Immune thrombocytopenia

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Section editor
Benjamin Tillman, MD
Vanderbilt University
Nashville, TN, USA
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Are you looking for a regimen but can't find it here? For placebo or observational studies in this condition, please visit this page. If you still can't find it, please let us know so we can add it!.

  • We have moved How I Treat articles to a dedicated page.
Last updated on 2024-07-23:
22 regimens on this page
32 variants on this page


Guidelines

Given the rapid change in evidence in many areas of hematology/oncology, readers are encouraged to consider any guideline published 5+ years ago to be for historical purposes, only.

ASH


BSH


Initial therapy

Dexamethasone monotherapy

Regimen variant #1

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Cheng et al. 2003 1997-01 to 2000-12 Phase 2
Wei et al. 2015 (ITP-002) 2011-01 to 2014-05 Phase 3 (E-esc) Prednisone Superior CR rate (co-primary endpoint)

Immunosuppressive therapy

4-day course

Subsequent treatment

  • ITP-002, if platelets remained below 30 x 109/L or bleeding by day 10, course is repeated once
  • Cheng et al. 2003, patients who had an initial response, but whose platelets dropped below 30 x 109/L within 6 months received: Dexamethasone & Prednisone

Regimen variant #2, bi-weekly dexamethasone

Study Dates of enrollment Evidence
Mazzucconi et al. 2007 1996-02 to 2000-06 Phase 2

Immunosuppressive therapy

  • Dexamethasone (Decadron) by the following age-based criteria:
    • 15 years old or older: 40 mg IV or PO once per day on days 1 to 4
    • Younger than 15 years old: 20 mg/m2 (maximum dose of 40 mg) IV or PO once per day on days 1 to 4
  • Dexamethasone (Decadron) by the following response-based criteria:
    • Patients who had platelet counts of less than or equal to 30 x 109/L between cycles and/or who had bleeding related to thrombocytopenia: 0.035 mg/kg PO once per day "between courses"

14-day cycle for 4 cycles

References

  1. Cheng Y, Wong RS, Soo YO, Chui CH, Lau FY, Chan NP, Wong WS, Cheng G. Initial treatment of immune thrombocytopenic purpura with high-dose dexamethasone. N Engl J Med. 2003 Aug 28;349(9):831-6. link to original article dosing details in manuscript have been reviewed by our editors PubMed content property of HemOnc.org
  2. Mazzucconi MG, Fazi P, Bernasconi S, De Rossi G, Leone G, Gugliotta L, Vianelli N, Avvisati G, Rodeghiero F, Amendola A, Baronci C, Carbone C, Quattrin S, Fioritoni G, D'Alfonso G, Mandelli F; Gruppo Italiano Malattie EMatologiche dell'Adulto (GIMEMA) Thrombocytopenia Working Party. 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. Epub 2006 Oct 31. link to original article dosing details in manuscript have been reviewed by our editors PubMed
  3. ITP-002: Wei Y, Ji XB, Wang YW, Wang JX, Yang EQ, Wang ZC, Sang YQ, Bi ZM, Ren CA, Zhou F, Liu GQ, Peng J, Hou M. High-dose dexamethasone vs prednisone for treatment of adult immune thrombocytopenia: a prospective multicenter randomized trial. Blood. 2016 Jan 21;127(3):296-302. Epub 2015 Oct 19. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT01356511


Dexamethasone & Eltrombopag

Regimen

Study Dates of enrollment Evidence
Gómez-Almaguer et al. 2014 (HE12-010) 2012-06 to 2013-07 Pilot, fewer than 20 pts reported

Immunosuppressive therapy

Growth factor therapy

5-week course

References

  1. HE12-010: Gómez-Almaguer D, Herrera-Rojas MA, Jaime-Pérez JC, Gómez-De León A, Cantú-Rodríguez OG, Gutiérrez-Aguirre CH, Tarín-Arzaga L, Hernández-Reyes J, Ruiz-Arguelles GJ. Eltrombopag and high-dose dexamethasone as frontline treatment of newly diagnosed immune thrombocytopenia in adults. Blood. 2014 Jun 19;123(25):3906-8. Epub 2014 May 6. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT01652599


Dexamethasone & Mycophenolate mofetil

Regimen

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Bradbury et al. 2021 (FLIGHT) 2017-10-25 to 2019-02-15 Phase 3 (E-esc) 1a. Dexamethasone
1b. Prednisolone 		Superior treatment failure (primary endpoint)

