Oral Pills Oral Pills Most second-line ITP therapies are available as oral pills, including the TPO-RAs eltrombopag (Promacta) and avatrombopag (Doptelet), the SYK inhibitor fostamatinib (Tavalisse), the BTK inhibitor rilzabrutinib (Wayrilz), and MMF (CellCept). The TPO-RAs are taken once a day and the other drugs are taken twice a day.e60dc2a1-f33c-4a05-9b50-8e3e8e597629bba8ac75-1d41-40a3-9836-551f8b3e3b41 Medical Monitoring Requirements Of the two oral TPO-RAs, “avatrombopag does not have hepatotoxicity that can be seen with eltrombopag,” says Cindy Neunert, MD , a hematologist at Columbia University Irving Medical Center in New York City, adding that “there’s no difference in their efficacy.”e60dc2a1-f33c-4a05-9b50-8e3e8e597629e2280994-0cd8-4693-a6ab-c1284a2a4b01 Because eltrombopag is hepatotoxic — it can damage the liver — you must undergo liver function tests every two weeks while you adjust to the medication and monthly thereafter.e60dc2a1-f33c-4a05-9b50-8e3e8e597629462b4b79-eb9f-4a89-affd-c44a64d77dbf And regardless of which TPO-RA you go with, you’ll likely need your blood counts checked monthly after your platelet levels stabilize.e60dc2a1-f33c-4a05-9b50-8e3e8e597629e2280994-0cd8-4693-a6ab-c1284a2a4b01 Fostamatinib can also damage the liver and requires routine liver function monitoring, along with blood pressure and white blood cell tests, every month for as long as you take the drug.e60dc2a1-f33c-4a05-9b50-8e3e8e597629b3406f38-4f0c-4338-833d-589a394f7bcf Rilzabrutinib can affect the liver and increase your risk of serious infections, which your provider may want to regularly check up on.e60dc2a1-f33c-4a05-9b50-8e3e8e5976293b9f3fdd-80cb-4555-8069-f5ca2c67ecb7 MMF can lower blood cell counts so your hematologist may choose to regularly monitor this for the first year.e60dc2a1-f33c-4a05-9b50-8e3e8e5976298fc7fcf5-0ce2-4eed-bd73-29a1ba2efafd Dietary Considerations Avatrombopag is meant to be taken with food, while MMF should be taken on an empty stomach at least two hours apart from antacids.e60dc2a1-f33c-4a05-9b50-8e3e8e5976298fc7fcf5-0ce2-4eed-bd73-29a1ba2efafde60dc2a1-f33c-4a05-9b50-8e3e8e597629462b4b79-eb9f-4a89-affd-c44a64d77dbf Eltrombopag has the strictest dietary rules of the oral pills because it can bind to minerals like iron, calcium, and magnesium in the gut, reducing the amount the body absorbs.e60dc2a1-f33c-4a05-9b50-8e3e8e597629e2280994-0cd8-4693-a6ab-c1284a2a4b01e60dc2a1-f33c-4a05-9b50-8e3e8e597629bd3048aa-114a-42ee-8417-443ebfe0a81b “So when somebody is taking it, they have to take it on an empty stomach and be a little hyper-careful about what they eat or drink relative to when they take the medicine,” says James Bussel, MD , a hematologist at Weill Cornell Medicine. “For example, if you took eltrombopag with a glass of milk, you might as well not have been taking anything, because it’ll all be entirely inactivated by the milk.” Specifically, you must take eltrombopag at least two hours before or four hours after dairy, calcium-fortified juices, antacids, and supplements containing minerals such as calcium, iron, magnesium, or zinc.e60dc2a1-f33c-4a05-9b50-8e3e8e597629e2280994-0cd8-4693-a6ab-c1284a2a4b01e60dc2a1-f33c-4a05-9b50-8e3e8e597629462b4b79-eb9f-4a89-affd-c44a64d77dbf Lifestyle and Fitting It In If maximum autonomy is important, oral ITP medications may be right for you. Most pills are taken at home at your preferred schedule, with no clinic visits for doses, making them convenient for travel. They also don’t require any needles. The trade-off is that the routine falls on you because these pills are taken every day, sometimes twice a day (unless you’re tapered to a different dose schedule). Eltrombopag also requires planning meals and supplements around each dose. e60dc2a1-f33c-4a05-9b50-8e3e8e59762974e63392-f3e2-4922-bcf3-4b9661d782f8
A chronic blood disorder in which the immune system attacks platelets (blood cells important for blood clotting), immune thrombocytopenia (ITP) has long been initially treated with corticosteroids . But steroids rarely provide lasting control and many patients need a second-line therapy.e60dc2a1-f33c-4a05-9b50-8e3e8e597629bd3048aa-114a-42ee-8417-443ebfe0a81b If an initial steroid-only treatment didn’t work for you, the 2026 American Society of Hematology (ASH) guidelines recommend trying a thrombopoietin receptor agonist (TPO-RA) or, as an alternative, an immunosuppressant drug called rituximab. And if you can’t take or don’t want either of those options, ASH suggests a spleen tyrosine kinase (SYK) inhibitor, Bruton’s tyrosine kinase (BTK) inhibitor, or the broad immunosuppressant mycophenolate mofetil (MMF).e60dc2a1-f33c-4a05-9b50-8e3e8e597629099855b6-fd26-4e63-a4e2-0b11843584e1 While a safe platelet count is the goal with any ITP therapy, your quality of life during your treatment journey matters. Many factors can shape your daily life, including how a drug is given, what kind of monitoring it needs, what dietary restrictions it imposes, and whether it’s an ongoing treatment or a one-time course. It’s worth considering these details before you decide.
