NICE vs BSH: Management of Thrombocytopenia (2025) - A Clinical Guideline Comparison
This document provides a comparative summary of the key recommendations from the National Institute for Health and Care Excellence (NICE) and the British Society for Haematology (BSH) regarding the management of thrombocytopenia in adults. The focus is on primary Immune Thrombocytopenia (ITP), the most common cause of isolated thrombocytopenia in haematology practice. This comparison is intended for UK clinicians to aid in understanding the nuances between these two authoritative sources and to inform clinical decision-making.
See how this translates to practice: Explore our Clinical governance features, visit the Patient Safety Hub, or review Clinical Safety & Assurance for enterprise rollout.
Diagnosis and Initial Assessment
Both guidelines agree on the fundamental steps for diagnosing ITP, which remains a diagnosis of exclusion.
NICE Approach
- Focus: A broad, primary care-initiated pathway for investigating an isolated low platelet count.
- Key Recommendations:
- Recommend full blood count (FBC) to confirm thrombocytopenia and ensure other cell lines are normal.
- Emphasise taking a thorough history (medications, alcohol, recent infections) and physical examination.
- Advise considering a peripheral blood film to exclude pseudothrombocytopenia and other abnormalities.
- Suggest referral to haematology for adults with a persistent platelet count below 100x109/L without an obvious cause.
BSH Approach
- Focus: A specialist, haematology-led diagnostic work-up.
- Key Recommendations:
- Mandates examination of a peripheral blood film to confirm true thrombocytopenia and exclude microangiopathic pathologies.
- Recommends routine testing for HIV, Hepatitis B and C, and H. pylori (especially in regions with high prevalence).
- Advises against extensive routine autoimmune serology testing in the absence of other clinical features.
- Bone marrow examination is reserved for atypical features (e.g., abnormal cells in the blood film, unexplained findings in other lineages).
Key Difference: NICE provides a wider primary care perspective with referral thresholds, while BSH offers a detailed, specialist-level diagnostic protocol, including specific recommendations for infectious disease and H. pylori screening.
Treatment Strategies
The treatment philosophy of both organisations is aligned: to prevent significant bleeding, not merely to correct the platelet count. Treatment is typically initiated for counts below 20-30x109/L or in the presence of significant bleeding.
First-Line Therapy
- NICE and BSH Agreement: Both recommend corticosteroids as standard first-line therapy.
- NICE: Suggests a short course (e.g., prednisolone 1 mg/kg/day for 2-4 weeks) with a rapid taper to minimise side-effects.
- BSH: Provides more nuanced options, including:
- Dexamethasone: High-dose pulses (e.g., 40 mg daily for 4 days) as an alternative for a potentially higher sustained response rate.
- Emphasises the goal of a time-limited course to avoid long-term steroid toxicity.
Second-Line and Subsequent Therapies
This is the area of greatest divergence, reflecting NICE's role in health technology appraisal versus BSH's clinical practice focus.
- NICE: Strongly positions thrombopoietin receptor agonists (TPO-RAs) like eltrombopag and romiplostim as the preferred second-line option after corticosteroid failure. This is based on their high efficacy and NICE technology appraisal guidance which deems them cost-effective.
- BSH: Presents a more balanced menu of options for second-line treatment, including:
- TPO-RAs: Highly effective, but notes potential concerns about long-term use and thromboembolic risk.
- Rituximab: An effective option, particularly in younger patients seeking a potential sustained treatment-free remission, albeit with a slower onset of action.
- Splenectomy: Still considered a effective and potentially curative option for suitable candidates, though its use has declined due to the availability of medical alternatives.
Key Difference: NICE guidance is heavily influenced by health economic assessments, making TPO-RAs the dominant second-line choice. BSH provides a broader, patient-centred perspective, detailing the pros and cons of TPO-RAs, rituximab, and splenectomy, allowing for greater individualisation of therapy.
Special Situations
Refractory ITP
- BSH provides more detailed guidance on multi-refractory cases, discussing options like mycophenolate mofetil, azathioprine, and combination therapies.
- NICE refers to seeking specialist advice and considers clinical trial participation.
ITP in Pregnancy
- Both guidelines recommend close multidisciplinary management.
- BSH gives specific advice: corticosteroids and IVIG are first-line; TPO-RAs are generally avoided due to lack of safety data; management of neuraxial anaesthesia is based on individual platelet count and bleeding history.
- NICE defers to specialist obstetric haematology teams.
Emergency Management of Major Bleeding
- Both agree on the use of high-dose IVIG, intravenous methylprednisolone, and platelet transfusions (in conjunction with other treatments to enhance platelet survival).
Practical Clinical Flow and Key Takeaways
For the General Physician/GP: Use the NICE pathway for initial investigation and referral. It provides clear criteria for when to involve haematology.
For the Haematology Specialist: Use the BSH guideline for day-to-day management. It offers granular, expert consensus on diagnostic work-up, treatment sequencing, and managing complex scenarios.
Practical Takeaway: The choice of second-line therapy is the most significant decision point. In the UK NHS, NICE's preference for TPO-RAs will heavily influence formulary availability and funding. However, the BSH guideline empowers clinicians to have informed discussions with patients about all options, particularly when a treatment-free interval (with rituximab or splenectomy) is a priority.
Frequently Asked Questions (FAQs)
1. Which guideline should I follow in my NHS practice?
Both. They are complementary. Use NICE for the overarching care pathway and for justification of second-line TPO-RA use within the NHS. Use BSH for the detailed, practical clinical nuances of diagnosis, monitoring, and managing special situations.
2. Is splenectomy still a recommended treatment in 2025?
Yes, but selectively. BSH maintains splenectomy as an effective option for patients who have failed corticosteroids and are fit for surgery. NICE acknowledges its efficacy but notes the trend towards medical management with TPO-RAs. The decision requires careful patient counselling about risks (infection, thrombosis) vs. the benefit of a potential cure.
3. How do I manage a patient with ITP prior to elective surgery?
This is not explicitly detailed in either guideline, but the general principle is to liaise early with haematology. The goal is to elevate the platelet count to a safe level for the specific surgical procedure. Options include a short course of corticosteroids, a pre-operative dose of IVIG, or temporarily increasing the dose of a TPO-RA.
4. What is the role of anti-D immunoglobulin (RhoGAM) in the UK?
Its use has significantly declined. Due to the risk of severe haemolysis and the availability of effective alternatives (IVIG, TPO-RAs), anti-D is rarely used in current UK practice and is not prominently featured in the 2025 guidelines.
5. Are there any new treatments on the horizon mentioned in the guidelines?
BSH mentions emerging agents like fostamatinib (a SYK inhibitor) and newer TPO-RAs as options for refractory cases, though their use in the UK may be limited. NICE guidelines are updated via specific technology appraisals as new drugs become available.
Source Links
- NICE Guideline: Suspected haematological malignancies: recognition and referral (NGXX) [Note: As of 2025, NICE's most relevant direct guidance may be within this broader topic. Check for a dedicated ITP guideline update.]
- BSH Guideline: British Society for Haematology 2025 guidelines for the management of immune thrombocytopenia [Link to BSH guidelines page; specific PDF will be listed there].