What is the management and review of thrombocytopenia (low platelet count)?

From the Guidelines

Thrombocytopenia management should prioritize treating the underlying cause and preventing bleeding complications, with approaches including observation, corticosteroids, IV immunoglobulin, and thrombopoietin receptor agonists, as recommended by the American Society of Hematology 2019 guidelines for immune thrombocytopenia 1. The approach to thrombocytopenia management depends on the severity of the platelet count, bleeding risk, and etiology.

• For mild thrombocytopenia (50,000-150,000/μL) without bleeding, observation may be sufficient.
• Moderate thrombocytopenia (20,000-50,000/μL) requires closer monitoring and potential intervention.
• Severe thrombocytopenia (<20,000/μL) typically warrants immediate treatment. First-line treatment for immune thrombocytopenia (ITP) includes corticosteroids like prednisone or dexamethasone, as well as IV immunoglobulin (IVIG) for emergency situations, as outlined in the American Society of Hematology 2019 guidelines 1. Second-line options include thrombopoietin receptor agonists, rituximab, or splenectomy, which can be considered for patients refractory to first-line therapy 1. It is essential to discontinue any offending medications in cases of drug-induced thrombocytopenia and to use alternative anticoagulation in heparin-induced thrombocytopenia. Platelet transfusions should be reserved for active bleeding or before procedures when counts are below 50,000-100,000/μL, but are contraindicated in certain conditions like heparin-induced thrombocytopenia and thrombotic thrombocytopenic purpura. Patients with thrombocytopenia should avoid aspirin and NSAIDs, limit alcohol consumption, and use electric razors to reduce bleeding risk while thrombocytopenic.

From the FDA Drug Label

Nplate is indicated for the treatment of thrombocytopenia in: Adult patients with immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. Pediatric patients 1 year of age and older with ITP for at least 6 months who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. Use the lowest dose of Nplate to achieve and maintain a platelet count ≥ 50 × 10^9/L as necessary to reduce the risk for bleeding. Administer Nplate as a weekly subcutaneous injection with dose adjustments based upon the platelet count response.

Thrombocytopenia Management with Romiplostim:

• The goal is to achieve and maintain a platelet count ≥ 50 × 10^9/L to reduce the risk for bleeding.
• The initial dose of Nplate is 1 mcg/kg, with future dose adjustments based on changes in platelet counts.
• Dose Adjustments:
  • Increase the dose by 1 mcg/kg if the platelet count is < 50 × 10^9/L.
  • Reduce the dose by 1 mcg/kg if the platelet count is > 200 × 10^9/L and ≤ 400 × 10^9/L for 2 consecutive weeks.
  • Do not dose if the platelet count is > 400 × 10^9/L, and resume Nplate at a reduced dose after the platelet count falls to < 200 × 10^9/L.
• Monitoring: Obtain complete blood counts (CBCs), including platelet counts, weekly during the dose adjustment phase and then monthly following establishment of a stable Nplate dose 2.

From the Research

Thrombocytopenia Management

Thrombocytopenia is a condition characterized by a low platelet count, typically less than 150 × 10^3 per μL 3. The management of thrombocytopenia depends on the underlying cause, severity, and presence of bleeding symptoms.

• Patients with a platelet count greater than 50 × 10^3 per μL are generally asymptomatic, while those with platelet counts between 20 and 50 × 10^3 per μL may experience mild skin manifestations such as petechiae, purpura, or ecchymosis 3.
• Patients with platelet counts of less than 10 × 10^3 per μL have a high risk of serious bleeding and may require hospitalization 3.
• The first step in evaluating thrombocytopenia is to exclude pseudothrombocytopenia by collecting blood in a tube containing heparin or sodium citrate and repeating the platelet count 3.

Diagnosis and Treatment

The diagnosis of immune thrombocytopenia (ITP) is based on the exclusion of other causes of isolated thrombocytopenia using patient history, physical examination, blood count, and evaluation of the peripheral blood film 4.

• The clinical treatment goals for ITP are to resolve bleeding events and prevent severe bleeding episodes, with a target platelet count of > 20-30 × 10^9/L 4.
• Corticosteroids are considered the standard initial treatment for newly diagnosed ITP, with subsequent medical therapies including thrombopoietin receptor agonists, rituximab, and fostamatinib 4.
• Surgical therapy with splenectomy may be considered for patients failing medical therapy 4.

Platelet Transfusion

Platelet transfusion is recommended for patients with active hemorrhage or platelet counts less than 10 × 10^3 per μL, in addition to treatment of underlying causative conditions 3.

• The decision to transfuse platelets should be based on the patient's individual risk of bleeding and the potential benefits and harms of transfusion 5, 6.
• Platelet transfusion thresholds for prophylactic transfusion in the ICU are largely derived from studies performed in stable hematology patients, and indications for platelet transfusions for the treatment of severe bleeding in thrombocytopenic patients remain largely empirical 6.

Activity Restrictions

Patients with platelet counts of less than 50 × 10^3 per μL should adhere to activity restrictions to avoid trauma-associated bleeding 3.

• The management of thrombocytopenia requires a comprehensive approach, taking into account the underlying cause, severity, and presence of bleeding symptoms, as well as the patient's individual risk factors and preferences 3, 4, 5, 7, 6.