Refractory immune thrombocytopenia (ITP) in adults remains a therapeutic challenge, affecting 3–8% of patients andassociated with significant bleeding risk, treatment-related toxicity, and impaired quality of life. This narrative review synthesizes contemporary evidence on the stepwise management of refractory ITP, emphasizing the transition from risk-adapted early intervention to advanced multimodal strategies. Key principles include early identification of highrisk patients using clinical, therapeutic response, and biological predictors, prompt diagnostic reappraisal to exclude secondary causes, and individualized sequencing of third-line and emerging therapies.
Current options encompass fostamatinib, Bruton tyrosine kinase (BTK) inhibitors, complement inhibitors, FcRn antagonists, and autologous hematopoietic stem cell transplantation in highly selected cases. Integration of TPO-RAs with immunosuppression, careful management of bleeding risk, and consideration of comorbidities are central to optimizing outcomes. Future directions point toward biomarker-driven therapy and novel agents targeting specific pathogenic pathways.

Bouchnafati Sanaa,"Management Strategies in Refractory Adult Immune Thrombocytopenia" International Journal of Advanced Multidisciplinary Research and Educational Development, V2(4): Page(382-384) July - August 2026. ISSN: 3107-6513. www.ijamred.com. Published by Scientific and Academic Research Publishing.