakis E, Farmaki E, Buchanan GR. Thrombocytopenic purpura after measles-mumps-rubella vaccination: a systematic review of the literature and guidance for management. J Pediatr. 2010 Apr. 156 (4):623-8. [Medline].
Reese JA, Li X, Hauben M, Aster RH, Bougie DW, Curtis BR. Identifying drugs that cause acute thrombocytopenia: an analysis using 3 distinct methods. Blood. 2010 Sep 23. 116(12):2127-33. [Medline].
Sundell IB, Koka PS. Thrombocytopenia in HIV infection: impairment of platelet formation and loss correlates with increased c-Mpl and ligand thrombopoietin expression. Curr HIV Res. 2006 Jan. 4(1):107-16. [Medline].
Emilia G, Luppi M, Zucchini P, et al. Helicobacter pylori infection and chronic immune thrombocytopenic purpura: long-term results of bacterium eradication and association with bacterium virulence profiles. Blood. 2007 Dec 1. 110(12):3833-41. [Medline]. [Full Text].
Franchini M, Cruciani M, Mengoli C, Pizzolo G, Veneri D. Effect of Helicobacter pylori eradication on platelet count in idiopathic thrombocytopenic purpura: a systematic review and meta-analysis. J Antimicrob Chemother. 2007 Aug. 60(2):237-46. [Medline]. [Full Text].
Inaba T, Mizuno M, Take S, et al. Eradication of Helicobacter pylori increases platelet count in patients with idiopathic thrombocytopenic purpura in Japan. Eur J Clin Invest. 2005 Mar. 35(3):214-9. [Medline].
Sato R, Murakami K, Watanabe K, et al. Effect of Helicobacter pylori eradication on platelet recovery in patients with chronic idiopathic thrombocytopenic purpura. Arch Intern Med. 2004 Sep 27. 164(17):1904-7. [Medline]. [Full Text].
Hwang JJ, Lee DH, Yoon H, Shin CM, Park YS, Kim N. The Effects of Helicobacter pylori Eradication Therapy for Chronic Idiopathic Thrombocytopenic Purpura. Gut Liver. 2015 Sep 9. [Medline].
Ahn ER, Tiede MP, Jy W, et al. Platelet activation in Helicobacter pylori-associated idiopathic thrombocytopenic purpura: eradication reduces platelet activation but seldom improves platelet counts. Acta Haematol. 2006. 116(1):19-24. [Medline].
Schultz CL, Mitra N, Schapira MM, Lambert MP. Influence of the American Society of Hematology guidelines on the management of newly diagnosed childhood immune thrombocytopenia. JAMA Pediatr. 2014 Oct. 168(10):e142214. [Medline].
Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med. 2002 Mar 28. 346(13):995-1008. [Medline].
Bussel JB. Novel approaches to refractory immune thrombocytopenic purpura. Blood Rev. 2002 Mar. 16(1):31-6. [Medline].
McMillan R. Therapy for adults with refractory chronic immune thrombocytopenic purpura. Ann Intern Med. 1997 Feb 15. 126(4):307-14. [Medline].
Godeau B, Durand JM, Roudot-Thoraval F, et al. Dapsone for chronic autoimmune thrombocytopenic purpura: a report of 66 cases. Br J Haematol. 1997 May. 97(2):336-9. [Medline].
Facon T, Caulier MT, Wattel E, et al. A randomized trial comparing vinblastine in slow infusion and by bolus i.v. injection in idiopathic thrombocytopenic purpura: a report on 42 patients. Br J Haematol. 1994 Mar. 86(3):678-80. [Medline].
FDA extends use of Promacta in young children with rare blood disorder. U.S. Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm459430.htm. August 24, 2015; Accessed: September 23, 2015.
Kuter DJ, Rummel M, Boccia R, Macik BG, Pabinger I, Selleslag D, et al. Romiplostim or standard of care in patients with immune thrombocytopenia. N Engl J Med. 2010 Nov 11. 363(20):1889-99. [Medline].
Bussel JB, Hsieh L, Buchanan GR, Stine K, Kalpatthi R, Gnarra DJ, et al. Long-term use of the thrombopoietin-mimetic romiplostim in children with severe chronic immune thrombocytopenia (ITP). Pediatr Blood Cancer. 2014 Oct 24. [Medline].
Michel M, Wasser J, Godeau B, Aledort L, Cooper N, Tomiyama Y, et al. Efficacy and safety of the thrombopoietin receptor agonist romiplostim in patients aged ≥65 years with immune thrombocytopenia. Ann Hematol. 2015 Sep 4. [Medline].
