What is your approach to treating refractory thrombocytopenia in lupus?

Refractory thrombocytopenia is challenging to treat. It is important to evaluate for non-SLE causes including infection, medications, and malignancy. It is also important to differentiate ITP from TTP/atypical HUS.

Once the ITP diagnosis is confirmed, I usually don't treat asymptomatic thrombocytopenia unless platelets drop below 20-30K. If patients are symptomatic or have persistent counts <20K, I usually treat them with Rituximab and/or thrombopoetin receptor agonists.

I agree with this approach, but would consider adding combination therapy if a rapid response is needed. One approach is using high dose steroids, cyclosporin, and weekly rituximab (Choi et al). In another small study, azathioprine, mycophenolate, and cyclosporin were used (Arnold et al).

Choi et al., PMID 25972158

Arnold et al., PMID 19897578