Immune Thrombocytopenia (ITP)

Disclaimer

These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Introduction

Immune Thrombocytopenia (ITP) is a condition of isolated thrombocytopenia caused by immune mediated destruction of platelets typically presenting in children aged 2 to 10 years of age.

ITP is a diagnosis of exclusion with the need for a thorough examination, history and blood film review prior to diagnosis. Majority of newly diagnosed (<3 months) ITP is self-limiting, with platelets spontaneously normalising within six months. However approximately 20% of patients may develop chronic (>6 months) ITP and require ongoing haematology follow up.

Patients typically present with cutaneous signs (petechiae and bruising) and less commonly mucosal bleeding (haematuria or epistaxis). Intracranial haemorrhage is a rare, but serious complication of ITP associated with significant mortality and morbidity.

If patients are well with no to minimal bleeding symptoms, they may be managed conservatively (watch and wait approach). Treatment with corticosteroids or intravenous immunoglobulin (IVIg) often has transient effects on platelet counts, and is not indicated unless there is evidence of bleeding.

Pre-referral investigations

FBP with film review for acute ITP is required.

Pre-referral management

Please ensure that the patient is safe and there is no active bleeding, no matter how minimal.
Education with the family to avoid contact sport, NSAIDS, aspirin or activities that place the child at risk of head injury.
Educate the family of potential bleeding complications of ITP and when to see advice. It is important that the family have access to a 24hour medical service, and if they live remotely, have a treatment plan for bleeding complications.
Provide family with Immune Thrombocytopenia - Health Fact sheet (PDF)

When to refer

All patients with ITP should be referred to PCH.

Newly diagnosed (<3 months) ITP should be referred to the general paediatric team, unless there is significant bleeding or ‘atypical’ features*. The general paediatric team should be contacted by phone to discuss the case, as immediate follow up is required.

Chronic ITP (>4-6 months) can be referred to haematology via outpatient referral given they are well. Haematology on call should be contacted if the patient has ‘atypical’ features or significant bleeding.

*Atypical features include abnormal examination (joint swelling or organomegaly, etc), abnormal laboratory indices apart from thrombocytopenia or other concerns.

How to refer

Routine non-urgent referrals from a GP or a Consultant are made via the Central Referral Service
Routine non-urgent referrals from a nurse practitioner, non-medical referrers or private hospitals are made via the PCH Referral Office (Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au)
Urgent referrals (less than seven days) are made via the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 2222 to discuss referral with the relevant speciality registrar.

Essential information to include in your referral

All relevant diagnostic results and their trends
Specific reason why specialist Haematology review is required.

Useful resources

Rodeghiero F, Stasi R, Gernsheimer T, Michel M, Provan D, Arnold DM, et al. Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009;113(11):2386-93.
Provan D, Arnold DM, Bussel JB, Chong BH, Cooper N, Gernsheimer T, et al. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv. 2019;3(22):3780-817.
Perth Children’s Hospital Emergency Department Guidelines: Immune Thrombocytopaenia
Immune Thrombocytopenia - Health Fact sheet (PDF)

Reviewer/Team:	Tina Carter, HoD Oncology and Haematology	Last reviewed:	Feb 2022
		Review date:	Feb 2025
Endorsed by:	Fast track approval	Date:	Fen 2022

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