What is the treatment for thrombocytopenia (low platelet count)?

Treatment of Thrombocytopenia

The treatment of thrombocytopenia should be tailored to the underlying cause, with platelet transfusions reserved for patients with severe thrombocytopenia (platelet count <10 × 10⁹/L) or active bleeding, while specific therapies like TPO receptor agonists are indicated for immune thrombocytopenia that fails first-line treatments. 1

Diagnosis and Assessment

Before initiating treatment, it's essential to determine:

1. Severity of thrombocytopenia:

   • Mild: 50-150 × 10⁹/L
   • Moderate: 20-50 × 10⁹/L
   • Severe: <20 × 10⁹/L
   • Very severe: <10 × 10⁹/L 1

2. Presence of bleeding:

   • Patients with platelet counts >50 × 10⁹/L are generally asymptomatic
   • Platelet counts between 20-50 × 10⁹/L may cause mild skin manifestations (petechiae, purpura)
   • Platelet counts <10 × 10⁹/L carry high risk of serious bleeding 2

3. Underlying cause:

   • Decreased production (bone marrow failure, chemotherapy)
   • Increased destruction (immune thrombocytopenia, DIC)
   • Splenic sequestration (hypersplenism)
   • Drug-induced thrombocytopenia
   • Specific syndromes (HIT, TTP, VITT) 3

Treatment Approaches by Cause

1. Hypoproliferative Thrombocytopenia (Chemotherapy/Transplant)

• Prophylactic platelet transfusion for platelet counts ≤10 × 10⁹/L 4, 1, 5
• Low-dose platelets (1.41 × 10¹¹/m²) are as effective as higher doses for hospitalized patients 5
• Medium-dose platelets (2.4 × 10¹¹/m²) may be more cost-effective for outpatients 5
• ABO-compatible platelets improve increments and decrease refractoriness 5

2. Immune Thrombocytopenia (ITP)

First-line treatment:

• Corticosteroids: Prednisone 1 mg/kg orally for 21 days then tapered is preferred over shorter courses 4
• IVIg or anti-D (for Rh-positive, non-splenectomized patients) are alternatives 4

Second-line treatment:

• Romiplostim (TPO receptor agonist): Initial dose 1 mcg/kg weekly subcutaneously, adjust by 1 mcg/kg increments to maintain platelet count ≥50 × 10⁹/L; maximum 10 mcg/kg weekly 6
• Most adult patients respond with 2-3 mcg/kg dose 6
• Discontinue if no response after 4 weeks at maximum dose 6

3. Vaccine-Induced Immune Thrombotic Thrombocytopenia (VITT)

• IVIg (first-line treatment)
• Non-heparin anticoagulants for confirmed thrombosis
• Corticosteroids if IVIg is insufficient
• Plasma exchange as alternative to second IVIg dose
• Rituximab for refractory cases 4

Platelet Transfusion Thresholds

Platelet transfusions are indicated based on specific thresholds:

• <10 × 10⁹/L: Prophylactic transfusion even without bleeding 1
• <20 × 10⁹/L: With active bleeding 1
• <50 × 10⁹/L: For major bleeding or before invasive procedures 1

For specific procedures:

• Central venous catheter insertion: >20 × 10⁹/L
• Lumbar puncture: >40-50 × 10⁹/L
• Epidural anesthesia: >80 × 10⁹/L
• Major surgery: >50 × 10⁹/L
• Neurosurgery: >100 × 10⁹/L 1

Anticoagulation Management in Thrombocytopenia

For patients requiring anticoagulation:

• <20 × 10⁹/L: Hold anticoagulation completely
• 20-50 × 10⁹/L: Consider half-dose or hold with close monitoring
• >50 × 10⁹/L: Continue standard dosing with regular monitoring 1

Precautions and Monitoring

1. Activity restrictions: Patients with platelet counts <50 × 10⁹/L should avoid activities with high risk of trauma 1, 2

2. Medication avoidance: Avoid medications affecting platelet function (aspirin, NSAIDs) 1

3. Monitoring:

   • Weekly CBC during dose adjustment of TPO agonists
   • Monthly CBC after stable dose established
   • Weekly CBC for at least 2 weeks after discontinuation 6

Special Considerations

• Pregnancy: Regular platelet count monitoring throughout pregnancy; delivery mode based on obstetric indications rather than platelet count alone 1

• Cancer patients with VTE: Therapeutic anticoagulation if platelets >50 × 10⁹/L; half-dose for 20-50 × 10⁹/L 1

• Heparin-induced thrombocytopenia: Immediately discontinue all heparin products and initiate non-heparin anticoagulant 1

The treatment approach should be guided by the underlying cause, severity of thrombocytopenia, and presence of bleeding, with the primary goal of reducing morbidity and mortality while improving quality of life.