Immunosuppressive therapy

References

  1. FLIGHT: Bradbury CA, Pell J, Hill Q, Bagot C, Cooper N, Ingram J, Breheny K, Kandiyali R, Rayment R, Evans G, Talks K, Thomas I, Greenwood R. Mycophenolate Mofetil for First-Line Treatment of Immune Thrombocytopenia. N Engl J Med. 2021 Sep 2;385(10):885-895. link to original article PubMed NCT03156452


Dexamethasone & Prednisone

Regimen variant #1

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Matschke et al. 2016 (EIS 2002) Not reported in abstract Phase 3 (E-esc) Prednisone Seems to have superior responding patients maintaining remission for at least 6 mo (secondary endpoint)

Immunosuppressive therapy

7-day course, then 21-day cycle for 6 cycles


Regimen variant #2

Study Dates of enrollment Evidence
Cheng et al. 2003 1997-01 to 2000-12 Phase 2

Preceding treatment

Immunosuppressive therapy

Indefinite course


Regimen variant #3, monthly dexamethasone

Study Dates of enrollment Evidence
Mazzucconi et al. 2007 1996-02 to 2000-06 Phase 2

Immunosuppressive therapy

  • Dexamethasone (Decadron) 40 mg PO once per day on days 1 to 4
  • Prednisone (Sterapred) by the following response-based criteria:
    • Patients who had platelet counts of less than or equal to 20 x 109/L between cycles: 0.25 mg/kg PO once per day "between courses"

28-day cycle for 6 cycles


References

  1. Cheng Y, Wong RS, Soo YO, Chui CH, Lau FY, Chan NP, Wong WS, Cheng G. Initial treatment of immune thrombocytopenic purpura with high-dose dexamethasone. N Engl J Med. 2003 Aug 28;349(9):831-6. link to original article dosing details in manuscript have been reviewed by our editors PubMed content property of HemOnc.org
  2. Mazzucconi MG, Fazi P, Bernasconi S, De Rossi G, Leone G, Gugliotta L, Vianelli N, Avvisati G, Rodeghiero F, Amendola A, Baronci C, Carbone C, Quattrin S, Fioritoni G, D'Alfonso G, Mandelli F; Gruppo Italiano Malattie EMatologiche dell'Adulto (GIMEMA) Thrombocytopenia Working Party. 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. Epub 2006 Oct 31. link to original article dosing details in manuscript have been reviewed by our editors PubMed
  3. EIS 2002: Matschke J, Müller-Beissenhirtz H, Novotny J, Vester I, Hertenstein B, Eisele L, Lax H, Ose C, Dührsen U. A Randomized Trial of Daily Prednisone versus Pulsed Dexamethasone in Treatment-Naïve Adult Patients with Immune Thrombocytopenia: EIS 2002 Study. Acta Haematol. 2016;136(2):101-7. Epub 2016 May 19. link to original article PubMed


Dexamethasone & Rituximab

Regimen ("R+3Dex")

Study Evidence
Imahiyerobo et al. 2013 Retrospective

Immunosuppressive therapy

14-day cycle for 3 cycles

References

  1. Abstract: Retrospective: Allison Imahiyerobo, Micha Thompson, Marina Izak Karaev, Waleed Ghanima, James B Bussel. Rituximab Combined With Three Cycles Of High Dose Dexamethasone Provides a Long Term Response Rate Similar To That Of Splenectomy In Patients With Immune Thrombocytopenia (ITP) Of Duration Less Than 2 Years. Blood Nov 2013,122(21)2310. link to abstract


Intravenous immunoglobulin monotherapy

IVIG: IntraVenous ImmunoGlobulin

Regimen

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Godeau et al. 1999 Not reported Phase 3 (E-esc) IVIG; 0.5 g/kg Superior response rate

