While enalumab trials used eltrombopag, an expert would combine it with other TPORAs like avatrombopag in practice. This is due to similar mechanisms and superior tolerability profiles of alternatives (e.g., no dietary restrictions or hepatotoxicity risk).
While ITP often appears alongside autoimmune thyroid disease, the progression of each condition is usually separate. Improvement or "burnout" of thyroid disease does not predict a similar course for ITP, which may be worsening simultaneously.
Giving a rapid bolus of platelets (colloid) to an ITP patient with an active, unmanaged brain bleed can increase pressure in ruptured vessels, exacerbating the bleed. The expert advises slow infusion and prioritizing antifibrinolytics like tranexamic acid first.
For ITP patients with cardiac comorbidities, fostamatinib is a compelling option because it lacks the theoretical thromboembolic risk of TPORAs. Basic science suggests it may even be anti-thrombotic, directly addressing a key safety concern in this high-risk population.
The primary goal after managing immune checkpoint inhibitor (ICI)-induced ITP is resuming cancer therapy. Data shows most patients do not experience a relapse of ITP upon re-challenge with the ICI, allowing them to continue their effective cancer treatment.
Despite updated ASH guidelines suggesting its use, some experts avoid upfront rituximab because it's not disease-modifying and may worsen the long-term autoimmune response. They prefer to reserve it for later-line or salvage settings rather than initial combination therapy.