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heme.itp.core.v1PRODUCTION
heme.itp.core.v1

Immune Thrombocytopenia (ITP) — initial diagnosis & acute Rx

hematologyacutesubacuteadultpediatric
Hard-required inputs
0 / 6
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm isolated thrombocytopenia + exclude pseudothrombocytopenia (citrate tube), drug-induced, secondary causes — ASH 2019 Neunert; Provan 2019

Inputs
3
Actions
0
Advance rule
Set
Advance when

Primary ITP diagnosis remains after exclusions

Patient inputs (9)

Pediatric ITP often self-limited (70–80% remit ≤6mo); adult management distinct — ASH 2019 Neunert

Drug-induced ITP (heparin → 4Ts; quinine, vanc, sulfa, etc.) — ASH 2019 Neunert; Provan 2019

Severity tier: <30k high-risk; <10k major bleed risk — ASH 2019 Neunert

Rule out other cytopenias (Evans, MDS, leukemia, aplastic) — ASH 2019 Neunert; BSH 2024

Rule out pseudothrombocytopenia, schistocytes (TTP/HUS), blasts — ASH 2019 Neunert; Provan 2019

Rule out DIC; baseline before procedures — ASH 2019 Neunert

SLE, APS, CVID screen → secondary ITP — ASH 2019 Neunert; BSH 2024

Viral (HIV, HCV, H. pylori, EBV, CMV); post-vaccination — ASH 2019 Neunert

Pregnancy-associated ITP vs gestational thrombocytopenia — ASH 2019 Neunert; NICE 2024

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

Severity triggers (6)

6 need judgement
  • informationallife_threateningmajor_bleeding_acute
    ICH / GI bleed / pulm hemorrhage with plt <30k — ASH 2019 Neunert
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereplt_under_10k
    Plt <10k regardless of bleeding — ASH 2019 Neunert; Provan Blood Adv 2019
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereheparin_induced_4ts
    Plt drop on heparin + 4Ts ≥4 — ASH 2019 Neunert; Warkentin 2003
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereevans_syndrome
    ITP + autoimmune hemolytic anemia (positive DAT + low Hb + retics up) — ASH 2019 Neunert; Provan Blood Adv 2019
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_with_itp
    ITP in pregnancy — ASH 2019 Neunert; NICE 2024
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpseudothrombocytopenia
    Low plt on EDTA but smear shows clumping — ASH 2019 Neunert; Provan Blood Adv 2019
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

ITP first-line (acute)
axis: itp_first_line
Selected axis "ITP first-line (acute)" by default fallback (first axis)
  • dexamethasone
    first line
    corticosteroid
    triggers: plt<30k_or_bleeding
    ASH 2019; FLIGHT — 40 mg ×4d preferred over prednisone
    rxcui 3264
  • prednisone
    first line
    corticosteroid
    triggers: plt<30k_or_bleeding, dex_unavailable
    ASH 2019 — 1 mg/kg/d ×2–3w taper
    rxcui 8640
  • ivig
    add on
    immunoglobulin
    triggers: rapid_response_needed, major_bleed
    ASH 2019 — 1 g/kg/d ×1–2d when rapid Rx required
    rxcui 1426680

outpatient playbook — drug actions (2)

  1. 1. taper steroid
    Dec 10 mg/week • PO • taper
    trigger: Stable response — ASH 2019 Neunert
    Minimize chronic steroid exposure — ASH 2019 Neunert; BSH 2024
  2. 2. transition to TPO-RA
    Per chronic axis • PO/SC • daily/weekly
    trigger: Need maintenance >3 months — ASH 2019 Neunert
    Steroid-sparing — ASH 2019 Neunert; BSH 2024

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Isolated thrombocytopenia (platelet count <100k) with otherwise normal CBC — ASH 2019 Neunert; Petechiae / purpura / mucocutaneous bleeding — ASH 2019 Neunert; Major bleeding (intracranial/GI) — emergency presentation — ASH 2019 Neunert; BSH 2024.

