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heme.itp.chronic.v1PRODUCTION
heme.itp.chronic.v1

Immune Thrombocytopenia (chronic, outpatient)

hematologychronicadultpediatric
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm chronic ITP (>12m) and exclude evolved secondary cause (ASH 2019 Neunert; Provan 2019 international consensus)

Inputs
1
Actions
0
Advance rule
Set
Advance when

Chronic ITP confirmed (ASH 2019 Neunert; Provan 2019)

Patient inputs (4)

Pediatric considerations + TPO-RA dosing (ASH 2019 Neunert; Provan 2019)

Trends drive dose adjustment (ASH 2019 Neunert)

Steroid response, IVIG response history (ASH 2019 Neunert)

TPO-RA thrombosis risk modifier (ASH 2019 Neunert; BSH 2024)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningmajor_bleeding — ASH 2019
    ICH / GI bleed / pulmonary hemorrhage in chronic ITP (ASH 2019 Neunert)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverethrombosis_on_tpo_ra — ASH 2019
    New DVT/PE/MI/stroke on TPO-RA (ASH 2019 Neunert; BSH 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereeltrombopag_LFT_alert — ASH 2019
    AST/ALT >3x ULN OR bilirubin >2x ULN on eltrombopag/fostamatinib (ASH 2019 Neunert; BSH 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefostamatinib_htn — ASH 2019
    New BP >150/95 on fostamatinib (FIT/FLIGHT Bussel 2018; BSH 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterituximab_pre_vaccinate — ASH 2019
    Planning rituximab — vaccination window (ASH 2019 Neunert; Provan 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepre_splenectomy_bundle — ASH 2019
    Pre-splenectomy planning (ASH 2019 Neunert)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_infection_post_rituximab — ASH 2019
    Recurrent infections + low IgG post-rituximab (Provan 2019; BSH 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Chronic ITP maintenance — TPO-RA / rituximab / fostamatinib / splenectomy (ASH 2019 Neunert; BSH 2024; Provan 2019)
axis: itp_chronic_maintenancestep tpo_ra_first_line - TPO-RA first-line for chronic ITP
Selected step "TPO-RA first-line for chronic ITP" — Chronic ITP (>12 months) with bleeding or plt <30k or impaired QoL (ASH 2019 Neunert; BSH 2024)
  • eltrombopag
    first line
    TPO_RA
    50 mg PO daily (25 mg if East Asian / hepatic impairment) • PO • daily
    triggers: chronic_itp, no_severe_LFT_disease
    RAISE (Cheng Lancet 2011); ASH 2019 Neunert; preferred oral; LFT monitoring; avoid divalent cations within 4 hours
    rxcui 711942
  • romiplostim
    first line
    TPO_RA
    1 mcg/kg SC weekly, titrate to plt 50-200k • SC • weekly
    triggers: chronic_itp, oral_route_not_preferred
    Kuter Lancet 2008; ASH 2019 Neunert; SC route
    rxcui 805452
  • avatrombopag
    first line
    TPO_RA
    20 mg PO daily with food • PO • daily, titrate to 40 mg max
    triggers: chronic_itp, no_food_restrictions
    Jurczak Br J Haematol 2018; BSH 2024; no food restrictions vs eltrombopag
    rxcui 2045726

outpatient playbook — drug actions (4)

  1. 1. eltrombopag/avatrombopag/romiplostim
    Per axis • PO/SC • daily-weekly
    trigger: Chronic ITP needing therapy
    TPO-RA first-line (ASH 2019 Neunert; BSH 2024)
  2. 2. rituximab
    375 mg/m² IV weekly × 4 • IV • q1w × 4
    trigger: TPO-RA failure
    ASH 2019 Neunert; Provan 2019
  3. 3. fostamatinib
    100-150 mg PO BID • PO • BID
    trigger: TPO-RA + rituximab failure
    FIT/FLIGHT (Bussel 2018/2021); BSH 2024
  4. 4. splenectomy
    Laparoscopic • surgical • one-time
    trigger: Multi-drug refractory >12 months
    ASH 2019 Neunert — reserved for refractory >12 months

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: ITP persisting >12 months on problem list (ASH 2019 Neunert; Provan 2019 international consensus); Persistent platelet <100k after first-line failed (ASH 2019 Neunert).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Immune Thrombocytopenia (chronic, outpatient)** (heme.itp.chronic.v1).
Phenotype framing: Persistent primary ITP / unrecognized secondary (CVID, lupus, lymphoproliferative) / Evans / refractory ITP (ASH 2019 Neunert; Provan 2019)
Scope: Confirm chronic ITP (>12m) and exclude evolved secondary cause (ASH 2019 Neunert; Provan 2019 international consensus)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Chronic ITP maintenance — TPO-RA / rituximab / fostamatinib / splenectomy (ASH 2019 Neunert; BSH 2024; Provan 2019)** — step "TPO-RA first-line for chronic ITP".
1. eltrombopag 50 mg PO daily (25 mg if East Asian / hepatic impairment) PO daily (TPO_RA, first line) — RAISE (Cheng Lancet 2011); ASH 2019 Neunert; preferred oral; LFT monitoring; avoid divalent cations within 4 hours
2. romiplostim 1 mcg/kg SC weekly, titrate to plt 50-200k SC weekly (TPO_RA, first line) — Kuter Lancet 2008; ASH 2019 Neunert; SC route
3. avatrombopag 20 mg PO daily with food PO daily, titrate to 40 mg max (TPO_RA, first line) — Jurczak Br J Haematol 2018; BSH 2024; no food restrictions vs eltrombopag