Supportive therapy

One dose

References

  1. Imbach P, Wagner HP, Berchtold W, Gaedicke G, Hirt A, Joller P, Mueller-Eckhardt C, Müller B, Rossi E, Barandun S. Intravenous immunoglobulin versus oral corticosteroids in acute immune thrombocytopenic purpura in childhood. Lancet. 1985 Aug 31;2(8453):464-8. link to original article PubMed
  2. Blanchette VS, Luke B, Andrew M, Sommerville-Nielsen S, Barnard D, de Veber B, Gent M. A prospective, randomized trial of high-dose intravenous immune globulin G therapy, oral prednisone therapy, and no therapy in childhood acute immune thrombocytopenic purpura. J Pediatr. 1993 Dec;123(6):989-95. link to original article PubMed
  3. Blanchette V, Imbach P, Andrew M, Adams M, McMillan J, Wang E, Milner R, Ali K, Barnard D, Bernstein M, Esseltine D, Chan KW, de Veber B, Israels S, Kobrinsky N, Luke B. Randomised trial of intravenous immunoglobulin G, intravenous anti-D, and oral prednisone in childhood acute immune thrombocytopenic purpura. Lancet. 1994 Sep 10;344(8924):703-7. link to original article PubMed
  4. Godeau B, Caulier MT, Decuypere L, Rose C, Schaeffer A, Bierling P. Intravenous immunoglobulin for adults with autoimmune thrombocytopenic purpura: results of a randomized trial comparing 05 and 1 g/kg bw. Br J Haematol. 1999 Dec;107(4):716-9. link to original article dosing details in abstract have been reviewed by our editors PubMed
  5. Godeau B, Chevret S, Varet B, Lefrère F, Zini JM, Bassompierre F, Chèze S, Legouffe E, Hulin C, Grange MJ, Fain O, Bierling P; French ATIP Study Group. Intravenous immunoglobulin or high-dose methylprednisolone, with or without oral prednisone, for adults with untreated severe autoimmune thrombocytopenic purpura: a randomised, multicentre trial. Lancet. 2002 Jan 5;359(9300):23-9. link to original article PubMed
  6. TIKI: Heitink-Pollé KMJ, Uiterwaal CSPM, Porcelijn L, Tamminga RYJ, Smiers FJ, van Woerden NL, Wesseling J, Vidarsson G, Laarhoven AG, de Haas M, Bruin MCA; TIKI Investigators. Intravenous immunoglobulin vs observation in childhood immune thrombocytopenia: a randomized controlled trial. Blood. 2018 Aug 30;132(9):883-891. Epub 2018 Jun 26. link to original article PubMed NTR 1563


Mycophenolate mofetil & Prednisolone

Regimen

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Bradbury et al. 2021 (FLIGHT) 2017-10-25 to 2019-02-15 Phase 3 (E-esc) 1a. Dexamethasone
1b. Prednisolone 		Superior treatment failure (primary endpoint)

Immunosuppressive therapy

References

  1. FLIGHT: Bradbury CA, Pell J, Hill Q, Bagot C, Cooper N, Ingram J, Breheny K, Kandiyali R, Rayment R, Evans G, Talks K, Thomas I, Greenwood R. Mycophenolate Mofetil for First-Line Treatment of Immune Thrombocytopenia. N Engl J Med. 2021 Sep 2;385(10):885-895. link to original article PubMed NCT03156452


Prednisone monotherapy

Regimen variant #1

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Wei et al. 2015 (ITP-002) 2011-01 to 2014-05 Phase 3 (C) Dexamethasone Inferior CR rate

Immunosuppressive therapy

  • Prednisone (Sterapred) 1 mg/kg/day PO on days 1 to 28, then tapered over 4 to 6 weeks with a goal of maintenance dosing less than 15 mg/day or "complete termination"
    • Taper schedule determined by treating physician

8- to 10-week course


Regimen variant #2

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Matschke et al. 2016 (EIS 2002) Not reported in abstract Phase 3 (C) Dexamethasone Seems to have inferior responding patients maintaining remission for at least 6 mo

Immunosuppressive therapy

  • Prednisone (Sterapred) as follows:
    • Weeks 1 to 2: 1 mg/kg/day PO
    • Weeks 3 to 19: Tapered over 19 weeks with a goal of maintenance dosing less than 7.5 mg/day at the end of week 19

19-week course

References

  1. Blanchette VS, Luke B, Andrew M, Sommerville-Nielsen S, Barnard D, de Veber B, Gent M. A prospective, randomized trial of high-dose intravenous immune globulin G therapy, oral prednisone therapy, and no therapy in childhood acute immune thrombocytopenic purpura. J Pediatr. 1993 Dec;123(6):989-95. link to original article PubMed
  2. Blanchette V, Imbach P, Andrew M, Adams M, McMillan J, Wang E, Milner R, Ali K, Barnard D, Bernstein M, Esseltine D, Chan KW, de Veber B, Israels S, Kobrinsky N, Luke B. Randomised trial of intravenous immunoglobulin G, intravenous anti-D, and oral prednisone in childhood acute immune thrombocytopenic purpura. Lancet. 1994 Sep 10;344(8924):703-7. link to original article PubMed
  3. ITP-002: Wei Y, Ji XB, Wang YW, Wang JX, Yang EQ, Wang ZC, Sang YQ, Bi ZM, Ren CA, Zhou F, Liu GQ, Peng J, Hou M. High-dose dexamethasone vs prednisone for treatment of adult immune thrombocytopenia: a prospective multicenter randomized trial. Blood. 2016 Jan 21;127(3):296-302. Epub 2015 Oct 19. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT01356511
  4. EIS 2002: Matschke J, Müller-Beissenhirtz H, Novotny J, Vester I, Hertenstein B, Eisele L, Lax H, Ose C, Dührsen U. A Randomized Trial of Daily Prednisone versus Pulsed Dexamethasone in Treatment-Naïve Adult Patients with Immune Thrombocytopenia: EIS 2002 Study. Acta Haematol. 2016;136(2):101-7. Epub 2016 May 19. link to original article PubMed


