From the Guidelines
Thrombocytopenia in a patient with cholelithiasis, CKD, and diabetes should be managed by identifying and addressing the underlying cause, with a focus on optimizing diabetes management using medications such as SGLT2 inhibitors and GLP-1 RAs, as recommended by the 2020 KDIGO clinical practice guideline 1.
Causes of Thrombocytopenia
The causes of thrombocytopenia in this patient can be multifactorial, including:
- Medication side effects
- Uremic toxins from CKD
- Bone marrow suppression
- Immune-mediated destruction
- Cholelithiasis-related inflammation
Management of Thrombocytopenia
Management should begin with identifying and addressing the underlying cause.
- If medication-induced, the offending drug should be discontinued.
- For CKD-related thrombocytopenia, optimizing dialysis may help.
- In severe cases (platelets <10,000/μL or with bleeding), platelet transfusions may be necessary.
- Specific treatments depend on the etiology:
- Corticosteroids for immune thrombocytopenia
- Erythropoietin for CKD-related bone marrow suppression
- Treating infections if present
- The patient's diabetes management should be optimized as hyperglycemia can affect platelet function, using medications such as SGLT2 inhibitors and GLP-1 RAs, as recommended by the 2020 KDIGO clinical practice guideline 1.
- For cholelithiasis-related inflammation causing thrombocytopenia, treating the gallbladder disease may resolve the issue.
Monitoring and Prevention
Regular monitoring of platelet counts is essential, with more frequent checks if counts are severely low.
- Patients should avoid medications that affect platelet function, such as NSAIDs and certain antiplatelet drugs, until platelet counts normalize.
- Optimizing CKD management, as outlined in the diabetic kidney disease management field guide for health care professionals 1, can also help reduce the risk of thrombocytopenia and its complications.
From the FDA Drug Label
In patients with chronic hepatitis C, ALVAIZ in combination with interferon and ribavirin may increase the risk of hepatic decompensation [see Warnings and Precautions (5. 1)]. ALVAIZ may increase the risk of severe and potentially life-threatening hepatotoxicity.
- 1 Treatment of Thrombocytopenia in Patients with Persistent or Chronic Immune Thrombocytopenia ALVAIZ® (eltrombopag tablets) are indicated for the treatment of thrombocytopenia in adult and pediatric patients 6 years and older with persistent or chronic immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy
The cause of thrombocytopenia in a patient with cholelithiasis, Chronic Kidney Disease (CKD), and diabetes mellitus is not directly addressed in the provided drug label. Management of thrombocytopenia with eltrombopag may be considered if the patient has persistent or chronic immune thrombocytopenia (ITP), but the label does not provide information on the management of thrombocytopenia in patients with cholelithiasis, CKD, and diabetes mellitus 2.
- The label indicates that ALVAIZ is used to treat thrombocytopenia in patients with ITP or chronic hepatitis C.
- It does not provide information on the use of ALVAIZ in patients with cholelithiasis, CKD, or diabetes mellitus.
From the Research
Causes of Thrombocytopenia
- Thrombocytopenia in patients with liver disease may result from elevated portal pressure and varix formation, reduced hepatic synthesis of coagulation proteins, qualitative platelet dysfunction, and/or thrombocytopenia 3
- Major mechanisms of thrombocytopenia in liver disease include splenic sequestration and impaired platelet production due to reduced thrombopoietin production 3
- Thrombocytopenia can also be caused by depressed thrombopoietin levels, direct bone marrow suppression, splenic sequestration, and increased destruction of platelets 4
Management of Thrombocytopenia
- Periprocedural management of thrombocytopenia of liver disease depends on both individual patient characteristics and the bleeding risk of the procedure 3
- Patients with a platelet count higher than or equal to 50 000/µL and those requiring low-risk procedures rarely require platelet-directed therapy 3
- 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
- Treatment options include thrombopoietin receptor agonists, platelet transfusion, and spleen-directed therapy 3
Relationship between Thrombocytopenia and Splenomegaly
- Hematocytopenia, including thrombocytopenia, is a common complication of splenomegaly caused by cirrhotic portal hypertension 5
- Splenectomy can be an effective treatment for splenomegaly associated with hematocytopenia, but patients without hematocytopenia may choose a non-surgical alternative treatment 5
- Distal splenorenal shunting (DSRS) can also effectively control profound thrombocytopenia resulting from presinusoidal portal hypertension or stable cirrhosis without sacrificing the spleen 6
Considerations for Patients with Cholelithiasis, CKD, and Diabetes Mellitus
- Patients with cholelithiasis, CKD, and diabetes mellitus may have multiple comorbidities that increase their risk of bleeding and thrombocytopenia 3, 4
- Management of thrombocytopenia in these patients should take into account their individual patient characteristics, bleeding risk, and comorbidities 3