Setting playbook (outpatient) — Maintain hemostatic plt count with lowest-toxicity regimen, prevent bleeding, support QoL (ASH 2019 Neunert; BSH 2024)
4. eltrombopag/avatrombopag/romiplostim Per axis PO/SC daily-weekly — Chronic ITP needing therapy (TPO-RA first-line (ASH 2019 Neunert; BSH 2024))
5. rituximab 375 mg/m² IV weekly × 4 IV q1w × 4 — TPO-RA failure (ASH 2019 Neunert; Provan 2019)
6. fostamatinib 100-150 mg PO BID PO BID — TPO-RA + rituximab failure (FIT/FLIGHT (Bussel 2018/2021); BSH 2024)
7. splenectomy Laparoscopic surgical one-time — Multi-drug refractory >12 months (ASH 2019 Neunert — reserved for refractory >12 months)

Non-pharmacologic actions:
- Avoid antiplatelet/NSAID unless essential (ASH 2019 Neunert; Provan 2019)
- Vaccinations (PCV20, Hib, MenACWY/B, flu, COVID) before rituximab/splenectomy (ASH 2019 Neunert)
- Education on bleeding signs and emergency contact (Provan 2019)
- Pregnancy counseling (Provan 2019)
- Dental hygiene for procedures (Provan 2019)

AVOID / contraindication checks:
- Tpo ra thrombosis risk (ASH 2019 Neunert; BSH 2024)
- Eltrombopag fostamatinib LFT monitoring (ASH 2019 Neunert; BSH 2024)
- Rituximab vaccinate before treatment (ASH 2019 Neunert; Provan 2019)
- Fostamatinib BP monitor (FIT/FLIGHT Bussel 2018; BSH 2024)
- Eltrombopag avoid divalent cations 4h (RAISE Cheng 2011; product label)
- Splenectomy vaccinate pre op (ASH 2019 Neunert)

Monitoring

Regimen monitoring:
- plt q1-4w by stability (ASH 2019 Neunert; BSH 2024)
- LFTs q2-4w on eltrombopag or fostamatinib (ASH 2019 Neunert; BSH 2024)
- BP q1w on fostamatinib (FIT/FLIGHT Bussel 2018; BSH 2024)
- CD19 after rituximab (Provan 2019)
- thrombosis surveillance on TPO RA (ASH 2019 Neunert)
- IgG levels if recurrent infection (Provan 2019; BSH 2024)

Setting (outpatient) monitoring:
- CBC q1-4 weeks by stability (ASH 2019 Neunert; BSH 2024)
- LFTs q2-4 weeks on eltrombopag/fostamatinib (ASH 2019 Neunert; BSH 2024)
- BP q1 week on fostamatinib (FIT/FLIGHT Bussel 2018; BSH 2024)
- Thrombosis surveillance on TPO-RA (ASH 2019 Neunert)

Follow-up plan: Vaccinations (encapsulated organisms if splenectomy planned) (ASH 2019 Neunert), pregnancy planning (Provan 2019), dental procedures plan
- Close-out criterion: Long-term plan documented (ASH 2019 Neunert; Provan 2019)

Monitoring phase: Plt q1-4w by stability; LFTs on eltrombopag/fostamatinib; BP on fostamatinib; thrombosis surveillance on TPO-RA (ASH 2019 Neunert; BSH 2024)

Disposition

Current setting: outpatient — Maintain hemostatic plt count with lowest-toxicity regimen, prevent bleeding, support QoL (ASH 2019 Neunert; BSH 2024)

Disposition criteria:
- Continue current regimen if plt >30k + no bleeding (ASH 2019 Neunert)
- Switch agent if intolerant or refractory after adequate trial (BSH 2024)
- Refer to specialty heme if multi-drug refractory (ASH 2019 Neunert)

Escalation triggers (move to higher acuity):
- Plt <30k + bleeding → ED/inpatient (ASH 2019 Neunert)
- New thrombosis on TPO-RA → hold + workup (ASH 2019 Neunert; BSH 2024)
- LFT >3x ULN → hold drug (ASH 2019 Neunert; BSH 2024)

Patient Action Plan

**Chronic ITP self-management & bleeding action plan**
Personalised values: baseline_platelet_count, current_TPO_RA_dose, last_bleeding_episode, home_BP_target_if_fostamatinib.

**Stable — feeling well** (green):
Triggers:
- 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)
Actions:
- 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)

**Caution — new bruising or bleeding** (yellow):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- Bruising worsening over hours (ASH 2019 Neunert)
- Unable to get medication (BSH 2024)
- Persistent gum or nose bleeding (ASH 2019 Neunert)

**Medical alert — major bleeding** (red):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- Any red zone symptom — go to ED now (ASH 2019 Neunert)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] ICH / GI bleed / pulmonary hemorrhage in chronic ITP (ASH 2019 Neunert)
- [SEVERE] New DVT/PE/MI/stroke on TPO-RA (ASH 2019 Neunert; BSH 2024)
- [SEVERE] AST/ALT >3x ULN OR bilirubin >2x ULN on eltrombopag/fostamatinib (ASH 2019 Neunert; BSH 2024)

Citations

- ASH 2019 ITP Guidelines (Neunert, Blood Adv 2019, PMID 31794604) + BSH 2024 + Provan 2019 international consensus report [PMID:31794604](https://pubmed.ncbi.nlm.nih.gov/31794604/)
- Cited evidence (PMID 18242413) [PMID:18242413](https://pubmed.ncbi.nlm.nih.gov/18242413/)
- Cited evidence (PMID 23361904) [PMID:23361904](https://pubmed.ncbi.nlm.nih.gov/23361904/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ASH 2019 ITP Guidelines (Neunert, Blood Adv 2019, PMID 31794604) + BSH 2024 + Provan 2019 international consensus report — PMID:31794604
  • Cited evidence (PMID 18242413) — PMID:18242413
  • Cited evidence (PMID 23361904) — PMID:23361904