RhIG monotherapy

RhIG: Rho(D) Immune Globulin

Regimen variant #1, 25 mcg/kg

Study Dates of enrollment Evidence
Bussel et al. 1991 Not reported Phase 2

Eligibility criteria

  • RhD-positive

Supportive therapy

4-day course


Regimen variant #2, 50 mcg/kg

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Newman et al. 2001 Not reported Randomized Phase 2, fewer than 20 pts (C) Rho(D); 75 mcg/kg Seems to have inferior platelet effect

Eligibility criteria

  • RhD-positive, adult, HIV-negative, non-splenectomized, platelet count less than or equal to 30 x 109/L

Supportive therapy

Supportive therapy

One dose; can be repeated if required to increase platelet count


Regimen variant #3, 75 mcg/kg

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Newman et al. 2001 Not reported Randomized Phase 2, fewer than 20 pts (E-esc) Rho(D); 50 mcg/kg Seems to have superior platelet effect

Eligibility criteria

  • RhD-positive, adult, HIV-negative, non-splenectomized, platelet count less than or equal to 30 x 109/L

Supportive therapy

Supportive therapy

One dose; can be repeated if required to increase platelet count

References

  1. Bussel JB, Graziano JN, Kimberly RP, Pahwa S, Aledort LM. Intravenous anti-D treatment of immune thrombocytopenic purpura: analysis of efficacy, toxicity, and mechanism of effect. Blood. 1991 May 1;77(9):1884-93. link to original article dosing details in manuscript have been reviewed by our editors PubMed
  2. Newman GC, Novoa MV, Fodero EM, Lesser ML, Woloski BM, Bussel JB. A dose of 75 microg/kg/day of iv anti-D increases the platelet count more rapidly and for a longer period of time than 50 microg/kg/day in adults with immune thrombocytopenic purpura. Br J Haematol. 2001 Mar;112(4):1076-8. link to original article dosing details in manuscript have been reviewed by our editors PubMed


TT4

TT4: Triple Therapy (4?)

Regimen

Study Dates of enrollment Evidence
Choi et al. 2015 Not reported Phase 2b

Note: The authors do not specify whether modified or non-modified cyclosporine was used in this protocol. Please contact them for clarifications.

Immunosuppressive therapy

28-day course

Dose and schedule modifications

  • Cyclosporine dose adjusted for target trough of 200 to 400 mcg/L

References

  1. Choi PY, Roncolato F, Badoux X, Ramanathan S, Ho SJ, Chong BH. A novel triple therapy for ITP using high-dose dexamethasone, low-dose rituximab, and cyclosporine (TT4). Blood. 2015 Jul 23;126(4):500-3. Epub 2015 May 13. link to original article dosing details in manuscript have been reviewed by our editors link to PMC article PubMed ANZCTRN 12611000015943


Relapsed or refractory

ATRA & Danazol

Regimen

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Feng et al. 2017 (U1111-1132-6877) 2012-06-01 to 2016-07-01 Randomized Phase 2 (E-esc) Danazol Superior 12-month sustained response (primary endpoint)

Targeted therapy

Endocrine therapy

16-week course

References

  1. U1111-1132-6877: Feng FE, Feng R, Wang M, Zhang JM, Jiang H, Jiang Q, Lu J, Liu H, Peng J, Hou M, Shen JL, Wang JW, Xu LP, Liu KY, Huang XJ, Zhang XH. Oral all-trans retinoic acid plus danazol versus danazol as second-line treatment in adults with primary immune thrombocytopenia: a multicentre, randomised, open-label, phase 2 trial. Lancet Haematol. 2017 Oct;4(10):e487-e496. Epub 2017 Sep 13. link to original article dosing details in abstract have been reviewed by our editors PubMed NCT01667263


Avatrombopag monotherapy

Regimen

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Bussel et al. 2014 (AKR-501-CL-003) Not reported Phase 2
Bussel et al. 2014 (AKR-501-CL-004) Not reported Phase 2
Jurczak et al. 2018 (E5501-G000-302) 2012-02-06 to 2015-04-09 Phase 3 (E-esc) Placebo Superior cumulative weeks of platelet response without rescue therapy for bleeding (primary endpoint)

