Around 80% of children with ITP are disease-free within 1 year; a watch and wait strategy is considered standard for those without bleeding. On the other hand, most adults (70-80%) have a chronic course with a higher bleeding risk, more pharmacological treatment and higher splenectomy rates. At least that is what we thought! As a recent 24-month follow-up of the Pediatric and Adult Registry on Chronic ITP (PARC-ITP) has recently refuted…

The PARC-ITP is an international registry which has collected prospective data in children and adults with newly diagnosed ITP, as a part of the Intercontinental Cooperative ITP Study Group (ICIS) founded in 1997. In a recent publication in the American Journal of Hematology, Alexandra Schifferli and colleagues on behalf of ICIS, analyze data contributed by 84 investigators of 74 participating centers in 31 countries, including many developing countries across the world (www.itpbasel.ch).¹ It represents the first prospective observational cohort of children and adults with newly diagnosed ITP which allows direct comparisons, including 3,360 children and 420 adults between 2004-2015.

In the study, the authors argue that conventional wisdom is limited by inconsistent studies and retrospective data.

The analysis of PARC-ITP at first presentation demonstrated fewer differences in clinical and laboratory findings at initial diagnosis between adults and children than expected.² Now in a 24-month follow-up it is shown that 70% of children achieved remission, compared to 45-56% of adults in 6-24 months. However, among those with persistent ITP, only 36% of children and 27% of adults achieved remission at 12 months, with a similar rate of later remissions, and ongoing treatment (40 vs 47%, respectively). Mean platelet counts in patients with ongoing TIP were similar, albeit children in remission showed a higher platelet count.

Adults had less bleeding manifestations than children (“non-bleeder” rate of 64% vs 36% at 24 mo.) in spite of a mean similar platelet count in “bleeders” vs “non-bleeders”. Intracranial hemorrhage incidence was reported in 0.6% of children and 1.7% of adults. This fact challenges the accepted paradigm that adults have a higher bleeding complication risk, albeit the number of elderly patients included was small.

Corticosteroids were prescribed in 19% of children and 49% of adults during the first 6 months. Use decreased over time with 21% of adults at 24 months vs 11% of children. The proportion of patients with corticosteroids in the group requiring treatment remained high at 24 mo. 65% children and 56% of adults. IVIG use was higher in children and similar to the rate of steroid use. Splenectomy was performed in 12.4% of adults and 6.2% of children at 24 months.

The study was limited by the lack of complete follow-up information particularly for patients in remission which is understandable and reflects real life, as patients in remission are more likely to miss clinic visits. The authors conclude that pediatric and adult ITP patients seem to share more common clinical and laboratory aspects than previously presumed, which should be kept in the hematologists’ mind, with more bleeders in the pediatric group and a similar rate of treatment for persistent-ITP patients. More importantly, this study reflects an example of an independent international collaboration which includes many developing countries, which is unfortunately still rare to find in this day and age.