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Immune thrombocytopenic purpura, a modern, stepped approach to low platelets.

Not every low platelet count needs a drug - and when it does, today\'s options go far beyond steroids. A specialist plan matters.

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Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against BSH, ASH and peer-reviewed haematology sources listed at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including TPO receptor agonists, fostamatinib and rituximab pathways.

Key facts

ITP at a glance.

The essentials, in plain English - what ITP is, what causes it, and how it is treated in modern UK haematology.

  • What it is

    Immune thrombocytopenia (ITP) - isolated low platelets from antibody-mediated destruction plus reduced marrow production.

  • Primary or secondary

    Primary ITP has no identifiable cause. Secondary ITP follows HIV, hepatitis C, lupus, lymphoma, drugs or Helicobacter pylori.

  • Acute vs chronic

    Acute ITP in children usually follows a viral illness and resolves. Chronic ITP (over 12 months) is more typical in adults.

  • Presentation

    Petechiae, purpura, easy bruising, gum bleeds, nosebleeds, heavy periods and, rarely, intracranial haemorrhage.

  • The threshold

    Platelets under 100 x 10^9/L define ITP; treatment is usually considered under 30 x 10^9/L or with bleeding.

  • Modern options

    Steroids, IVIG, TPO receptor agonists (eltrombopag, romiplostim, avatrombopag), fostamatinib, rituximab and splenectomy.

Why this guide matters

A modern ITP plan, not just steroids.

Care has changed. Second-line agents now include TPO receptor agonists, fostamatinib and rituximab - splenectomy is later, not first.

  • Not every low count needs treatment

    Above 30 x 10^9/L and no bleeding, observation is often the right answer - and safer than steroid exposure.

  • Second-line care has transformed

    TPO receptor agonists and fostamatinib have shifted many patients off long-term steroids and away from splenectomy.

  • Secondary causes are treatable

    HIV, hepatitis C, H. pylori, lymphoma and drug reactions all cause secondary ITP - and each has its own fix.

How the diagnosis is made

From low platelets to a clear plan.

The steps a UK haematologist will normally follow, in order - so you understand each test and why it matters.

  1. 01

    Assessing

    History and drug review

    Recent viral illness, family history and every medicine, supplement and alcohol source - many drugs cause thrombocytopenia.

  2. 02

    Assessing

    Bleeding and examination

    Petechiae, purpura, mucosal bleeding and mild splenomegaly are all recorded. Marked splenomegaly points elsewhere.

  3. 03

    Assessing

    FBC and blood film

    Isolated thrombocytopenia with no schistocytes, no blasts and normal red and white cells is the ITP fingerprint.

  4. 04

    Confirming

    Secondary cause screen

    Coagulation, LFTs, HIV, hepatitis C, ANA, immunoglobulins and, where relevant, Helicobacter pylori testing.

  5. 05

    Confirming

    Rule out the mimics

    TTP, HUS, DIC, myelodysplasia, aplastic anaemia and heparin-induced thrombocytopenia each have their own pattern.

  6. 06

    Planning

    Bone marrow (selective)

    Reserved for older adults, atypical features or treatment failure - not routine in classical ITP.

  7. 07

    Planning

    Specialist haematology MDT

    A haematology-led plan sets the threshold for treatment, the first-line agent and the second-line escalation route.

Typical timeline: first consultation to a settled treatment plan within a few weeks.

Symptoms

What ITP actually looks like.

Mucocutaneous bleeding is the classic picture - and the pattern that separates ITP from many of its mimics.

  • Petechiae

    Pinpoint red or purple spots, most often on the lower legs - a hallmark of very low platelets.

  • Purpura and bruising

    Larger flat purple patches and easy bruising from minimal trauma or spontaneously.

  • Ecchymoses

    Wider bruise-like discolouration where small vessels have leaked into the skin.

  • Mucosal bleeding

    Nosebleeds, bleeding gums and blood blisters inside the mouth - a warning of higher bleeding risk.

  • Heavy periods

    Menorrhagia is common in women with ITP and may be the first clue - see our guide to heavy menstrual bleeding.

  • GI or urinary bleeding

    Blood in stool or urine needs prompt review - it can signify more significant bleeding.

  • Fatigue

    A recognised and often under-appreciated symptom of ITP, independent of platelet count.

  • Red flag - intracranial bleeding

    Sudden severe headache, confusion or neurological signs is a medical emergency - call 999.

Treatment

How ITP is treated in the UK.

Observation first where safe, steroids or IVIG when needed, then TPO agonists, fostamatinib, rituximab or splenectomy for chronic disease.

  • Observation

    Platelets above 30 x 10^9/L with no bleeding are often watched rather than treated - many patients do well without drugs.

  • Corticosteroids

    Prednisolone or short-course high-dose dexamethasone is the standard first-line agent - fast, effective, but not for the long term.

  • Intravenous immunoglobulin

    IVIG raises platelets quickly for bleeding, surgery or steroid failure - specialist commissioned and given as an infusion.

  • Anti-D immunoglobulin

    For selected Rh-positive non-splenectomised adults - a niche but useful option under haematology guidance.

