The target platelet count for ITP patients should be tailored to their lifestyle, bleeding history, and quality of life goals. A normal platelet count is not necessary, and different thresholds are appropriate for different patients (e.g., someone planning a ski trip versus a sedentary individual).

The VEHIT2 trial protocol, combining yanalumab and eltrombopag shortly after steroid failure, represents a paradigm shift. It moves beyond sequential single-agent therapy to explore if early, potent intervention can fundamentally reduce the long-term severity and chronic nature of ITP.

Pulsed dexamethasone provides no overall response rate benefit compared to a standard prednisone taper in first-line ITP treatment. It may offer a slightly faster response (by about one day) but carries a higher risk of acute steroid complications, particularly psychosis in older adults.

Beyond raising platelet counts, the newly approved BTK inhibitor rilzabrutinib provides dramatic improvements in the fatigue associated with ITP. This unique benefit, likely due to its anti-inflammatory properties, makes it a strong consideration for patients where fatigue is a primary quality of life issue.

Platelet aggregation studies show riluzobrutinib does not impair platelet function. This unique profile suggests it may not need to be stopped before surgery, avoiding the risk of a perilous drop in platelet counts for ITP patients—a key differentiator from other BTK inhibitors.

Patients with ITP who fail or are intolerant to one TPO receptor agonist (e.g., eltrombopag) should not be considered a class failure. Switching to another TPO agent is a viable strategy that can induce a response in nearly half of these cases, particularly for intolerance.

To minimize steroid toxicity, a thrombopoietin receptor agonist (TPORA) should be the immediate second-line therapy for ITP patients who fail their initial course of corticosteroids. There is no need to trial multiple other therapies before considering a TPORA.

While not standard of care, TPO receptor agonists like romiplostim can be used in the third trimester of pregnancy to raise platelet counts above 75,000 for epidural anesthesia. This is considered a reasonable option after critical fetal development is complete, avoiding the need for pre-pregnancy splenectomy.

Eltrombopag is a potent iron chelator that can cause or worsen iron deficiency. In ITP patients with existing iron deficiency, alternative TPO receptor agonists like avatrombopag or romiplostim, which do not chelate iron, should be used instead.