ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats

Dana N LeVine¹, Robert Goggs², Barbara Kohn³, Andrew J Mackin⁴, Linda Kidd⁵, Oliver A Garden⁶, Marjory B Brooks⁷, Erin R B Eldermire⁸, Anthony Abrams-Ogg⁹, Elizabeth H Appleman¹⁰, Todd M Archer¹¹, Domenico Bianco¹², Shauna L Blois⁹, Benjamin M Brainard¹³, Mary Beth Callan¹⁴, Claire L Fellman¹⁵, Jillian M Haines¹⁶, Anne S Hale¹⁷, Alice A Huang¹⁸, John M Lucy¹⁹, Shana K O'Marra²⁰, Elizabeth A Rozanski¹⁵, John M Thomason⁴, Jenny E Walton²¹, Helen E Wilson²²

Affiliations

¹ Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA.
² Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
³ Small Animal Clinic, School of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany.
⁴ Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA.
⁵ Linda Kidd Veterinary Internal Medicine Consulting, Carlsbad, California, USA.
⁶ School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana, USA.
⁷ Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
⁸ Flower-Sprecher Veterinary Library, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
⁹ Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada.
¹⁰ Department of Internal Medicine, The Animal Medical Center, New York, New York, USA.
¹¹ Bluff City Veterinary Specialists, Memphis, Tennessee, USA.
¹² College of Veterinary Medicine, Western University of Health Sciences, Pomona, California, USA.
¹³ Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA.
¹⁴ Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
¹⁵ Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA.
¹⁶ Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA.
¹⁷ Zia Pet Hospital, Rio Rancho, New Mexico, USA.
¹⁸ BluePearl Pet Hospital, Kirkland, Washington, USA.
¹⁹ Oradell Animal Hospital, Paramus, New Jersey, USA.
²⁰ Northwest Veterinary Critical Care Services, Vancouver, Washington, USA.
²¹ Veterinary Apheresis Service UK, Washington, Tyne and Wear, United Kingdom.
²² Langford Vets, University of Bristol, Langford, Somerset, United Kingdom.

PMID: 38779941
PMCID: PMC11256181
DOI: 10.1111/jvim.17079

ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats

Dana N LeVine et al. J Vet Intern Med. 2024 Jul-Aug.

. 2024 Jul-Aug;38(4):1982-2007.

doi: 10.1111/jvim.17079. Epub 2024 May 23.

Authors

Affiliations

¹ Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, Alabama, USA.
² Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
³ Small Animal Clinic, School of Veterinary Medicine, Freie Universität Berlin, Berlin, Germany.
⁴ Department of Clinical Sciences, College of Veterinary Medicine, Mississippi State University, Mississippi State, Mississippi, USA.
⁵ Linda Kidd Veterinary Internal Medicine Consulting, Carlsbad, California, USA.
⁶ School of Veterinary Medicine, Louisiana State University, Baton Rouge, Louisiana, USA.
⁷ Department of Population Medicine and Diagnostic Sciences, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
⁸ Flower-Sprecher Veterinary Library, College of Veterinary Medicine, Cornell University, Ithaca, New York, USA.
⁹ Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada.
¹⁰ Department of Internal Medicine, The Animal Medical Center, New York, New York, USA.
¹¹ Bluff City Veterinary Specialists, Memphis, Tennessee, USA.
¹² College of Veterinary Medicine, Western University of Health Sciences, Pomona, California, USA.
¹³ Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA.
¹⁴ Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
¹⁵ Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA.
¹⁶ Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, Washington, USA.
¹⁷ Zia Pet Hospital, Rio Rancho, New Mexico, USA.
¹⁸ BluePearl Pet Hospital, Kirkland, Washington, USA.
¹⁹ Oradell Animal Hospital, Paramus, New Jersey, USA.
²⁰ Northwest Veterinary Critical Care Services, Vancouver, Washington, USA.
²¹ Veterinary Apheresis Service UK, Washington, Tyne and Wear, United Kingdom.
²² Langford Vets, University of Bristol, Langford, Somerset, United Kingdom.

