The complex immune dysregulation of ITP can impact platelet counts, bleeding, and HRQoL.1,3-6
In ITP, dysregulation of immune pathways results in increased platelet destruction and decreased platelet production.7

<h3>Bleeding occurs in around 60% of patients. Bleeding symptoms vary and can include8:</h3>

Petechiae and purpura, usually on the extremities1,9

black

Heavy menstrual bleeding1

Bleeding blisters and epistaxis1,9

Intracranial haemorrhage8

Learn more about how ITP can affect patients’ quality of life

Some ITP patients may experience systemic symptoms, including fatigue, fever, tachycardia, and cognitive effects, such as headaches and memory impairment.1,12-14

<h3>Severe bleeding occurs in 7% to 10% of adult patients and is typically correlated with lower platelet counts.10,11</h3>

<a href="${link:{uuid:{5951058e-a726-4620-a2dc-66df25bdf733},repository:{articles},path:{/Global/indications/itp/treating-itp}}}">Treatment of ITP</a> typically focuses on managing primary symptoms such as petechiae, purpura, and bleeding. However, patients with ITP often experience other symptoms such as fatigue and difficulties with memory and concentration that can profoundly affect their quality of life. That is why it is important to use treatment strategies that help improve HRQoL in ITP patients.1,12-14

<h3>Purpura and petechiae in ITP</h3>
ITP is an autoimmune blood disorder where easy bruising, petechiae and purpura often appear as common symptoms typically in lower extremities. Petechiae and purpura occur due to bleeding under the skin or mucous membranes.15,16
Petechiae in thrombocytopenia 
 Petechiae are small, non-blanching red or purple pinpoint lesions, usually less than 2 mm, that appear on the skin and mucous membranes. Petechial rashes result from bleeding into the skin’s dermal layer.15,17
Purpura in thrombocytopenia 
 Purpura refers to larger areas of cutaneous bleeding, which appear as purple or red patches on the skin that measure greater than 2 mm in size.15,17
In patients with ITP, purpura can appear due to even minor trauma or spontaneously due to low platelet levels. Purpura can also appear in mucosal membranes such as the hard palate, nasal septum, or gums, which can lead to bleeding gums.15,16,18

<h3>Other ITP bleeding symptoms and complications of thrombocytopenia</h3>
A low platelet count can lead to certain types of bleeding symptoms in ITP patients, including nose bleeds (epistaxis), gum bleeds (gingival), mouth blood blisters, blood in urine or stools, and heavy menstrual bleeding.9,19
Platelet levels &lt;10,000/μL could be associated with spontaneous widespread haematomas, and severe bleeding in ITP usually occurs when the platelet count is &lt;10 (x109/L). Severe bleeding can manifest as intracranial haemorrhages, gastrointestinal tract bleeds, and macroscopic haematuria. In some studies, severe bleeding occurred in approximately 7% to 10% of adult patients and typically correlated with lower platelet counts.10-12,16,20,21
ITP and intracranial haemorrhaging (brain bleed) 
 Intracranial haemorrhaging (ICH) is a rare and serious complication of ITP. The incidence of ICH in ITP patients is 1.54% in all ages.19,20,22,23
ICH symptoms that are a cause for concern include headache, persistent vomiting, altered mental status, and seizures. Risk factors for ICH include extremely low platelet counts of &lt;10,000/μL, head trauma, antiplatelet medication use, and severe bleeding.19,20,22,23

<h3>The symptoms of ITP go beyond bleeding</h3>
Learn more about the less visible symptoms of ITP and <a href="${link:{uuid:{9d762c77-664a-467f-a4f0-78211ab9453e},repository:{articles},path:{/Global/indications/itp/living-with-itp}}}">how they impact ITP patients’ quality of life</a>.&nbsp;

<h2>Primary ITP is a diagnosis of exclusion7,24,25</h2>
<ul>
 <li>Platelet counts &lt;100,000/μL can indicate ITP</li>
 <li>Platelet counts &lt;50,000/μL can indicate severe thrombocytopenia</li>
</ul>
<h3>But the lack of a specific test means other potential causes of thrombocytopenia must be ruled out7,24,26,27</h3>
Causes of secondary ITP include7,24,26,27:
<ul>
 <li>Chronic lymphocytic leukaemia (CLL)</li>
 <li>Helicobacter pylori infection</li>
 <li>COVID-19 infection</li>
</ul>
<h3>ITP is further classified as either newly diagnosed, persistent, or chronic27:</h3>

