From the Guidelines
Thrombocytopenia is a condition characterized by a low platelet count, and its management depends on the underlying cause, severity, and patient's bleeding risk, with treatment options including observation, corticosteroids, intravenous immunoglobulin, thrombopoietin receptor agonists, rituximab, splenectomy, and platelet transfusions, as recommended by the American Society of Hematology 2019 guidelines for immune thrombocytopenia 1. The main causes of thrombocytopenia include:
- Decreased production (bone marrow disorders like leukemia, aplastic anemia, or drug toxicity)
- Increased destruction (immune thrombocytopenia, disseminated intravascular coagulation, or thrombotic thrombocytopenic purpura)
- Sequestration (hypersplenism)
- Dilution (massive transfusions) For mild cases without bleeding, observation may be sufficient, while for immune thrombocytopenia, first-line treatment typically includes corticosteroids like prednisone (1 mg/kg/day for 2-4 weeks with gradual taper) or dexamethasone (40 mg daily for 4 days) 1. Intravenous immunoglobulin (1 g/kg for 1-2 days) provides rapid but temporary response in emergency situations, and second-line options include thrombopoietin receptor agonists like eltrombopag (starting at 50 mg daily) or romiplostim (1 μg/kg weekly subcutaneously, adjusted based on response), rituximab (375 mg/m² weekly for 4 weeks), or splenectomy 1. Drug-induced thrombocytopenia requires discontinuation of the offending medication, and platelet transfusions are generally reserved for severe thrombocytopenia (below 10,000/μL) with active bleeding or before invasive procedures, as recommended by the American Society of Clinical Oncology clinical practice guideline update 1. The underlying pathophysiology involves either inadequate platelet production in the bone marrow or accelerated peripheral destruction, with treatment aimed at addressing these mechanisms to restore normal platelet counts and prevent bleeding complications, as discussed in the American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia 1.
From the Research
Causes of Thrombocytopenia
- Decreased platelet production 2, 3, 4
- Increased destruction of platelets 2, 3, 4
- Splenic sequestration 2, 4
- Dilution or clumping of platelets 2
- Infections 3
- Malignancy 3
- Liver disease 2, 3
- Autoimmune disorders 3
- Disseminated intravascular coagulation 3
- Pregnancy 3
- Medications 2, 3
- Coagulation disorders 3
- Vitamin B12 deficiency 5, 6
Management of Thrombocytopenia
- Treatment is determined by the underlying cause of the thrombocytopenia 3
- Transfusion of platelets is recommended when patients have active hemorrhage or when platelet counts are less than 10 × 10^3 per μL 2
- Treatment of underlying causative conditions (when possible) 2
- Activity restrictions to avoid trauma-associated bleeding in patients with platelet counts of less than 50 × 10^3 per μL 2
- Ensuring adequate platelet counts to decrease bleeding risk before invasive procedures, which may require a platelet transfusion 2