A group of experts from Spain recently released consensus guidelines on the management of patients with immune thrombocytopenia (ITP) in the context of infection with and vaccination for SARS-CoV-2, the virus that causes COVID-19.
Led by Tomás José González-López, MD, of Hospital Universitario de Burgos in Spain, researchers said the guidelines are necessary because patients with ITP “are at increased risk for lower platelet counts in the setting of infections and vaccinations, and both SARS-CoV-2 infection and vaccination can cause thrombocytopenia. Therefore, the ITP population requires special management considerations in such circumstances.”
The main conclusion of the consensus guidelines, which were published in Infectious Diseases and Therapy, was that there is no greater risk for severe SARS-CoV-2 infection in patients with ITP than in the general population. Patients with stable ITP who test negative for COVID-19 should continue with their regular treatment.
Treatment of ITP secondary to COVID-19 is similar to that outside of the COVID-19 setting. The consensus guidelines recommended a platelet threshold of 30 × 109/L in adults with newly diagnosed ITP who are asymptomatic or have minor mucocutaneous bleeding to begin treatment with steroids.
“We shall start prednisone at a dose of 0.5-1 mg/kg/day and keep it for a maximum of two weeks, withdrawing it shortly afterwards for a maximum of eight weeks,” they wrote. “We recommend dexamethasone use at standard ITP doses as an alternate steroid to be used in this scenario.”
The need for hospital admission should also be considered in patients with newly diagnosed ITP.
Use of rituximab was not recommended “since it can decrease the formation of antibodies against SARS-CoV-2 virus.” The use of immunosuppressants in general is discouraged “unless there is no other therapeutic option.”
Platelet transfusion is unusual but could increase the prothrombotic state sometimes generated by COVID-19. Therefore, transfusion is only recommended in cases of active bleeding that translate into a life-threatening hemorrhage.
Intravenous immunoglobulin at a dose of 2 g/kg should be considered in patients with severe COVID-19 who have already received corticosteroids and have platelet counts below 20 × 109/L or have active bleeding.
Additionally, when considering a diagnosis of thrombocytopenia or ITP from COVID-19, ITP should remain a diagnosis of exclusion, with no confirmatory test.
“In this setting, the diagnosis of ITP secondary to SARS-CoV-2 infection will be given by the presence of thrombocytopenia in a patient with no prior history of low platelet counts who, in the context of a recent SARS-CoV-2 infection, develops a platelet count drop not attributable to any other cause,” they wrote.
Additionally, the guidelines emphasized that the risk of ITP secondary to vaccination against SARS-CoV-2 is low, “similar to that of other vaccines against viral agents available on the market” and that pregnant women and patients with ITP are not contraindicated for vaccination against COVID-19.
Dr. González-López said hematology providers should “know the most frequent side effects of vaccination and whether they affect patients with ITP as well as the general population.”
“It is also important to know that patients with active ITP who are going to be vaccinated against SARS-CoV-2 need different management or follow-up procedures than those recommended for the overall population,” Dr. González-López said.
The experts identified three rare causes of post-vaccine thrombocytopenia: primary ITP, vaccine-induced thrombotic thrombocytopenia, and acquired thrombotic thrombocytopenic purpura. The consensus guidelines outline specific therapeutic management for each.
Any conflicts of interest declared by the authors can be found in the original article.
Leah Lawrence is a freelance health writer and editor based in Delaware.
Reference
González-López TJ, Barez A, Bernardo-Gutierrez A, et al. Recommendations on the management of patients with immune thrombocytopenia (ITP) in the context of SARS-CoV-2 infection and vaccination: consensus guidelines from a Spanish ITP expert group [published online, 2022 Dec 15]. Infect Dis Ther. doi: 10.1007/s40121-022-00745-2.
