Clinical Commander

All dossiers
heme.itp.chronic.v1

Immune Thrombocytopenia (chronic, outpatient)

hematologychronicadultpediatricoutpatienttransition
Start encounter →Print handoutPRODUCTION

Scaffold manifest only. No design brief, no problem package, no atoms. Sources workup: workup.itp_standalone. Receives chronic-phase transition from heme.itp.core.v1 (INTEGRATED) — author pass should mirror its second-line axis.

Entry points (2)

  • problem_list
    ITP persisting >12 months on problem list (ASH 2019 Neunert; Provan 2019 international consensus)
    chronic_itp
  • lab_abnormality
    Persistent platelet <100k after first-line failed (ASH 2019 Neunert)
    persistent_thrombocytopenia

Required inputs (4)

  • agerequired
    demographic • used at CONTEXT
    Pediatric considerations + TPO-RA dosing (ASH 2019 Neunert; Provan 2019)
  • platelet_countrequired
    lab • used at CONTEXT
    Trends drive dose adjustment (ASH 2019 Neunert)
  • first_line_responserequired
    history • used at CONTEXT
    Steroid response, IVIG response history (ASH 2019 Neunert)
  • thrombosis_risk
    history • used at CONTEXT
    TPO-RA thrombosis risk modifier (ASH 2019 Neunert; BSH 2024)

12-phase flow (12)

  1. 1FRAME
    Confirm chronic ITP (>12m) and exclude evolved secondary cause (ASH 2019 Neunert; Provan 2019 international consensus)
    inputs: platelet_count
    advance: Chronic ITP confirmed (ASH 2019 Neunert; Provan 2019)
  2. 2ENTRY
    Triggered from heme.itp.core.v1 transition or de novo chronic presentation (ASH 2019 Neunert)
    advance: Patient routed (ASH 2019 Neunert)
  3. 3CONTEXT
    Capture prior treatment history, comorbidities, vaccination status, thrombosis risk (ASH 2019 Neunert; BSH 2024)
    inputs: first_line_response, thrombosis_risk
    advance: Treatment history complete (ASH 2019 Neunert; BSH 2024)
  4. 4RED_FLAGS
    Major bleeding; thrombosis on TPO-RA; LFT derangement on eltrombopag/fostamatinib; severe steroid toxicity (ASH 2019 Neunert; BSH 2024)
    advance: Stable (ASH 2019 Neunert; BSH 2024)
  5. 5INITIAL_WORKUP
    Routine CBC + diff + LFTs (if on TPO-RA/fostamatinib); reassess secondary causes if therapy failing (ASH 2019 Neunert; Provan 2019)
    inputs: platelet_count
    actions: panel.cbc
    advance: Baseline trending established (ASH 2019 Neunert)
  6. 6BRANCHING_WORKUP
    BM biopsy if refractory; ANA/SLE workup; consider iTTP if MAHA features (ASH 2019 Neunert; Provan 2019)
    advance: Refractory etiology resolved (ASH 2019 Neunert; Provan 2019)
  7. 7DIFFERENTIAL
    Persistent primary ITP / unrecognized secondary (CVID, lupus, lymphoproliferative) / Evans / refractory ITP (ASH 2019 Neunert; Provan 2019)
    advance: Subtype reaffirmed (ASH 2019 Neunert; Provan 2019)
  8. 8RISK_STRATIFICATION
    Bleeding burden (ITP-BAT) + thrombosis + treatment-toxicity composite (ASH 2019 Neunert; BSH 2024)
    advance: Risk profile documented (ASH 2019 Neunert; BSH 2024)
  9. 9TREATMENT
    TPO-RA (romiplostim/eltrombopag/avatrombopag) preferred chronic (ASH 2019 Neunert; BSH 2024); rituximab; fostamatinib (FIT/FLIGHT Bussel 2018); splenectomy reserved (ASH 2019); emerging: rilzabrutinib (LUNA 3 NEJM 2024), efgartigimod (ADVANCE Lancet 2023)
    advance: Maintenance plan executed (ASH 2019 Neunert; BSH 2024)
  10. 10DISPOSITION
    Hem clinic with frequency by stability; transition to primary care once stable (ASH 2019 Neunert)
    advance: Disposition set (ASH 2019 Neunert)
  11. 11MONITORING
    Plt q1-4w by stability; LFTs on eltrombopag/fostamatinib; BP on fostamatinib; thrombosis surveillance on TPO-RA (ASH 2019 Neunert; BSH 2024)
    inputs: platelet_count
    actions: panel.cbc
    advance: Cadence documented (ASH 2019 Neunert; BSH 2024)
  12. 12FOLLOWUP
    Vaccinations (encapsulated organisms if splenectomy planned) (ASH 2019 Neunert), pregnancy planning (Provan 2019), dental procedures plan
    advance: Long-term plan documented (ASH 2019 Neunert; Provan 2019)