Should a patient with thrombocytopenia receive NPlate (romiplostim) today, two weeks after the last dose, with a current platelet count of 69,000?

Management of Romiplostim (NPlate) in a Patient with Thrombocytopenia due to Portal Hypertension

Yes, the patient should receive their scheduled NPlate dose today, as their current platelet count of 69,000/μL is above the threshold requiring dose modification and continuing therapy is appropriate to maintain platelet counts and reduce bleeding risk.

Assessment of Current Status

• Current platelet count: 69,000/μL
• Last NPlate dose: 65mcg given 2 weeks ago (9/12/25)
• Underlying condition: Thrombocytopenia due to portal hypertension with splenic sequestration and cirrhosis

Rationale for Continuing NPlate

1. Platelet count is above critical threshold: The patient's current platelet count of 69,000/μL is:

   • Above the threshold of 50,000/μL that would necessitate holding therapy 1
   • Not in the range requiring dose reduction (>200,000/μL) 1
   • Not in the range requiring dose interruption (>400,000/μL) 1

2. Appropriate dosing interval: The 2-week interval between doses appears to be maintaining adequate platelet counts, as evidenced by the current level of 69,000/μL.

3. FDA-approved use: While the patient's thrombocytopenia is due to portal hypertension rather than ITP (the primary indication), the current platelet count suggests the medication is effectively managing the thrombocytopenia.

Monitoring Recommendations

After administering today's dose, the following monitoring is recommended:

• Complete blood count in 1-2 weeks to assess response
• Monitor for signs of bleeding
• Evaluate for any adverse effects, particularly thrombotic events

Important Considerations

1. Treatment goal: The goal of therapy is to maintain a platelet count ≥50 × 10^9/L to reduce bleeding risk, not to normalize platelet counts 1.

2. Dose adjustments: According to the FDA label for romiplostim, dose adjustments should be made as follows 1:

   • If platelet count <50 × 10^9/L: Increase dose by 1 mcg/kg
   • If platelet count >200 × 10^9/L and ≤400 × 10^9/L for 2 consecutive weeks: Reduce dose by 1 mcg/kg
   • If platelet count >400 × 10^9/L: Hold dose until <200 × 10^9/L, then resume at reduced dose

3. Off-label use caution: The FDA label specifies that romiplostim is not indicated for thrombocytopenia due to causes other than ITP 1. However, in clinical practice, it has been used for other forms of thrombocytopenia with careful monitoring.

4. Bleeding risk: Patients with platelet counts <50,000/μL are at increased risk for bleeding 2. The current count of 69,000/μL suggests adequate protection against spontaneous bleeding.

Potential Pitfalls to Avoid

1. Inappropriate dose interruption: Interrupting therapy when platelet counts are adequate (>50,000/μL) may lead to recurrent thrombocytopenia and increased bleeding risk.

2. Thrombotic risk: While maintaining appropriate platelet counts, monitor for signs of thrombosis, which has been reported with TPO receptor agonists, although the incidence is low (0.08 per 100 patient-weeks) 3.

3. Bone marrow fibrosis: Long-term use of romiplostim has been associated with bone marrow fibrosis in animal studies 1, though this has not been a significant clinical concern in human studies.

4. Rebound thrombocytopenia: Abrupt discontinuation may lead to worsening thrombocytopenia below baseline levels.

By continuing the scheduled NPlate dose today, you are maintaining an appropriate treatment regimen that is effectively managing the patient's thrombocytopenia while minimizing risks.