From the Guidelines
Watchful waiting with a limited evaluation for liver disease is the most appropriate approach for this 68-year-old male with persistent mild thrombocytopenia, given his history of heavy alcohol use and poorly controlled diabetes. The patient's condition appears stable, and he is asymptomatic without bleeding, which suggests that his current medications, including Eliquis and metoprolol, can be continued as the thrombocytopenia is mild and predates Eliquis initiation 1. However, considering his history of heavy alcohol use, which can directly suppress platelet production in the bone marrow and cause splenic sequestration if there is developing portal hypertension, even with normal transaminases, a limited evaluation for liver disease would be reasonable despite normal AST/ALT values 1. I recommend checking:
- A complete blood count with peripheral smear
- Comprehensive metabolic panel including albumin, bilirubin, and alkaline phosphatase
- Possibly an abdominal ultrasound to assess for portal hypertension or splenomegaly His diabetes may also contribute to the thrombocytopenia, so encouraging continued reduction in alcohol intake and improved diabetes management is crucial, as these interventions may help improve platelet counts over time 1. Follow-up platelet counts every 3-6 months would be appropriate to monitor for stability or progression. Given the patient's history of heavy drinking, risk stratification with clinical assessment and possibly Fibroscan/ARFI elastography should be considered, as recommended by guidelines on the management of abnormal liver blood tests 1.
From the Research
Patient Evaluation
The patient is a 68-year-old male with a flutter well controlled on metoprolol and eliquis, and persistent mild thrombocytopenia with platelet counts of 119 and 117 two months later. The patient has a history of heavy drinking, which is improving, and diabetes with an A1c of 8.4%.
Thrombocytopenia and Liver Disease
Thrombocytopenia is a common complication in patients with chronic liver disease (CLD) 2, 3, 4. The pathophysiology of thrombocytopenia in CLD is multifactorial and includes splenic sequestration, bone marrow suppression, and reduced thrombopoietin production. Thrombopoietin is predominantly produced by the liver, and its levels are reduced in patients with advanced liver disease 3, 4.
Watchful Waiting
Watchful waiting is a form of clinical management where immediate curative treatment is not given, and the patient undergoes a period of observation with periodic tests to monitor the progression of the illness 5, 6. The decision to choose watchful waiting is complex and involves an array of emotions, including uncertainty and anxiety 6.
Evaluation for Liver Disease
Given the patient's history of heavy drinking and thrombocytopenia, evaluation for liver disease may be necessary. Although the patient's AST and ALT levels are normal, thrombocytopenia can be an indicator of advanced liver disease 2, 3, 4. Further testing, such as liver ultrasound or liver function tests, may be needed to rule out liver disease.
Management
The management of thrombocytopenia in patients with CLD is complex and requires a multidisciplinary approach. Treatment options may include medications to stimulate thrombopoietin production, such as eltrombopag, or procedures to reduce splenic sequestration, such as splenectomy or splenic artery embolization 2, 3, 4. Watchful waiting may be an appropriate approach for patients with mild thrombocytopenia and no evidence of liver disease, but close monitoring of platelet counts and liver function is necessary 5, 6.
- The patient's thrombocytopenia may be related to his history of heavy drinking and potential liver disease.
- Evaluation for liver disease, including liver ultrasound or liver function tests, may be necessary.
- Watchful waiting may be an appropriate approach, but close monitoring of platelet counts and liver function is necessary.
- Treatment options, such as medications to stimulate thrombopoietin production, may be considered if liver disease is diagnosed.