Objective

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

Assessment

**Immune Thrombocytopenia (ITP) — initial diagnosis & acute Rx** (heme.itp.core.v1).
Phenotype framing: Primary ITP / secondary (drug, autoimmune, viral, post-transfusion, vaccine-induced) / Evans / MDS / TTP / HIT / DIC — ASH 2019 Neunert; Provan 2019
Scope: Confirm isolated thrombocytopenia + exclude pseudothrombocytopenia (citrate tube), drug-induced, secondary causes — ASH 2019 Neunert; Provan 2019

No severity triggers fired against current inputs.

Plan

Regimen axis: **ITP first-line (acute)**.
1. dexamethasone (corticosteroid, first line) — ASH 2019; FLIGHT — 40 mg ×4d preferred over prednisone
2. prednisone (corticosteroid, first line) — ASH 2019 — 1 mg/kg/d ×2–3w taper
3. ivig (immunoglobulin, add on) — ASH 2019 — 1 g/kg/d ×1–2d when rapid Rx required

Setting playbook (outpatient) — Stabilize, taper to maintenance, transition to chronic engine if persists >12 months — ASH 2019 Neunert; Provan 2019
4. taper steroid Dec 10 mg/week PO taper — Stable response — ASH 2019 Neunert (Minimize chronic steroid exposure — ASH 2019 Neunert; BSH 2024)
5. transition to TPO-RA Per chronic axis PO/SC daily/weekly — Need maintenance >3 months — ASH 2019 Neunert (Steroid-sparing — ASH 2019 Neunert; BSH 2024)

Non-pharmacologic actions:
- Vaccinations — ASH 2019 Neunert; BSH 2024
- NSAID counseling — ASH 2019 Neunert; Provan Blood Adv 2019
- Pregnancy planning if applicable — ASH 2019 Neunert; NICE 2024

AVOID / contraindication checks:
- Steroid monitor glucose bp — ASH 2019 Neunert Blood Adv
- Ivig renal failure risk — ASH 2019 Neunert Blood Adv; Provan Blood Adv 2019

Monitoring

Regimen monitoring:
- plt q24-72h during response — ASH 2019 Neunert Blood Adv
- glucose BP on steroids — ASH 2019 Neunert Blood Adv

Setting (outpatient) monitoring:
- CBC q1-2 weeks initially then q1-4 weeks — ASH 2019 Neunert
- LFTs q2-4 weeks if on eltrombopag/fostamatinib — ASH 2019 Neunert; NICE 2024

Follow-up plan: Hem clinic follow-up; vaccination plan if rituximab/splenectomy planned; transition to chronic engine if persistent >12 months — ASH 2019 Neunert; BSH 2024
- Close-out criterion: Follow-up scheduled

Monitoring phase: Plt count q24–72h while titrating; LFTs on eltrombopag/fostamatinib; thrombosis surveillance on TPO-RA; steroid toxicity surveillance — ASH 2019 Neunert; NICE 2024

Disposition

Current setting: outpatient — Stabilize, taper to maintenance, transition to chronic engine if persists >12 months — ASH 2019 Neunert; Provan 2019

Disposition criteria:
- Continue current step or transition to chronic ITP engine at >12 months — ASH 2019 Neunert

Escalation triggers (move to higher acuity):
- Recurrent bleed → restart inpatient bundle — ASH 2019 Neunert
- Persistent >12 months → chronic engine — ASH 2019 Neunert; Provan Blood Adv 2019

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] ICH / GI bleed / pulm hemorrhage with plt <30k — ASH 2019 Neunert
- [SEVERE] Plt <10k regardless of bleeding — ASH 2019 Neunert; Provan Blood Adv 2019
- [SEVERE] Plt drop on heparin + 4Ts ≥4 — ASH 2019 Neunert; Warkentin 2003

Citations

- ASH 2019 ITP Guidelines (Neunert Blood Advances) + 2025 ASH Draft Update + International Consensus Report 2019 [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 Advances) + 2025 ASH Draft Update + International Consensus Report 2019 — PMID:31794604
  • Cited evidence (PMID 18242413) — PMID:18242413
  • Cited evidence (PMID 23361904) — PMID:23361904