Growth factor therapy

Continued indefinitely

References

  1. AKR-501-CL-003: Bussel JB, Kuter DJ, Aledort LM, Kessler CM, Cuker A, Pendergrass KB, Tang S, McIntosh J. A randomized trial of avatrombopag, an investigational thrombopoietin-receptor agonist, in persistent and chronic immune thrombocytopenia. Blood. 2014 Jun 19;123(25):3887-94. Epub 2014 May 6. link to original article PubMed NCT00441090
  2. AKR-501-CL-004: Bussel JB, Kuter DJ, Aledort LM, Kessler CM, Cuker A, Pendergrass KB, Tang S, McIntosh J. A randomized trial of avatrombopag, an investigational thrombopoietin-receptor agonist, in persistent and chronic immune thrombocytopenia. Blood. 2014 Jun 19;123(25):3887-94. Epub 2014 May 6. link to original article PubMed NCT00625443
  3. E5501-G000-302: Jurczak W, Chojnowski K, Mayer J, Krawczyk K, Jamieson BD, Tian W, Allen LF. Phase 3 randomised study of avatrombopag, a novel thrombopoietin receptor agonist for the treatment of chronic immune thrombocytopenia. Br J Haematol. 2018 Nov;183(3):479-490. Epub 2018 Sep 7. link to original article link to PMC article dosing details in manuscript have been reviewed by our editors PubMed NCT01438840


Cyclosporine monotherapy

Regimen

Study Dates of enrollment Evidence
Emilia et al. 2002 Not reported Pilot, fewer than 20 pts

Note: The authors do not specify whether modified or non-modified cyclosporine was used in this protocol. Please contact them for clarifications.

Immunosuppressive therapy

  • Cyclosporine A as follows:
    • Days 1 to 6: 5 mg/kg/day PO split into twice per day dosing
    • Day 7 onwards: 2.5 to 3 mg/kg/day PO with dose adjusted for target trough of 200 to 400 mcg/L

References

  1. Emilia G, Morselli M, Luppi M, Longo G, Marasca R, Gandini G, Ferrara L, D'Apollo N, Potenza L, Bertesi M, Torelli G. Long-term salvage therapy with cyclosporin A in refractory idiopathic thrombocytopenic purpura. Blood. 2002 Feb 15;99(4):1482-5. link to original article dosing details in manuscript have been reviewed by our editors PubMed


Danazol monotherapy

Regimen

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Ahn et al. 1983 Not reported Pilot, >20 pts
Feng et al. 2017 (U1111-1132-6877) 2012-06-01 to 2016-07-01 Randomized Phase 2 (C) ATRA & Danazol Inferior 12-month sustained response

Note: Ahn et al. 1983 gave a range of 200 mg PO from two to four times per day; the dose below is from U1111-1132-6877

Endocrine therapy

16-week course

References

  1. Ahn YS, Harrington WJ, Simon SR, Mylvaganam R, Pall LM, So AG. Danazol for the treatment of idiopathic thrombocytopenic purpura. N Engl J Med. 1983 Jun 9;308(23):1396-9. link to original article dosing details in manuscript have been reviewed by our editors PubMed
  2. U1111-1132-6877: Feng FE, Feng R, Wang M, Zhang JM, Jiang H, Jiang Q, Lu J, Liu H, Peng J, Hou M, Shen JL, Wang JW, Xu LP, Liu KY, Huang XJ, Zhang XH. Oral all-trans retinoic acid plus danazol versus danazol as second-line treatment in adults with primary immune thrombocytopenia: a multicentre, randomised, open-label, phase 2 trial. Lancet Haematol. 2017 Oct;4(10):e487-e496. Epub 2017 Sep 13. link to original article dosing details in abstract have been reviewed by our editors PubMed NCT01667263


Dexamethasone monotherapy

Regimen

Study Dates of enrollment Evidence
Andersen 1994 Not reported Pilot, fewer than 20 pts

Immunosuppressive therapy

28-day cycles for 6 cycles

References

  1. Andersen JC. Response of resistant idiopathic thrombocytopenic purpura to pulsed high-dose dexamethasone therapy. N Engl J Med. 1994 Jun 2;330(22):1560-4. link to original article dosing details in manuscript have been reviewed by our editors PubMed


Dexamethasone & Rituximab

Regimen ("R+3Dex")

Study Evidence
Imahiyerobo et al. 2013 Retrospective

Immunosuppressive therapy

14-day cycle for 3 cycles

References

  1. Abstract: Allison Imahiyerobo, Micha Thompson, Marina Izak Karaev, Waleed Ghanima, James B Bussel. Rituximab Combined With Three Cycles Of High Dose Dexamethasone Provides a Long Term Response Rate Similar To That Of Splenectomy In Patients With Immune Thrombocytopenia (ITP) Of Duration Less Than 2 Years. Blood Nov 2013,122(21)2310. link to abstract


Eltrombopag monotherapy

Regimen variant #1

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Grainger et al. 2015 (PETIT2) 2012-03-15 to 2014-01-02 Phase 3 (E-esc) Placebo Superior durable platelet response (primary endpoint)

Note: This regimen was intended for pediatric patients.