Low platelet counts are one facet of ITP, but when we look at it from another angle, we see the multiple dimensions of ITP. Immune thrombocytopenia (ITP) is a condition of complex immune dysregulation that reduces platelet counts—causing bleeding, bruising, fatigue, and other health-related quality-of-life (HRQoL) issues—while increasing inflammation and the risk of thromboembolic events (TEs).1-5

Defining ITP

IMMUNE-THROMBOCYTOPENIC-ITP

In a study, patients living with ITP rated their health-related quality of life (HRQoL) significantly worse than the general US population. They also reported worse HRQoL than patients living with hypertension, arthritis, or cancer, and similar to that of patients living with diabetes.1*
*The study used the Short-Form 36 questionnaire to evaluate the HRQoL of 73 adult ITP patients compared with that of the general US population and of patients with 6 other relatively common chronic disorders.1
<h3>ITP can impact patient HRQoL in multiple ways, including:&nbsp;</h3>

<h3>Fatigue</h3>
Reported as severe by patients with ITP, often regardless of platelet counts2

<h3>Heavy menstrual bleeding</h3>
Rated by patients and doctors as one of the most severe ITP symptoms2

<h3>Thromboembolic events (TEs)</h3>
Compared to patients without ITP, there is up to a 2x higher risk of TEs3

<h3>Cerebral microbleeds (CMBs)</h3>
Associated with lower platelet count and longer disease duration4

<h2>Fatigue is common and can be severe in patients with ITP2</h2>
In the Immune Thrombocytopenia World Impact Survey (I-WISh)* of 1507 patients and 472 physicians, patients rated functional, psychological, and emotional aspects of their condition. In I-WISh2:

58% of patients reported fatigue at diagnosis (n=870/1507),2&nbsp;

and 73% of those patients rated fatigue as severe (n=637/870)2

<h4>Even in patients with low disease activity, prevalence of severe fatigue exists, and fatigue persists even after platelet counts have increased. Disease activity alone does not explain variance in ITP.2,5</h4>
<h3>Factors that may play a role in fatigue5,6:</h3>
<ul>
 <li>Inflammation</li>
 <li>Physical and functional well-being</li>
 <li>Physical activity</li>
</ul>
Research shows that ITP is also linked to reduced activity and a notable increase in general, mental, and physical fatigue.7,8&nbsp;
The exact causes of fatigue and the underlying pathophysiology are not fully understood. However, ITP-related excessive and prolonged bleeding leads to iron deficiency and anaemia, which can be contributors to fatigue. Learn more about the <a href="${link:{uuid:{c74a8bbe-8c42-444b-b7ca-84850a1d0137},repository:{articles},path:{/Global/indications/itp/mechanism-of-disease}}}">causes and pathophysiology of ITP</a>.6,9,10
Furthermore, ITP-related activity restrictions can result in frustration, social withdrawal, and mood decline.7,11

—Male living with ITP, Germany

*I-WISh was an online, cross-sectional survey of patients with ITP and haematologists or haemato-oncologists who treat patients with ITP in 13 countries. The patient questionnaire collected information on demographics and diagnosis, symptoms of ITP, HRQoL and emotion associated with ITP, impact of ITP on work, finances, and support, treatment received, and patient and physician relationship. The physician survey comprised 6 sections that collected information on demographics, diagnosis of ITP and patient caseload, symptoms of ITP, impact of ITP on aspects of patients’ physical, emotional, HRQoL, social health, treatment patterns, and patient and physician relationship. There were 2 questions about the emotional impact of ITP, and the responses were based on a 7-point Likert scale (1 = never, 7 = a great deal). There was 1 additional question on the need for professional support.7

<h2>Heavy menstrual bleeding can have a major negative impact on patient HRQoL2</h2>

45% of women with ITP reported heavy menstrual bleeding at diagnosis2

and 83% of those said it was one of their most severe symptoms2

<h2>Thromboembolic events (TEs) are also more common among patients with ITP3</h2>

