Treatment of Thrombocytopenia
The treatment of thrombocytopenia should be guided by the platelet count, presence of bleeding, and underlying cause, with glucocorticoid therapy (prednisone 1-2 mg/kg/day) being the appropriate initial treatment for patients with immune thrombocytopenia (ITP) with platelet counts <30,000/μL. 1
Evaluation and Classification
Thrombocytopenia is defined as a platelet count less than 150 × 10³/μL and can be classified by severity:
- Mild: 50-150 × 10⁹/L
- Moderate: 20-50 × 10⁹/L
- Severe: <20 × 10⁹/L
- Very severe: <10 × 10⁹/L 2
Before initiating treatment, it's essential to:
- Rule out pseudothrombocytopenia (laboratory artifact)
- Determine if thrombocytopenia is acute or chronic
- Identify the underlying cause (decreased production, increased destruction, splenic sequestration, or dilution) 3
Treatment Algorithm Based on Platelet Count and Bleeding
For Platelet Count <10 × 10⁹/L
- High risk of serious bleeding 3
- Immediate platelet transfusion is recommended regardless of bleeding status 2
- For ITP: Start glucocorticoid therapy (prednisone 1-2 mg/kg/day) 1
For Platelet Count 10-20 × 10⁹/L
- Treatment is indicated regardless of symptoms 1
- For ITP: Glucocorticoid therapy (prednisone 1-2 mg/kg/day) 1
- Platelet transfusion if active bleeding is present 2
For Platelet Count 20-30 × 10⁹/L
- For ITP: Glucocorticoid therapy (prednisone 1-2 mg/kg/day) is appropriate 1
- Monitor closely for bleeding signs
For Platelet Count 30-50 × 10⁹/L
- For ITP: Treat if clinically important bleeding is present 1
- For other causes: Treatment may not be necessary unless bleeding or invasive procedures planned
For Platelet Count >50 × 10⁹/L
- Generally asymptomatic and may not require specific treatment for the thrombocytopenia 3
- Treatment of underlying cause may still be necessary
Treatment Based on Specific Causes
Immune Thrombocytopenia (ITP)
First-line therapy:
Second-line therapy (if inadequate response to glucocorticoids):
Refractory ITP (failing first and second-line therapies):
- Combination chemotherapy 1
- Rituximab
- Immunosuppressive agents
Drug-Induced Thrombocytopenia
- Discontinue the suspected medication
- Consider alternative medications
- Monitor platelet count for recovery
Heparin-Induced Thrombocytopenia (HIT)
- Immediately discontinue all heparin products
- Initiate non-heparin anticoagulant (argatroban, bivalirudin, fondaparinux) 2
Management of Bleeding
For Minor Bleeding
- Local measures (pressure, ice)
- Antifibrinolytic agents (tranexamic acid)
For Major/Life-Threatening Bleeding
- Platelet transfusion to maintain count >50 × 10⁹/L 2
- For ITP with severe bleeding: Combination therapy with:
- High-dose glucocorticoids
- IVIg
- Platelet transfusions 5
Platelet Transfusion Thresholds for Procedures
| Procedure | Recommended Platelet Count |
|---|---|
| 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 |
Anticoagulation Management in Thrombocytopenia
| Platelet Count | Anticoagulant Management |
|---|---|
| <20 × 10⁹/L | Hold anticoagulants completely |
| 20-50 × 10⁹/L | Consider half-dose or hold with close monitoring |
| >50 × 10⁹/L | Continue standard dosing with regular monitoring |
Special Considerations
Pregnancy
- Regular platelet count monitoring throughout pregnancy
- Mode of delivery based on obstetric indications rather than platelet count alone 2
Activity Restrictions
- Patients with platelet counts <50 × 10⁹/L should avoid activities with high risk of trauma 2, 3
- Limit alcohol intake and avoid medications that affect platelet function (aspirin, NSAIDs) 2
Monitoring
- Weekly CBCs during dose adjustment phase of treatment
- Monthly CBCs after establishing stable treatment
- Weekly monitoring for at least 2 weeks after discontinuing treatment 4
The treatment approach should prioritize addressing the underlying cause while preventing serious bleeding complications through appropriate platelet count management.