Cheng G, Saleh MN, Marcher C, et al. Eltrombopag for management of chronic immune thrombocytopenia (RAISE): a 6-month, randomised, phase 3 study. Lancet. 2011 Jan 29. 377(9763):393-402. [Medline].
Khan LR, Nixon SJ. Laparoscopic splenectomy is a better treatment for adult ITP than steroids--it should be used earlier in patient management. Conclusions of a ten-year follow-up study. Surgeon. 2007 Feb. 5(1):3-4, 6-8. [Medline].
Rescorla FJ, West KW, Engum SA, Grosfeld JL. Laparoscopic splenic procedures in children: experience in 231 children. Ann Surg. 2007 Oct. 246(4):683-7; discussion 687-8. [Medline].
Bell WR Jr. Role of splenectomy in immune (idiopathic) thrombocytopenic purpura. Blood Rev. 2002 Mar. 16(1):39-41. [Medline].
Rodeghiero F, Frezzato M, Schiavotto C, Castaman G, Dini E. Fulminant sepsis in adults splenectomized for idiopathic thrombocytopenic purpura. Haematologica. 1992 May-Jun. 77(3):253-6. [Medline].
Zarrabi MH, Rosner F. Serious infections in adults following splenectomy for trauma. Arch Intern Med. 1984 Jul. 144(7):1421-4. [Medline].
Beattie JF, Michelson ML, Holman PJ. Acute babesiosis caused by Babesia divergens in a resident of Kentucky. N Engl J Med. 2002 Aug 29. 347(9):697-8. [Medline].
Crary SE, Buchanan GR. Vascular complications after splenectomy for hematologic disorders. Blood. 2009 Oct 1. 114(14):2861-8. [Medline].
Robinette CD, Fraumeni JF Jr. Splenectomy and subsequent mortality in veterans of the 1939-45 war. Lancet. 1977 Jul 16. 2(8029):127-9. [Medline].
Purcell PL, Crary SE, Adix LM, Alder AC, Buchanan GR. Postsplenectomy vascular complications: Feasibility of studying patients with splenectomy following trauma. Am J Hematol. 2009 May. 84(5):316-7. [Medline].
George JN, Woolf SH, Raskob GE, et al. Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology. Blood. 1996 Jul 1. 88(1):3-40. [Medline]. [Full Text].
Facon T, Caulier MT, Fenaux P, et al. Accessory spleen in recurrent chronic immune thrombocytopenic purpura. Am J Hematol. 1992 Nov. 41(3):184-9. [Medline].
Dolan JP, Sheppard BC, DeLoughery TG. Splenectomy for immune thrombocytopenic purpura: surgery for the 21st century. Am J Hematol. 2008 Feb. 83(2):93-6. [Medline].
Balagué C, Vela S, Targarona EM, et al. Predictive factors for successful laparoscopic splenectomy in immune thrombocytopenic purpura: study of clinical and laboratory data. Surg Endosc. 2006 Aug. 20(8):1208-13. [Medline].
Blanchette VS, Carcao M. Childhood acute immune thrombocytopenic purpura: 20 years later. Semin Thromb Hemost. 2003 Dec. 29(6):605-17. [Medline].
Roganovic J. Rituximab treatment in refractory idiopathic thrombocytopenic purpura in children. Eur J Pediatr. 2005 May. 164(5):334. [Medline].
Taube T, Schmid H, Reinhard H, von Stackelberg A, Overberg US. Effect of a single dose of rituximab in chronic immune thrombocytopenic purpura in childhood. Haematologica. 2005 Feb. 90(2):281-3. [Medline]. [Full Text].
Cooper N, Evangelista ML, Amadori S, Stasi R. Should rituximab be used before or after splenectomy in patients with immune thrombocytopenic purpura?. Curr Opin Hematol. 2007 Nov. 14(6):642-6. [Medline].
Zaja F, Volpetti S, Chiozzotto M, Puglisi S, Isola M, Buttignol S, et al. Long-term follow-up analysis after rituximab salvage therapy in adult patients with immune thrombocytopenia. Am J Hematol. 2012 May 21. [Medline].
George JN. Management of immune thrombocytopenia--something old, something new. N Engl J Med. 2010 Nov 11. 363(20):1959-61. [Medline].
McMillan R, Bussel JB, George JN, Lalla D, Nichol JL. Self-reported health-related quality of life in adults with chronic immune thrombocytopenic purpura. Am J Hematol. 2008 Feb. 83(2):150-4. [Medline].
