Therapy of adult ITP before splenectomy. (1) Minimal emergent therapy includes IV methylprednisolone and IVIG. IV anti-D and platelet transfusions may be given as needed; repeated or continuous platelet transfusions may be required in urgent situations; all 3 modalities given prior to transfusions may help preserve their longevity in the circulation. (2) We generally initiate therapy with prednisone and add either IV anti-D (in Rh+, direct antiglobulin-negative patients) or IVIG as needed for persistent severe thrombocytopenia with the goal of attaining a platelet count of greater than 30 000 × 109/L and cessation of bleeding. Details of therapy and duration of treatment are discussed in text. (3) Thrombocytopenia recurs in most adults as corticosteroids are tapered. The treatment modality depends on the severity of the thrombocytopenia and bleeding, tolerance of treatment, and patient preference as discussed in “Initial therapy for nonemergent indications.” We would generally treat for a minimum of 3 months and a maximum of 12 months, barring evidence of late improvement, before considering splenectomy. (4) We recommend splenectomy for those clearly requiring therapy beyond 12 months to maintain a hemostatic platelet count and sooner in select individuals intolerant of therapy, with active lifestyles or comorbid risk factors that make higher platelet counts desirable. po indicates orally; prn, as needed; and q, every.