PMID: 38779941
PMCID: PMC11256181
DOI: 10.1111/jvim.17079

Abstract

Management of immune thrombocytopenia (ITP) in dogs and cats is evolving, but there are no evidence-based guidelines to assist clinicians with treatment decisions. Likewise, the overall goals for treatment of ITP have not been established. Immunosuppressive doses of glucocorticoids are the first line treatment, but optimal treatment regimens beyond glucocorticoids remain uncertain. Additional options include secondary immunosuppressive drugs such as azathioprine, modified cyclosporine, and mycophenolate mofetil, usually selected based on clinician preference. Vincristine, human IV immunoglobulin (hIVIg), and transfusion of platelet or red blood cell-containing products are often used in more severe cases. Splenectomy and thrombopoietin receptor agonists are usually reserved for refractory cases, but when and in which patient these modalities should be employed is under debate. To develop evidence-based guidelines for individualized treatment of ITP patients, we asked 20 Population Intervention Comparison Outcome (PICO) format questions. These were addressed by 17 evidence evaluators using a literature pool of 288 articles identified by a structured search strategy. Evidence evaluators, using panel-designed templates and data extraction tools, summarized evidence and created guideline recommendations. These were integrated by treatment domain chairs and then refined by iterative Delphi survey review to reach consensus on the final guidelines. In addition, 19 non-PICO questions covering scenarios in which evidence was lacking or of low quality were answered by expert opinion using iterative Delphi surveys with panelist integration and refinement. Commentary was solicited from multiple relevant professional organizations before finalizing the consensus. The rigorous consensus process identified few comparative treatment studies, highlighting many areas of ITP treatment requiring additional studies. This statement is a companion manuscript to the ACVIM Consensus Statement on the Diagnosis of Immune Thrombocytopenia in Dogs and Cats.

Keywords: glucocorticoids; immunoglobulin; immunosuppressive; platelet; transfusion; vincristine.

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Conflict of interest statement

Dana LeVine has received relevant research funding from American Kennel Club Canine Health Fund, BodeVet, Morris Animal Foundation, and the Veterinary & Comparative Clinical Immunology Society (VCCIS) and honoraria for speaking engagements from the ACVIM Forum, ECVIM‐CA Congress, ACVIM ACE, CVMA, and CanWest and is also a consultant for Cellphire Therapeutics. Robert Goggs has received relevant research funding from the American Kennel Club Canine Health Fund, Aurin Biotech, BodeVet, Morris Animal Foundation, and Okava Pharmaceuticals and honoraria for speaking engagements from ACVIM Forum, EVECC Congress, IVECCS, PacVet, UnisVet, and VCCIS. Barbara Kohn has held lectures, had research collaborations, and acted as a consultant for veterinary pharmaceutical and diagnostic companies. Linda Kidd was a Veterinary Field Specialist for Zoetis Diagnostics August 2022 to July 2023 and is an Associate Editor of the Journal of Veterinary Internal Medicine. OIiver A. Garden has received relevant research funding from the Kennel Club (UK) and Okava Pharmaceuticals and speaking honoraria from the ACVIM Forum, ECVIM‐CA Congress, and ACVP/ACSVP Annual Meeting. He has served as a consultant for Okava Pharmaceuticals and is the President of VCCIS. Marjory B. Brooks has received relevant research funding from the American Kennel Club and honoraria for speaking engagements from ACVIM Advanced Continuing Education, University of North Carolina Chapel Hill Symposium of Hemostasis, and the Society of Toxicologic Pathology's Symposium. Benjamin M. Brainard has received sponsorship from BodeVet Inc. for studies analyzing the properties of the lyophilized StablePlate RX or related products and has consulted for Cellphire, Inc. Anne S. Hale has equity in VetStem and was previously employed as the Chief Development Officer.

Figures

**FIGURE 1**
Overview of the methodology of the treatment domain. EE, evidence evaluator; PICO Population Intervention Comparison Outcome.

**FIGURE 2**
Treatment goals and an algorithm for the initial management of dogs and cats with immune thrombocytopenia. BUN, blood urea nitrogen; DOGiBAT, daily canine bleeding assessment tool; EACA, epsilon aminocaproic acid; FWB, fresh whole blood; GI, gastrointestinal; hIVIg, human IV immunoglobulin; PC, platelet concentrate; Plts, platelet count; PRP, platelet‐rich plasma; TDM, therapeutic drug monitoring; TXA, tranexamic acid.

**FIGURE 3**
Treatment goals and an algorithm for the management of drug withdrawal, remission and relapse in dogs and cats with immune thrombocytopenia. Dx, diagnosis; hIVIg, human IV immunoglobulin; Plts, platelet count; Rx, treatment; TDM, therapeutic drug monitoring.

See this image and copyright information in PMC

References

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ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats

Affiliations

ACVIM consensus statement on the treatment of immune thrombocytopenia in dogs and cats

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

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