Newland A. Thrombopoietin mimetic agents in the management of immune thrombocytopenic purpura. Semin Hematol. 2007 Oct. 44(4 suppl 5):S35-45. [Medline].
von dem Borne A, Folman C, van den Oudenrijn S, et al. The potential role of thrombopoietin in idiopathic thrombocytopenic purpura. Blood Rev. 2002 Mar. 16(1):57-9. [Medline].
Jamali F, Lemery S, Ayalew K, Robottom S, Robie-Suh K, Rieves D, et al. Romiplostim for the treatment of chronic immune (idiopathic) thrombocytopenic purpura. Oncology (Williston Park). 2009 Jul. 23(8):704-9. [Medline].
Bussel JB, Cheng G, Saleh MN, et al. Eltrombopag for the treatment of chronic idiopathic thrombocytopenic purpura. N Engl J Med. 2007 Nov 29. 357(22):2237-47. [Medline].
Bengtson KL, Skinner MA, Ware RE. Successful use of anti-CD20 (rituximab) in severe, life-threatening childhood immune thrombocytopenic purpura. J Pediatr. 2003 Nov. 143(5):670-3. [Medline].
Bennett CM, Rogers ZR, Kinnamon DD, et al. Prospective phase 1/2 study of rituximab in childhood and adolescent chronic immune thrombocytopenic purpura. Blood. 2006 Apr 1. 107(7):2639-42. [Medline]. [Full Text].
Braendstrup P, Bjerrum OW, Nielsen OJ, et al. Rituximab chimeric anti-CD20 monoclonal antibody treatment for adult refractory idiopathic thrombocytopenic purpura. Am J Hematol. 2005 Apr. 78(4):275-80. [Medline]. [Full Text].
Bruin M, Bierings M, Uiterwaal C, et al. Platelet count, previous infection and FCGR2B genotype predict development of chronic disease in newly diagnosed idiopathic thrombocytopenia in childhood: results of a prospective study. Br J Haematol. 2004 Dec. 127(5):561-7. [Medline].
Chang M, Nakagawa PA, Williams SA, et al. Immune thrombocytopenic purpura (ITP) plasma and purified ITP monoclonal autoantibodies inhibit megakaryocytopoiesis in vitro. Blood. 2003 Aug 1. 102(3):887-95. [Medline]. [Full Text].
Gernsheimer T. Pathophysiology and thrombokinetics in autoimmune thrombocytopenia. Blood Rev. 2002 Mar. 16(1):7-8. [Medline].
Gudbrandsdottir S, Birgens HS, Frederiksen H, Jensen BA, Jensen MK, Kjeldsen L, et al. Rituximab and dexamethasone vs dexamethasone monotherapy in newly diagnosed patients with primary immune thrombocytopenia. Blood. 2013 Mar 14. 121(11):1976-81. [Medline].
Lalayanni C, Stavroyianni N, Saloum R, Tsompanakou A, Anagnostopoulos A. Rituximab is effective for selected patients with chronic steroid-refractory immune thrombocytopenic purpura. Hematology. 2004 Aug. 9(4):287-9. [Medline].
Liebman H. Other immune thrombocytopenias. Semin Hematol. 2007 Oct. 44(4 suppl 5):S24-34. [Medline].
Mikhael J, Northridge K, Lindquist K, Kessler C, Deuson R, Danese M. Short-term and long-term failure of laparoscopic splenectomy in adult immune thrombocytopenic purpura patients: A systematic review. Am J Hematol. 2009 Jul 16. [Medline].
Pace DE, Chiasson PM, Schlachta CM, Mamazza J, Poulin EC. Laparoscopic splenectomy for idiopathic thrombocytopenic purpura (ITP). Surg Endosc. 2003 Jan. 17(1):95-8. [Medline].
Raj K, Narayanan S, Augustson B, et al. Rituximab is effective in the management of refractory autoimmune cytopenias occurring after allogeneic stem cell transplantation. Bone Marrow Transplant. 2005 Feb. 35(3):299-301. [Medline].
Sailler L. Rituximab off label use for difficult-to-treat auto-immune diseases: reappraisal of benefits and risks. Clin Rev Allergy Immunol. 2008 Feb. 34(1):103-10. [Medline].
Stasi R, Stipa E, Forte V, Meo P, Amadori S. Variable patterns of response to rituximab treatment in adults with chronic idiopathic thrombocytopenic purpura. Blood. 2002 May 15. 99(10):3872-3. [Medline]. [Full Text].