Management of Major Bleeds in Patients with Immune Thrombocytopenia.

BACKGROUND: A standard approach to the recognition and management of major bleeding in immune thrombocytopenia (ITP) is lacking. METHODS: Retrospective cohort study of ITP patients presenting to the ED with severe thrombocytopenia (platelet count <20x10(9) /L) and bleeding in 4 academic hospitals from 2008 to 2016. We defined a major ITP bleed as a bleed at a critical site or causing hemodynamic instability. RESULTS: We identified 112 ITP patients (n=141 visits) who presented to the ED with platelets <20x10(9) /L and bleeding. Twenty-nine patients (26%) had 32 ED visits with major bleeds. Risk factors for major bleeds were older age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.06), male sex (OR 3.25, 95% CI 1.22-9.32), and more prior ITP therapies (OR 1.42, 95% CI 1.10-1.87). Acute treatment of major bleeds required a median of 3 treatments (IQR 2-4), which included intravenous immune globulin (91% of visits), corticosteroids (78% of visits) and platelet transfusions (75% of visits). Three patients (10%) died, 9 (31%) developed recurrent bleeds, 1 (3%) developed arterial thrombosis and 1 (3%) had permanent neurological disability. Six patients presented with minor bleeding and subsequently developed a major bleed after a median of 2 days (IQR 1-3). All 6 patients had oral purpura and 4 of 6 had gross hematuria preceding the major bleed. CONCLUSIONS: Major ITP bleeds are associated with significant morbidity and mortality. Oral purpura and hematuria often preceded major bleeds. Further research is needed to refine the definition of a major ITP bleed and develop evidence-based treatment strategies.