  • TPO receptor agonists

    Eltrombopag, romiplostim and avatrombopag stimulate platelet production - a mainstay of second-line care. See our TPO receptor agonist page.

  • Fostamatinib

    An oral SYK inhibitor licensed for chronic refractory ITP - specialist commissioned. See our fostamatinib page.

  • Rituximab

    A B-cell targeted infusion that can induce lasting remissions - See our rituximab page.

  • Splenectomy

    Reserved for refractory disease, ideally after 12 months, with pre-op vaccinations and lifelong penicillin prophylaxis.

What this guide is based on

The sources behind every claim on this page.

UK haematology guidance and international consensus, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your haematologist knows your history and platelet trend - always follow their advice for your individual care.

  • British Society for Haematology (BSH). Guidelines for the investigation and management of ITP in adults.

  • American Society of Hematology (ASH). ITP clinical practice guideline.

  • NICE. Technology appraisals for eltrombopag, romiplostim, avatrombopag and fostamatinib.

  • ITP Support Association. UK patient guidance and resources.

Red flags

When low platelets need urgent attention.

Most ITP is manageable in the outpatient clinic. These are the situations where waiting is not safe.

  • Intracranial haemorrhage

    Sudden severe headache, vomiting, confusion or focal neurology at very low platelet counts is a 999 emergency.

  • Uncontrolled mucosal bleeding

    Persistent nosebleeds, gum bleeds or wet purpura on the palate signal higher bleeding risk and need same-day review.

  • GI or urinary bleeding

    Fresh or dark blood in stool, or visible blood in urine, warrants urgent haematology assessment.

  • Postpartum ITP

    Very low platelets around delivery need careful obstetric and haematology co-management - transfer of maternal antibodies can affect the neonate.

  • Rapid platelet fall

    A steep drop over days can herald secondary causes such as evolving TTP, HIT or drug reaction - review the film urgently.

  • Suspected TTP or HUS

    Thrombocytopenia with anaemia, schistocytes, fever, neurology or kidney failure is a haematological emergency, not ITP.

  • New splenomegaly or lymphadenopathy

    Points away from primary ITP toward lymphoma or another secondary cause - specialist imaging and review.

  • Pregnancy and ITP

    Pregnancy alters both platelet thresholds and treatment choices - joint obstetric-haematology planning is essential.

  • Refractory disease

    Failure of two or more lines of therapy triggers specialist MDT review and consideration of emerging agents such as rilzabrutinib.

Living with it

A chronic condition, with a clear playbook.

Four things that make the biggest difference day to day - knowing your trend, avoiding antiplatelets, sensible activity and peer support.

A quiet reminder

A platelet count is a number, not the whole picture.

Bleeding history, symptoms and how you feel matter as much as the number - treatment is guided by all of it together.

  1. 01 Awareness

    Know your platelet trend

    Understanding your usual count and what triggers dips helps you and your team catch problems early.

  2. 02 Avoid

    No aspirin, no NSAIDs

    Aspirin, ibuprofen and other antiplatelets and NSAIDs worsen bleeding - always tell any prescriber you have ITP.

  3. 03 Activity

    Sensible activity choices

    Low counts and contact sports don't mix. Most other exercise is fine and encouraged - discuss with your haematologist.

  4. 04 Support

    You are not alone

    The ITP Support Association offers peer support and patient-friendly information for adults, children and families.

Frequently asked

Everything we get asked about ITP.

Quick answers on thresholds, TPO agonists, splenectomy and secondary causes.

  • What is immune thrombocytopenia (ITP)?

    ITP is an autoimmune condition where antibodies destroy platelets and reduce their production, leading to isolated thrombocytopenia (platelets under 100 x 10^9/L). It was previously called idiopathic thrombocytopenic purpura, though the term "immune" has replaced "idiopathic" now that the immune mechanism is understood.

  • Is ITP the same as TTP?

    No. Thrombotic thrombocytopenic purpura (TTP) is a haematological emergency with microangiopathic anaemia, schistocytes and end-organ damage - very different from ITP. See our guide to thrombotic thrombocytopenic purpura for the distinction.

  • Do all patients need treatment?

    No. Adults with platelets above 30 x 10^9/L and no bleeding are often observed. Treatment is usually reserved for counts below that threshold, for active bleeding, before surgery or for lifestyle need such as contact sports.

  • What is a TPO receptor agonist?

    Thrombopoietin receptor agonists (eltrombopag, romiplostim, avatrombopag) stimulate the bone marrow to make more platelets. They have transformed second-line care of chronic ITP and are commissioned via a specialist TPO-RA clinic.

  • Is splenectomy still used?

    Yes, but far less than before. Modern practice delays splenectomy until after 12 months of chronic disease and typically after trying medical second-line options. Pre-splenectomy vaccinations and lifelong penicillin prophylaxis are essential.

  • Can secondary causes be reversed?

    Often, yes. Helicobacter pylori eradication, treatment of HIV or hepatitis C, and stopping a culprit drug can lift platelets in secondary ITP. A careful search for a treatable cause is a core part of every workup.

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