Patient handout

Immune Thrombocytopenia (chronic, outpatient)

PRODUCTION

1. Your condition

This handout is for immune thrombocytopenia (chronic, outpatient). Your care team identified this based on: itp persisting >12 months on problem list (ash 2019 neunert; provan 2019 international consensus).

Other reasons your team may use this plan: persistent platelet <100k after first-line failed (ash 2019 neunert).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
eltrombopag	50 mg PO daily (25 mg if East Asian / hepatic impairment)	PO	daily	RAISE (Cheng Lancet 2011); ASH 2019 Neunert; preferred oral; LFT monitoring; avoid divalent cations within 4 hours
romiplostim	1 mcg/kg SC weekly, titrate to plt 50-200k	SC	weekly	Kuter Lancet 2008; ASH 2019 Neunert; SC route
avatrombopag	20 mg PO daily with food	PO	daily, titrate to 40 mg max	Jurczak Br J Haematol 2018; BSH 2024; no food restrictions vs eltrombopag

Plan: Chronic ITP maintenance — TPO-RA / rituximab / fostamatinib / splenectomy (ASH 2019 Neunert; BSH 2024; Provan 2019)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Stable — feeling well

If you have:

Platelet count >30k at last check (ASH 2019 Neunert treatment threshold)
No new bruises, petechiae, or bleeding (ASH 2019 Neunert)
Taking medications as prescribed (ASH 2019 Neunert)

Do this:

Continue all ITP medications as prescribed (ASH 2019 Neunert)
Avoid NSAIDs (ibuprofen, naproxen, aspirin) (Provan 2019)
Avoid contact sports without provider approval (Provan 2019)
Keep follow-up appointments and lab schedule (ASH 2019 Neunert)
Maintain dental hygiene; inform dentist of ITP (Provan 2019)

YELLOW — Caution — new bruising or bleeding

If you have:

New petechiae or unexplained bruising (ASH 2019 Neunert)
Mild gum bleeding with brushing (Provan 2019)
Heavy menstrual bleeding (ASH 2019 Neunert)
Missed dose of TPO-RA (BSH 2024)
New medication that may affect platelets (ASH 2019 Neunert)

Do this:

Contact ITP/hematology clinic within 24 hours (ASH 2019 Neunert)
Check CBC if home access (ASH 2019 Neunert)
Resume missed dose only after consulting provider (BSH 2024)
Avoid all NSAIDs (Provan 2019)
Hold any new antiplatelet or anticoagulant medications until cleared (ASH 2019 Neunert)

Call your provider if:

Bruising worsening over hours (ASH 2019 Neunert)
Unable to get medication (BSH 2024)
Persistent gum or nose bleeding (ASH 2019 Neunert)

RED — Medical alert — major bleeding

If you have:

Bleeding from gums or nose lasting >20 minutes (ASH 2019 Neunert)
Blood in urine or stool (ASH 2019 Neunert)
Coughing up blood (ASH 2019 Neunert)
Severe headache, confusion, weakness, or vomiting (ASH 2019 Neunert)
Sudden vision changes (ASH 2019 Neunert)
Heavy unexpected bleeding from a wound (ASH 2019 Neunert)

Do this:

Go to ED immediately — do not drive yourself (ASH 2019 Neunert)
Bring complete medication list (ASH 2019 Neunert)
Tell ED you have ITP and last platelet count (ASH 2019 Neunert)
Apply pressure to any external bleeding (ASH 2019 Neunert)
Avoid lying flat if head injury suspected (ASH 2019 Neunert)

Call your provider if:

Any red zone symptom — go to ED now (ASH 2019 Neunert)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

ICH / GI bleed / pulmonary hemorrhage in chronic ITP (ASH 2019 Neunert)(life-threatening)
New DVT/PE/MI/stroke on TPO-RA (ASH 2019 Neunert; BSH 2024)
AST/ALT >3x ULN OR bilirubin >2x ULN on eltrombopag/fostamatinib (ASH 2019 Neunert; BSH 2024)

5. Follow-up

Vaccinations (encapsulated organisms if splenectomy planned) (ASH 2019 Neunert), pregnancy planning (Provan 2019), dental procedures plan

6. Sources

Guideline: ASH 2019 ITP Guidelines (Neunert, Blood Adv 2019, PMID 31794604) + BSH 2024 + Provan 2019 international consensus report