From the Guidelines
Thrombocytopenia related to liver disease should be treated by addressing the underlying liver condition, and thrombopoietin receptor agonists like avatrombopag or lusutrombopag can be used to stimulate platelet production before invasive procedures, as they have been shown to be effective in increasing platelet counts without increasing the risk of thrombosis 1.
Treatment Approach
The primary approach to treating thrombocytopenia related to liver disease involves addressing the underlying liver condition through:
- Alcohol cessation
- Antiviral therapy for hepatitis
- Management of autoimmune hepatitis
Platelet Transfusions
Platelet transfusions may be necessary in cases of severe thrombocytopenia with bleeding or before invasive procedures, typically given as 1 unit per 10 kg body weight. However, the use of platelet transfusions should be cautious, as they carry potential risks, including transfusion-related lung injury syndromes 1.
Thrombopoietin Receptor Agonists
Thrombopoietin receptor agonists like avatrombopag (40-60 mg daily for 5-7 days before procedures) or lusutrombopag can stimulate platelet production by binding to thrombopoietin receptors on megakaryocytes. These medications have been shown to be effective in increasing platelet counts without increasing the risk of thrombosis 1.
Portal Hypertension Management
In cases of portal hypertension, beta-blockers like propranolol (starting at 20 mg twice daily) may help reduce splenic sequestration of platelets. However, the management of portal hypertension should be individualized, and the use of beta-blockers should be cautious, as they may have adverse effects in patients with advanced liver disease.
Refractory Cases
For refractory cases, splenectomy or partial splenic embolization might be considered, though these carry significant risks in patients with advanced liver disease. The use of these procedures should be individualized, and the potential benefits and risks should be carefully weighed.
Monitoring
Regular monitoring of platelet counts and liver function is essential throughout treatment, as it allows for the adjustment of treatment strategies and the early detection of potential complications.
Recent Guidelines
Recent guidelines from the European Association for the Study of the Liver (EASL) recommend the use of thrombopoietin receptor agonists like avatrombopag or lusutrombopag in patients with thrombocytopenia related to liver disease who are scheduled to undergo an invasive procedure 1. These guidelines also emphasize the importance of addressing the underlying liver condition and the cautious use of platelet transfusions.
From the FDA Drug Label
1.2 Treatment of Thrombocytopenia in Patients with Hepatitis C Infection 2.3 Recommended Dosage for Chronic Hepatitis C-associated Thrombocytopenia 5.1 Hepatic Decompensation in Patients with Chronic Hepatitis C 5.2 Hepatotoxicity 8.6 Hepatic Impairment
Thrombocytopenia related to liver disease is treated with eltrombopag (PO), which is indicated for the treatment of thrombocytopenia in patients with Hepatitis C Infection. The recommended dosage for Chronic Hepatitis C-associated Thrombocytopenia is specified in the drug label. However, it is essential to note the warnings for Hepatic Decompensation and Hepatotoxicity in patients with chronic hepatitis C. Additionally, the label provides information on Hepatic Impairment, which should be considered when treating patients with liver disease 2.
- Key considerations:
- Hepatic Decompensation
- Hepatotoxicity
- Hepatic Impairment
From the Research
Thrombocytopenia and Liver Disease
Thrombocytopenia is a common complication of liver disease, with a multifactorial pathophysiology involving:
- Splenomegaly and increased splenic sequestration of circulating platelets
- Reduced hepatic synthesis of thrombopoietin, resulting in diminished platelet production and release from the bone marrow
- Increased platelet destruction or consumption 3, 4, 5
Treatment of Thrombocytopenia in Liver Disease
Treatment of thrombocytopenia in liver disease depends on individual patient characteristics and the bleeding risk of the procedure:
- Patients with a platelet count higher than or equal to 50,000/µL and those requiring low-risk procedures rarely require platelet-directed therapy
- For those with a platelet count below 50,000/µL who require a high-risk procedure, platelet-directed therapy should be considered, especially if the patient has other risk factors for bleeding 3
- Thrombopoietin receptor agonists, such as avatrombopag and lusutrombopag, are available for targeted treatment of thrombocytopenia in patients with advanced liver disease undergoing invasive procedures 4, 6
Management of Thrombocytopenia
Management of thrombocytopenia in liver disease involves:
- Risk-adapted management, including a restrictive transfusion regimen
- Use of thrombopoietin agonists to increase platelet counts
- Consideration of other strategies, such as spleen-directed therapy or transjugular intrahepatic portosystemic shunt placement, in high-risk patients who have an inadequate response to or are otherwise unable to receive these therapies 3, 6