From the Guidelines
Management of low platelets (thrombocytopenia) should prioritize maintaining platelets above 30,000/μL to prevent spontaneous bleeding and above 50,000/μL for invasive procedures, with treatment depending on the severity, cause, and bleeding risk, as recommended by the American Society of Hematology 2019 guidelines for immune thrombocytopenia 1.
Treatment Approach
The approach to treating thrombocytopenia involves:
- Observation for mild cases without bleeding
- Avoiding antiplatelet medications and activities with bleeding risk for moderate thrombocytopenia
- Platelet transfusions for severe thrombocytopenia or active bleeding
Specific Treatments
Specific treatments depend on the cause:
- Corticosteroids (prednisone 1-2 mg/kg/day for 2-4 weeks) for immune thrombocytopenia (ITP) 1
- Intravenous immunoglobulin (IVIG 1 g/kg for 1-2 days) for acute ITP with bleeding
- Thrombopoietin receptor agonists like eltrombopag (25-75 mg daily) or romiplostim (1-10 μg/kg weekly) for chronic ITP 1
- Treating infections for infection-related thrombocytopenia
- Discontinuing offending medications for drug-induced cases
Monitoring and Prevention
Regular monitoring of platelet counts is essential to assess response to treatment, with frequency depending on severity and stability of counts. Patients should avoid NSAIDs, aspirin, and activities with high bleeding risk.
Second-Line Therapy
For patients who do not respond to first-line therapy, second-line options include splenectomy, thrombopoietin receptor agonists, and rituximab, with the choice of therapy depending on the individual patient's circumstances and the potential risks and benefits of each option 1.
From the Research
Low Platelet Management
- The management of low platelet count, also known as thrombocytopenia, depends on the underlying cause and severity of the condition 2.
- 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 2.
- For patients with immune thrombocytopenia (ITP), the standard initial treatment is oral corticosteroids to increase platelet counts 3, 4.
- Other treatment options for ITP include intravenous immunoglobulin (IVIg), intravenous Rh immunoglobulin (IV RhIg), and splenectomy 5, 3.
- Thrombopoietin receptor agonists are also being investigated as a potential treatment option for ITP 3.
- The decision to treat newly diagnosed patients with ITP is based on several factors, including the desire to increase platelet count to prevent bleeding, induce remission, and improve health-related quality of life (HRQoL) 4.
- Corticosteroids are a crucial component of first-line therapy for ITP, but extended and recurrent use can be associated with substantial toxicity, and clinical practice guidelines recommend limiting corticosteroid treatment to no more than 6 weeks in adults with ITP receiving initial therapy 6.
Treatment Strategies
- For stable patients being evaluated as outpatients, the first step is to exclude pseudothrombocytopenia by collecting blood in a tube containing heparin or sodium citrate and repeating the platelet count 2.
- If thrombocytopenia is confirmed, the next step is to distinguish acute from chronic thrombocytopenia by obtaining or reviewing previous platelet counts 2.
- Patients with acute thrombocytopenia may require hospitalization, while those with chronic thrombocytopenia may be managed on an outpatient basis 2.
- Transfusion of platelets is recommended when patients have active hemorrhage or when platelet counts are less than 10 × 10^3 per μL, in addition to treatment (when possible) of underlying causative conditions 2.
Special Considerations
- Patients with platelet counts of less than 50 × 10^3 per μL should adhere to activity restrictions to avoid trauma-associated bleeding 2.
- It is essential to ensure adequate platelet counts to decrease bleeding risk before invasive procedures, which may require a platelet transfusion 2.
- Clinical practice guidelines recommend treatments more suitable for long-term disease control, such as thrombopoietin receptor agonists, rituximab, or splenectomy, rather than repeated courses of corticosteroids 6.