Subcutaneous Injections Subcutaneous Injections The TPO-RA romiplostim (Nplate) is the only second-line ITP therapy that comes in a subcutaneous (under-the-skin) injection form. Unlike the daily schedule of the oral medications, romiplostim is a single injection given each week.e60dc2a1-f33c-4a05-9b50-8e3e8e597629099855b6-fd26-4e63-a4e2-0b11843584e1 Romiplostim is typically given by a healthcare provider, but depending on your clinic, you may be able to do the injection at home, Dr. Neunert says. “For some patients, it would be weekly in the clinic, and that may be an added burden,” she says. “But if you’re able to get it for home, then for some patients, once a week is actually preferable.” Dr. Bussel also suggests that home injections can make treatment with romiplostim more palatable if you or a caregiver are willing to learn how to give them. “And another thing is, what if your next-door neighbor is a nurse or EMT, or your niece is a nurse, or something like that?” he says. Medical Monitoring Requirements Romiplostim requires routine medical monitoring of blood counts, so you’ll still need regular blood tests even if you do the injections at home. After you reach stable platelet levels, your care providers will check your blood counts on a monthly basis.e60dc2a1-f33c-4a05-9b50-8e3e8e597629e2280994-0cd8-4693-a6ab-c1284a2a4b01e60dc2a1-f33c-4a05-9b50-8e3e8e59762997c5f351-77ef-4080-b1ec-f838169bd8cf Dietary Considerations There are no specific dietary considerations or rules when taking romiplostim.e60dc2a1-f33c-4a05-9b50-8e3e8e59762997c5f351-77ef-4080-b1ec-f838169bd8cf Lifestyle and Fitting It In Romiplostim may be challenging to fit into your lifestyle if you need to come into the clinic every week to get your injection. But if you can do the injections at home and you’re okay with needles, it may be easier to remember a once-a-week dose than daily pills. The drug’s liver safety and lack of dietary requirements also make it an attractive option if you’re choosing between romiplostim and eltrombopag.e60dc2a1-f33c-4a05-9b50-8e3e8e59762997c5f351-77ef-4080-b1ec-f838169bd8cf
Questions for Your Doctor Key Questions for Your Hematologist To determine which second-line ITP treatment is right for you, here are some questions you may want to ask your hematologist.e60dc2a1-f33c-4a05-9b50-8e3e8e597629e2280994-0cd8-4693-a6ab-c1284a2a4b01e60dc2a1-f33c-4a05-9b50-8e3e8e597629099855b6-fd26-4e63-a4e2-0b11843584e1e60dc2a1-f33c-4a05-9b50-8e3e8e597629d47473db-de44-423d-b35c-59a19e30a6e6 If I want to avoid clinic appointments, which treatments would work best? If I find daily oral pills too difficult to stick with, can I switch to the injection or infusion options? Do I have to come into the clinic to get romiplostim injections? Could romiplostim injections still work for me if I travel a lot? Given my history of clots, high blood pressure, infections, or liver problems, which option is safest? Given eltrombopag’s liver and dietary considerations, why would I choose it over the other TPO-RAs?
Intravenous Infusions Intravenous Infusions Rituximab (Rituxan) is the only second-line treatment for ITP given by IV infusion. Unlike the pill- and injection-based therapies, rituximab is a one-time course of four infusions given weekly at a clinic. This means rituximab can lead to a lasting response in some people, though the effect often fades over time, and further treatment may be needed after the initial course.e60dc2a1-f33c-4a05-9b50-8e3e8e597629bba8ac75-1d41-40a3-9836-551f8b3e3b41e60dc2a1-f33c-4a05-9b50-8e3e8e597629099855b6-fd26-4e63-a4e2-0b11843584e1 Medical Monitoring Requirements Before starting rituximab, you will be screened for hepatitis B , which the drug can reactivate because of the way it affects the immune system. You will also need to get any necessary vaccines before starting it.e60dc2a1-f33c-4a05-9b50-8e3e8e597629eb715467-e98a-4075-b4bb-ff85b4370b1f When somebody gets rituximab, Bussel says, “vaccines are pretty useless for them for at least 4 to 6 months, if not up to 12 months.” You may also have to undergo blood tests before and after your course of treatment to measure your levels of immunoglobulin (antibodies), which are vital for immune system function. If your levels drop significantly after treatment, you may need immunoglobulin replacement therapy to avoid serious infection risks.e60dc2a1-f33c-4a05-9b50-8e3e8e597629f2b9edcb-a460-4f8e-8a57-f92933f0d3a2e60dc2a1-f33c-4a05-9b50-8e3e8e597629e33a57c5-0629-4dcf-a6b8-77d37fe32650 During the infusions, your provider will monitor you for any infusion reactions — like rash, fever, hives , muscle aches, headache, and temporary rises in blood pressure — and will likely give you steroids beforehand to prevent them.e60dc2a1-f33c-4a05-9b50-8e3e8e597629d47473db-de44-423d-b35c-59a19e30a6e6 Dietary Considerations There are no specific dietary considerations with rituximab therapy.e60dc2a1-f33c-4a05-9b50-8e3e8e597629eb715467-e98a-4075-b4bb-ff85b4370b1fe60dc2a1-f33c-4a05-9b50-8e3e8e597629f2b9edcb-a460-4f8e-8a57-f92933f0d3a2 Lifestyle and Fitting It In Rituximab might be right for you if you want to avoid daily or weekly home drug regimens. But the one-time treatment course does require time blocks in the clinic over four weeks and steroid premedication before each infusion. It’s also important to consider the drug’s temporary impact on your immune system.
