How to manage thrombocytopenia in an elderly patient with ESRD and breast cancer?

Management of Thrombocytopenia in an 81-Year-Old with ESRD and Breast Cancer

For this 81-year-old African-American female with persistent moderate thrombocytopenia (platelets 49-101k), ESRD, breast cancer, and a negative bone marrow biopsy, a thrombopoietin receptor agonist (TPO-RA) such as romiplostim is the most appropriate next step in management. 1

Assessment of Current Thrombocytopenia

• Patient has persistent moderate thrombocytopenia with platelets ranging from 49-101k over the past year
• Bone marrow biopsy from 11/2/2023 was negative, ruling out bone marrow infiltration
• Two major comorbidities that could contribute to thrombocytopenia:
  • End-stage renal disease (ESRD)
  • Left breast cancer
  • Pancytopenia (suggesting a broader hematologic issue)

Diagnostic Considerations

1. Rule out pseudothrombocytopenia:

   • Check for platelet clumping by examining peripheral blood smear
   • Consider collecting blood in a tube containing heparin or sodium citrate 1

2. Evaluate for potential causes:

   • ESRD-related uremic thrombocytopathy
   • Cancer-related immune thrombocytopenia
   • Drug-induced thrombocytopenia (review all medications)
   • Heparin-induced thrombocytopenia (if on dialysis with heparin exposure)

Treatment Algorithm

1. For platelets consistently <50k (current 49k):

   • Initiate TPO-RA therapy - romiplostim is preferred based on evidence in ESRD patients 1, 2
   • Starting dose: 1 mcg/kg subcutaneously weekly, with dose adjustments to maintain platelets >50k 3
   • Romiplostim has been successfully used in patients with ESRD on hemodialysis 2

2. Monitoring recommendations:

   • Check platelet count weekly initially, then every 2-4 weeks once stable
   • Target platelet count: 50-100 × 10⁹/L (not aiming for normal counts) 1
   • Monitor for signs of thrombosis, particularly with history of breast cancer

3. Anticoagulation considerations (if needed for dialysis):

   • With current platelet count <50k, consider reducing anticoagulant dosing to 50% of therapeutic dose 1
   • Full therapeutic anticoagulation can be resumed once platelets are >50k

4. Activity restrictions:

   • Recommend activity restrictions to avoid trauma-associated bleeding until platelets >50k 1

Special Considerations for This Patient

1. ESRD considerations:

   • No dose adjustment needed for romiplostim in renal impairment 3
   • Romiplostim has been successfully used in dialysis patients with thrombocytopenia 2

2. Breast cancer considerations:

   • Ensure breast cancer treatment is not compromised by thrombocytopenia
   • If chemotherapy is planned, TPO-RA therapy can help maintain adequate platelet counts 4
   • Monitor for potential thrombotic complications, as both cancer and TPO-RAs can increase thrombosis risk

3. Age considerations:

   • At 81 years, the patient is at higher risk for bleeding complications with thrombocytopenia
   • Careful monitoring for adverse effects of therapy is essential

Alternative Options

1. If romiplostim is unavailable or ineffective:

   • Consider eltrombopag 25-50mg daily (starting with lower dose due to age) 5
   • Note that eltrombopag requires more frequent monitoring for hepatotoxicity

2. For acute bleeding or severe thrombocytopenia (<10k):

   • Platelet transfusions may be necessary 1
   • Consider IVIG (0.8-1 g/kg) for temporary increase in platelet count 1

3. If TPO-RAs fail:

   • Short course of corticosteroids (prednisone 1-2 mg/kg/day for maximum 14 days) 1
   • Consider rituximab if other options fail 1

The case demonstrates the complexity of managing thrombocytopenia in elderly patients with multiple comorbidities. TPO-RAs have shown efficacy in patients with ESRD and cancer-related thrombocytopenia, making romiplostim the most appropriate next step for this patient.