Growth factor therapy

  • Eltrombopag (Promacta) with starting dose by the following age-, race-, and weight-based criteria:
    • 6 to 17 years old AND 27 kg or more AND NOT East Asian: 50 mg PO once per day
    • 6 to 17 years old AND 27 kg or more AND East Asian: 25 mg PO once per day
    • 6 to 17 years old AND less than 27 kg AND NOT East Asian: 37.5 mg PO once per day
    • 6 to 17 years old AND less than 27 kg AND East Asian: 25 mg PO once per day
    • 1 to 5 years old AND NOT East Asian: 1.2 mg/kg/day PO (oral suspension)
    • 1 to 5 years old AND East Asian: 0.8 mg/kg/day PO (oral suspension)

Continued indefinitely

Dose and schedule modifications

  • Dose adjusted to a maximum of 75 mg/day, with temporary discontinuation for platelet count greater than 400 x 109/L

Regimen variant #2

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Bussel et al. 2009 (TRA100773) 2006-02-06 to 2006-04-17 Phase 3 (E-esc) Placebo Superior plt count of greater than or equal to 50 x 109/L on day 43 (primary endpoint)
Saleh et al. 2012 (EXTEND) 2006-06 to not reported Phase 2

Growth factor therapy

Continued indefinitely

Dose and schedule modifications

  • TRA100773: The dose could be increased from 50 mg to 75 mg after 3 weeks in patients whose platelet counts were less than 50 x 109/L. Treatment was discontinued in patients who attained a platelet count greater than 200 x 109/L
  • EXTEND: Dose and schedule were individualized with the goal of achieving and maintaining platelets between 50 and 200 x 109/L

Regimen variant #3

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Cheng et al. 2010 (RAISE-ITP) 2006-11-22 to 2007-07-31 Phase 3 (E-esc) Placebo Superior RR (primary endpoint)

Note: this trial should not be confused with the trial by the same name in colorectal cancer.

Growth factor therapy

6-month course

Dose and schedule modifications

  • Increase to 75 mg PO once per day allowed after day 22 for patients with platelet counts lower than 50 x 109/L
  • Decrease to 25 mg PO once per day required for platelets counts between 200 and 400 x 109/L
  • Drug was held for platelet count greater than 400 x 109/L, until platelet count dropped below 150 x 109/L

Regimen variant #4

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Bussel et al. 2007 (TRA100773 phase 2) 2005-02 to 2005-11 Randomized Phase 2 (E-esc) Placebo Superior RR (secondary endpoint)

Growth factor therapy

Up to 6-week course

References

  1. TRA100773 phase 2: Bussel JB, Cheng G, Saleh MN, Psaila B, Kovaleva L, Meddeb B, Kloczko J, Hassani H, Mayer B, Stone NL, Arning M, Provan D, Jenkins JM. Eltrombopag for the treatment of chronic idiopathic thrombocytopenic purpura. N Engl J Med. 2007 Nov 29;357(22):2237-47. link to original article PubMed NCT00102739
  2. TRA100773: Bussel JB, Provan D, Shamsi T, Cheng G, Psaila B, Kovaleva L, Salama A, Jenkins JM, Roychowdhury D, Mayer B, Stone N, Arning M. Effect of eltrombopag on platelet counts and bleeding during treatment of chronic idiopathic thrombocytopenic purpura: a randomised, double-blind, placebo-controlled trial. Lancet. 2009 Feb 21;373(9664):641-8. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT00102739
  3. RAISE-ITP: Cheng G, Saleh MN, Marcher C, Vasey S, Mayer B, Aivado M, Arning M, Stone NL, Bussel JB. Eltrombopag for management of chronic immune thrombocytopenia (RAISE): a 6-month, randomised, phase 3 study. Lancet. 2011 Jan 29;377(9763):393-402. Epub 2010 Aug 23. Erratum in: Lancet. 2011 Jan 29;377(9763):382. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT00370331
  4. EXTEND: Saleh MN, Bussel JB, Cheng G, Meyer O, Bailey CK, Arning M, Brainsky A; EXTEND Study Group. Safety and efficacy of eltrombopag for treatment of chronic immune thrombocytopenia: results of the long-term, open-label EXTEND study. Blood. 2013 Jan 17;121(3):537-45. Epub 2012 Nov 20. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT00351468
  5. PETIT2: Grainger JD, Locatelli F, Chotsampancharoen T, Donyush E, Pongtanakul B, Komvilaisak P, Sosothikul D, Drelichman G, Sirachainan N, Holzhauer S, Lebedev V, Lemons R, Pospisilova D, Ramenghi U, Bussel JB, Bakshi KK, Iyengar M, Chan GW, Chagin KD, Theodore D, Marcello LM, Bailey CK. Eltrombopag for children with chronic immune thrombocytopenia (PETIT2): a randomised, multicentre, placebo-controlled trial. Lancet. 2015 Oct 24;386(10004):1649-58. Epub 2015 Jul 28. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT01520909
  6. Yang R, Li J, Jin J, Huang M, Yu Z, Xu X, Zhang X, Hou M. Multicentre, randomised phase III study of the efficacy and safety of eltrombopag in Chinese patients with chronic immune thrombocytopenia. Br J Haematol. 2017 Jan;176(1):101-110. link to original article PubMed