Patients with ITP face up to a 2X higher risk of TEs compared to patients without ITP3*
Risk factors for TEs in ITP12:
<ul>
 <li>Mechanisms of ITP itself</li>
 <li>Patient comorbidities and past history</li>
 <li>Current ITP treatments patient may be taking</li>
</ul>
*Adjusted risk ratio of 1.7 in a retrospective cohort study of 1140 patients with ITP and 5657 patients without ITP.3

<h2>Patients with ITP might also suffer from cerebral microbleeds4</h2>

CMBs were associated with lower platelet count and longer disease duration. The strong association between CMBs and ITP duration could indicate that CMBs may accumulate over time.4

In a 2020 study published in Blood,* 43% of patients with ITP had CMBs (n=21/49)4

*A cross-sectional prospective study of 49 patients with ITP and nadir platelet counts &lt;30,000/μL and 18 age-matched healthy controls that used susceptibility-weighted magnetic resonance imaging (MRI) to detect CMBs as a marker of occult haemorrhage.4

<h3>Neurological symptoms and cognitive effects of immune thrombocytopenia</h3>

Neurological manifestations in ITP without clinically significant bleeding are rare.14
However, patients with ITP might also suffer from cognitive impairment.14

50% of patients with ITP experience some level of cognitive impairment (N=69)13

Can ITP cause headaches?
Individuals&nbsp;with ITP can suffer from headaches and migraines. A sudden headache in ITP patients can also be an indication of the rare but severe complication of intracranial haemorrhage (ICH), which can cause other neurological symptoms.2,15-17

Patients reported significant quality of life (QoL) challenges related to their ITP1

Living with ITP

<h3>ITP Patient-Reported Outcomes Assessment Questionnaire (ITP-PAQ)5,6</h3>
ITP-PAQ is a validated tool that was designed to measure the HRQoL and treatment impact specifically for patients diagnosed with ITP.
The questionnaire typically evaluates various aspects of life affected by ITP, such as emotional well-being, and physical and social functioning. Additionally, the survey aids in assessing symptoms and their severity, including bruising and bleeding.&nbsp;
The ITP-PAQ facilitates a better overall understanding of how ITP affects individuals beyond clinical measures alone and their HRQoL.
<h3>ITP Life Quality Index (ILQI)1,6</h3>
The ILQI is a validated 10-item questionnaire that was developed to aid clinical discussions between patients and physicians about patients’ disease experiences, facilitating a patient-centric approach toward treatment decision-making. The ILQI typically involves surveys or questionnaires that patients complete, detailing their experiences, symptoms, and how these affect their quality of life.

<h3>Modified Fatigue Impact Scale (MFIS)2,7</h3>
The MFIS measures the impacts of fatigue on physical, cognitive, and psychosocial functioning.&nbsp;
This validated scale consists of a series of statements related to fatigue and its impact over a longer time, usually 4 weeks. The respondents rate their experiences over this period. The total scoring can then help healthcare providers understand the severity of fatigue and its effects on daily functioning. &nbsp;
In contrast to the MFIS, the daily fatigue impact scale (D-FIS) is a scoring tool to measure the short-term impact of fatigue in everyday life.
<h3>The Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F)4,8</h3>
The FACIT-F is a validated scale that provides a 13-item tool to determine self-reported fatigue and its impact on daily activities and function.&nbsp;
The questionnaire includes questions regarding the intensity and frequency of fatigue, its effects on social and personal activities, and the overall energy level.&nbsp;
<h3>The Daytime Sleepiness Scale3</h3>
The daytime sleepiness scale is often represented by the validated Epworth Sleepiness Scale (ESS), a scale used to evaluate patients for excessive daytime sleepiness. The questionnaire measures how likely someone falls asleep in various situations.

For ITP patients, several scales are available to measure and track fatigue and its impact on quality of life. These tools can help patients and healthcare providers gauge symptoms and adjust their ITP treatment accordingly.1-4

Assessing fatigue in ITP patients

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Defining ITP

Latest Articles

Defining ITP

Living with ITP

Assessing fatigue in ITP patients

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