What is the initial management for a 91-year-old male with thrombocytosis (elevated platelet count)?

From the Guidelines

The initial management for a 91-year-old male with thrombocytosis should focus on determining the underlying cause and assessing the risk of thrombotic complications, with low-dose aspirin (81-100 mg daily) considered for primary thrombocytosis to reduce thrombotic risk, as per the guidelines for myeloproliferative neoplasms 1. Given the patient's advanced age, it is crucial to evaluate the risk of thrombosis and bleeding, and to manage cardiovascular risk factors.

• The approach to thrombocytosis management differs based on whether the condition is reactive (secondary) or primary (essential thrombocythemia), with treatment targeting the underlying condition for reactive thrombocytosis.
• For primary thrombocytosis, cytoreductive therapy may be considered for high-risk patients, with hydroxyurea being a common first-line agent, although its use in a 91-year-old patient would require careful consideration of potential side effects and comorbidities.
• Regular monitoring of blood counts is essential, typically every 2-4 weeks initially, then every 2-3 months once stable, with treatment goals including maintaining platelet counts below 400,000/μL while minimizing medication side effects 1.
• The patient's comorbidities, medication interactions, and bleeding risk must be carefully considered when developing the treatment plan, especially given the patient's advanced age, and asymptomatic patients may not require cytoreductive therapy, with a focus on monitoring for new thrombosis or bleeding, and managing cardiovascular risk factors 1.

From the Research

Initial Management of Thrombocytosis

The initial management for a 91-year-old male with thrombocytosis (elevated platelet count) involves several considerations, including the risk of thrombosis and bleeding.

• The use of low-dose aspirin is recommended for the control of vascular events in patients with essential thrombocythemia (ET), a condition characterized by an elevated platelet count 2.
• However, the decision to use aspirin should be individualized, taking into account the patient's risk of thrombosis and bleeding, as well as the presence of any contraindications 3.
• In patients with ET, low-dose aspirin (81-100 mg) once daily is often recommended, but twice-daily administration may be necessary to maintain adequate platelet inhibition 2, 4.

Aspirin Dosage and Administration

• The optimal dosage and administration of aspirin in patients with thrombocytosis is not well established, but studies suggest that twice-daily dosing may be more effective than once-daily dosing in maintaining platelet inhibition 4.
• The use of plain aspirin is preferred over enteric-coated aspirin, as some patients with ET may display poor responsiveness to the latter 2.
• The efficacy of aspirin therapy should be monitored, and the dosage adjusted as needed to maintain adequate platelet inhibition 2, 4.

Cytoreductive Therapy

• Cytoreductive therapy, such as hydroxyurea, may be considered in patients with ET who are at high risk of thrombosis or have a high platelet count 5.
• However, the use of cytoreductive therapy in patients with thrombocytosis should be individualized, taking into account the patient's risk of thrombosis and bleeding, as well as the presence of any contraindications 5, 3.
• In patients with ET, cytoreductive therapy may be used in combination with aspirin to reduce the risk of thrombosis and bleeding 5, 6.