Fostamatinib monotherapy

Regimen

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Bussel et al. 2018 (FIT1) 2014-2016 Phase 3 (E-esc) Placebo Superior stable response (primary endpoint)
Bussel et al. 2018 (FIT2) 2015-01 to 2016-08 Phase 3 (E-esc) Placebo Superior stable response (primary endpoint)

Targeted therapy

24-week course

Dose and schedule modifications

  • Dose may be increased to 150 mg PO twice per day after 4 weeks if needed to achieve platelet count of at least 50 x 109/L

References

  1. FIT1: Bussel J, Arnold DM, Grossbard E, Mayer J, Treliński J, Homenda W, Hellmann A, Windyga J, Sivcheva L, Khalafallah AA, Zaja F, Cooper N, Markovtsov V, Zayed H, Duliege AM. Fostamatinib for the treatment of adult persistent and chronic immune thrombocytopenia: results of two phase 3, randomized, placebo-controlled trials. Am J Hematol. 2018 Jul;93(7):921-930. Epub 2018 May 15. link to original article link to PMC article PubMed NCT02076399
  2. FIT2: Bussel J, Arnold DM, Grossbard E, Mayer J, Treliński J, Homenda W, Hellmann A, Windyga J, Sivcheva L, Khalafallah AA, Zaja F, Cooper N, Markovtsov V, Zayed H, Duliege AM. Fostamatinib for the treatment of adult persistent and chronic immune thrombocytopenia: results of two phase 3, randomized, placebo-controlled trials. Am J Hematol. 2018 Jul;93(7):921-930. Epub 2018 May 15. link to original article link to PMC article PubMed NCT02076412
  3. Review: Newland A, Lee EJ, McDonald V, Bussel JB. Fostamatinib for persistent/chronic adult immune thrombocytopenia. Immunotherapy. 2018 Jan;10(1):9-25. link to original article PubMed


Mycophenolate mofetil monotherapy

Regimen

Study Dates of enrollment Evidence
Taylor et al. 2015 1993-2013 Retrospective

Immunosuppressive therapy

Continued indefinitely

References

  1. Retrospective: Taylor A, Neave L, Solanki S, Westwood JP, Terrinonive I, McGuckin S, Kothari J, Cooper N, Stasi R, Scully M. Mycophenolate mofetil therapy for severe immune thrombocytopenia. Br J Haematol. 2015 Nov;171(4):625-30. Epub 2015 Aug 6. link to original article PubMed


Rituximab monotherapy

Regimen

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Godeau et al. 2008 (PTAI) Not reported Phase 2
Ghanima et al. 2015 (RITP) 2006-08-17 to 2011-06-30 Phase 3 (E-esc) Placebo Did not meet primary endpoint of rate of treatment failure within 78 weeks

Patients in PTAI had "ITP lasting 6 or more months before inclusion; at least 1 previous treatment for ITP; and platelet count less than 30 x 109/L at inclusion" and were candidates for splenectomy."

