How can a woman manage ITP and low platelets at 43?

Question

Hi doctor,

My 43-year-old sister was diagnosed with chronic immune thrombocytopenia (ITP) 18 months ago after experiencing extremely heavy menstrual bleeding that landed her in the emergency room. At that time, her platelet count was only 8,000, which explained the severe bleeding and bruising from minor bumps.

Her hematologist initially prescribed Prednisone, which raised her platelet count to 45,000, but she gained 25 pounds and developed diabetes. She then received Rituximab infusions, but her platelet count dropped back to 15,000 after a few months. Currently, she is taking Eltrombopag daily, which keeps her platelets around 30,000, but she is experiencing elevated liver enzymes.

The most difficult issue is unpredictable bleeding. Her periods sometimes last two weeks, and she requires iron transfusions for anemia. Even small cuts bleed excessively, and bruises cover her arms and legs, making normal daily activities challenging. Her gynecologist is considering endometrial ablation to stop her periods, but is concerned about bleeding complications during the procedure.

We are concerned about whether chronic ITP can go into remission or if this is a lifelong condition. We are also worried about splenectomy, since other treatments have not worked well.

Please help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Management of chronic immune thrombocytopenia (ITP):

You should consult a hematologist for further management of thrombocytopenia.
First-line treatment: Start tablet Prednisolone 20 mg, gradually increasing up to 60 mg as tolerated. Consult your specialist doctor, discuss with them, and take the medicines with their consent.
If thrombocytopenia is not controlled: Start IVIG (intravenous immunoglobulin) as the second-line treatment.
If still not controlled: Consider splenectomy, which can be performed either laparoscopically or as an open procedure.
If symptomatic bleeding occurs: You may need a platelet transfusion.
Pregnancy planning: Once platelet levels increase above 100,000, pregnancy can be considered.

Discuss a preconception plan with a consultant gynecologist.
Start tablet folic acid 5 mg once at night for three months prior to conception.

Target platelet levels during pregnancy and delivery:

Normal delivery: More than 50,000.
Cesarean section or epidural anesthesia: More than 80,000.

MDTA (multi-disciplinary team approach) management during pregnancy and delivery:

Consult a hematologist, obstetrician or gynecologist, anesthesiologist, and blood bank.

Management of heavy menstrual bleeding:

Tablet Primolute N (Norethisterone) 5 mg: Three times a day continuously for three months (can be increased to double or if needed)
Tablet Tranexamic Acid 500 mg: Take morning and night for six days.
Tablet Mefenamic Acid 500 mg: Take morning and night for six days.
Tablet Osteocare D3 (calcium and vitamin supplement): Take only at night for two months.
Tablet Cholecalciferol 200,000 IU: one tablet every 15 days for six months.

I hope this has helped you.

Please feel free to reach out to me again if you have further queries.

Thank you.