Don’t treat patients with immune thrombocytopenic purpura (ITP) in the absence of bleeding or a very low platelet count.
Treatment for ITP should be aimed at treating and preventing bleeding episodes and improving quality of life. Unnecessary treatment exposes patients to potentially serious treatment side effects and can be costly, with little expectation of clinical benefit. The decision to treat ITP should be based on an individual patient’s symptoms, bleeding risk (as determined by prior bleeding episodes and risk factors for bleeding such as use of anticoagulants, advanced age, high-risk activities, etc.), social factors (distance from the hospital/travel concerns), side effects of possible treatments, upcoming procedures, and patient preferences. In the pediatric setting, treatment is usually not indicated in the absence of mucosal bleeding regardless of platelet count. In the adult setting, treatment may be indicated in the absence of bleeding if the platelet count is very low. However, ITP treatment is rarely indicated in adult patients with platelet counts greater than 30,000/microL unless they are preparing for surgery or an invasive procedure, or have a significant additional risk factor for bleeding. In patients preparing for surgery or other invasive procedures, short-term treatment may be indicated to increase the platelet count prior to the planned intervention and during the immediate post-operative period.
These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.
1-5: The American Society of Hematology (ASH) Choosing Wisely® Task Force utilized a modified Delphi technique to collect suggestions from committee members and recipients of its clinically focused newsletter, the ASH Practice Update. Respondents were asked to consider the core values of harm, cost, strength of evidence, frequency and control. Fifty-nine of 167 ASH committee members (35%) and 2 recipients of the ASH Practice Update submitted 81 unique suggestions. The Task Force used a nominal group technique (NGT) to identify the top 20 items, which were scored by ASH committee and practice community members, with a 46 percent participation rate. ASH’s Task Force reviewed all scores to develop a 10-item list. A professional methodologist conducted a systematic literature review on each of the 10 items; the Task Force chair served as the second reviewer. Evidence reviews and source material for the 10 items were shared with ASH’s Task Force, which ranked the items according to the core values. The Task Force then identified the top 5 items plus 1 alternate. ASH member content experts provided external validation for the veracity and clarity of the items.
6–10: Suggestions for the second ASH Choosing Wisely list were solicited from members of the ASH Committee on Practice, the ASH Committee on Quality, the ASH Choosing Wisely Task Force, ASH Consult-a-Colleague volunteers and members of the ASH Practice Partnership. Six principles were used to prioritize items: avoiding harm to patients, producing evidence-based recommendations, considering both the cost and frequency of tests and treatments, making recommendations in the clinical purview of the hematologist, and considering the potential impact of recommendations. Harm avoidance was established as the campaign’s preeminent guiding principle. Guided by the 6 principles, the ASH Choosing Wisely Task Force scored all suggestions. Modified group technique was used to select 10 semi-finalist items. Systematic reviews of the literature were then completed for each of the 10 semi-finalist items. Guided by the 6 core principles outlined above, and by the systematic reviews of the evidence, the ASH Choosing Wisely Task Force selected 5 recommendations for inclusion in ASH’s second Choosing Wisely Campaign.
ASH’s disclosure and conflict of interest policy can be found at www.hematology.org.
Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr., Crowther MA; American Society of Hematology. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 Apr 21;117(16):4190–207.