Immunosuppressive therapy

Supportive therapy

  • (per Godeau et al. 2008):
  • Patients received Streptococcus pneumoniae and Haemophilus influenzae vaccination at least 2 weeks before the first dose of rituximab
  • Acetaminophen (Tylenol) 1000 mg once on day 1, given prior to rituximab
  • Methylprednisolone (Solumedrol) 60 mg IV once on day 1, given prior to rituximab

7-day cycle for 4 cycles (4-week course)

References

  1. PTAI: Godeau B, Porcher R, Fain O, Lefrère F, Fenaux P, Cheze S, Vekhoff A, Chauveheid MP, Stirnemann J, Galicier L, Bourgeois E, Haiat S, Varet B, Leporrier M, Papo T, Khellaf M, Michel M, Bierling P. Rituximab efficacy and safety in adult splenectomy candidates with chronic immune thrombocytopenic purpura: results of a prospective multicenter phase 2 study. Blood. 2008 Aug 15;112(4):999-1004. Epub 2008 May 7. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT00225875
  2. Prospective cohort: Patel VL, Mahévas M, Lee SY, Stasi R, Cunningham-Rundles S, Godeau B, Kanter J, Neufeld E, Taube T, Ramenghi U, Shenoy S, Ward MJ, Mihatov N, Patel VL, Bierling P, Lesser M, Cooper N, Bussel JB. Outcomes 5 years after response to rituximab therapy in children and adults with immune thrombocytopenia. Blood. 2012 Jun 21;119(25):5989-95. link to original article dosing details in manuscript have been reviewed by our editors link to PMC article PubMed
  3. RITP: Ghanima W, Khelif A, Waage A, Michel M, Tjønnfjord GE, Romdhan NB, Kahrs J, Darne B, Holme PA; RITP study group. Rituximab as second-line treatment for adult immune thrombocytopenia (the RITP trial): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet. 2015 Apr 25;385(9978):1653-61. Epub 2015 Feb 4. link to original article dosing details in abstract have been reviewed by our editors PubMed NCT00344149


Romiplostim monotherapy

Regimen

Study Dates of enrollment Evidence Comparator Comparative Efficacy
Kuter et al. 2008 (Amgen 20030105) 2005-03-01 to 2006-12-31 Phase 3 (E-esc) Placebo Superior durable platelet response (primary endpoint)
Kuter et al. 2008 (Amgen 20030212) 2005-03-01 to 2006-12-31 Phase 3 (E-esc) Placebo Superior durable platelet response (primary endpoint)
Tarantino et al. 2016 (Amgen 20080279) 2012-01-24 to 2014-09-03 Phase 3 (E-esc) Placebo Superior durable platelet response (primary endpoint)

Patients in Amgen 20030105 had undergone splenectomy. Patients in Amgen 20080279 were younger than 18 years old at time of study entry; see paper for details on dose titration.

Growth factor therapy

7-day cycles

References

  1. Amgen 20030105: Kuter DJ, Bussel JB, Lyons RM, Pullarkat V, Gernsheimer TB, Senecal FM, Aledort LM, George JN, Kessler CM, Sanz MA, Liebman HA, Slovick FT, de Wolf JT, Bourgeois E, Guthrie TH Jr, Newland A, Wasser JS, Hamburg SI, Grande C, Lefrère F, Lichtin AE, Tarantino MD, Terebelo HR, Viallard JF, Cuevas FJ, Go RS, Henry DH, Redner RL, Rice L, Schipperus MR, Guo DM, Nichol JL. Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet. 2008 Feb 2;371(9610):395-403. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT00102323
  2. Amgen 20030212: Kuter DJ, Bussel JB, Lyons RM, Pullarkat V, Gernsheimer TB, Senecal FM, Aledort LM, George JN, Kessler CM, Sanz MA, Liebman HA, Slovick FT, de Wolf JT, Bourgeois E, Guthrie TH Jr, Newland A, Wasser JS, Hamburg SI, Grande C, Lefrère F, Lichtin AE, Tarantino MD, Terebelo HR, Viallard JF, Cuevas FJ, Go RS, Henry DH, Redner RL, Rice L, Schipperus MR, Guo DM, Nichol JL. Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet. 2008 Feb 2;371(9610):395-403. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT00102336
  3. Amgen 20080279: Tarantino MD, Bussel JB, Blanchette VS, Despotovic J, Bennett C, Raj A, Williams B, Beam D, Morales J, Rose MJ, Carpenter N, Nie K, Eisen M. Romiplostim in children with immune thrombocytopenia: a phase 3, randomised, double-blind, placebo-controlled study. Lancet. 2016 Jul 2;388(10039):45-54. Epub 2016 Apr 18. link to original article dosing details in manuscript have been reviewed by our editors PubMed NCT01444417


Vinblastine-loaded platelets

Regimen

Study Dates of enrollment Evidence Efficacy
Ahn et al. 1978 Not reported Phase 1 CR in 6 of 11 patients

References

  1. Phase 1: Ahn YS, Byrnes JJ, Harrington WJ, Cayer ML, Smith DS, Brunskill DE, Pall LM. The treatment of idiopathic thrombocytopenia with vinblastine-loaded platelets. N Engl J Med. 1978 May 18;298(20):1101-7. link to original article PubMed


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