From the Guidelines
For a patient with mild thrombocytopenia, a normal peripheral smear, and no symptoms, the next step in management is close monitoring with regular complete blood count (CBC) checks every 1-3 months without immediate intervention. This approach is supported by the American Society of Hematology 2019 guidelines for immune thrombocytopenia 1, which emphasize the importance of considering the patient's overall clinical context, including the presence of symptoms and the risk of bleeding, when deciding on the management strategy. Given that the patient's platelet count is mildly decreased (137 and 138 on repeat) but still within a range that is often considered mild thrombocytopenia, and there are no symptoms or abnormalities on the peripheral smear, an aggressive treatment approach is not warranted at this time. The patient should be educated on the risks associated with thrombocytopenia, the importance of avoiding medications that can affect platelet function such as aspirin and NSAIDs, and the need to report any signs of bleeding or bruising promptly 1. If the patient requires surgery or invasive procedures, their platelet count should be reassessed beforehand to evaluate the risk of bleeding and the potential need for preoperative intervention. Investigating the underlying cause of thrombocytopenia, if not already done, is also crucial, considering common causes such as medication effects, viral infections, or immune-mediated processes. This conservative management strategy is justified by the low risk of significant bleeding in patients with mild thrombocytopenia and the potential for many cases to resolve spontaneously or remain stable without progressing to more severe thrombocytopenia. It's also important to note that while corticosteroids are a common initial treatment for immune thrombocytopenia, as discussed in the international consensus report on the investigation and management of primary immune thrombocytopenia 1, their use is typically reserved for patients with more severe thrombocytopenia or those who are symptomatic, due to the potential for significant side effects. Therefore, for a patient with mild, asymptomatic thrombocytopenia, close monitoring rather than immediate pharmacological intervention is the most appropriate next step in management.
From the Research
Next Steps in Management
The patient has a platelet count of 137, which is considered mildly thrombocytopenic, with a repeat count of 138 and no symptoms, as well as a normal peripheral smear.
- The patient's platelet count is above 50 × 10^3 per µL, which suggests that they are unlikely to have symptoms 2, 3.
- Given the patient's stable condition and lack of symptoms, the next step would be to distinguish acute from chronic thrombocytopenia by obtaining or reviewing previous platelet counts 3.
- If the thrombocytopenia is confirmed to be chronic, the patient may not require immediate intervention, but rather monitoring and potentially treatment of any underlying causative conditions 2, 3.
- It is also important to consider the possibility of pseudothrombocytopenia, which can be excluded by collecting blood in a tube containing heparin or sodium citrate and repeating the platelet count 3.
Considerations for Treatment
- Treatment is based on the etiology of the thrombocytopenia, and in some cases, treating the secondary cause can result in normalization of platelet counts 2.
- If the patient is diagnosed with immune thrombocytopenia, treatment options may include romiplostim and eltrombopag as a second-line treatment 4.
- Platelet transfusion is recommended when patients have active hemorrhage or when platelet counts are less than 10 × 10^3 per µL, in addition to treatment of underlying causative conditions 3, 5.