What is the management of severe thrombocytopenia (low platelet count) following chemotherapy?

From the Guidelines

Severe thrombocytopenia post chemotherapy should be managed with platelet transfusions when the platelet count falls to 10 × 10^9 cells/L or less to reduce the risk of spontaneous bleeding, as recommended by the AABB 1. The primary goal in managing severe thrombocytopenia after chemotherapy is to prevent bleeding complications.

• The AABB recommends transfusing hospitalized adult patients with a platelet count of 10 × 10^9 cells/L or less to reduce the risk for spontaneous bleeding 1.
• The recommended dose is up to a single apheresis unit or equivalent, as greater doses are not more effective, and lower doses equal to one half of a standard apheresis unit are equally effective 1.
• Prophylactic platelet transfusions have been found to significantly reduce the risk for spontaneous grade 2 or greater bleeding, with an odds ratio of 0.53 [95% CI, 0.32 to 0.87] 1.
• The threshold platelet count at which platelets should be transfused prophylactically to reduce the bleeding risk in hospitalized patients with therapy-induced hypoproliferative thrombocytopenia is 10 × 10^9 cells/L, as a greater platelet count threshold (20 × 10^9 or 30 × 10^9 cells/L) was not associated with a significantly lower incidence of grade 2 or greater bleeding 1. Key considerations in the management of severe thrombocytopenia post chemotherapy include:
• Monitoring platelet counts daily in severe cases
• Avoiding medications that impair platelet function, such as NSAIDs and certain antibiotics
• Implementing bleeding precautions, such as avoiding invasive procedures, using soft toothbrushes, and preventing constipation with stool softeners
• Considering the use of thrombopoietin receptor agonists or other medications to stimulate platelet production in refractory cases.

From the FDA Drug Label

Nplate is not indicated for the treatment of thrombocytopenia due to myelodysplastic syndrome (MDS) or any cause of thrombocytopenia other than ITP [see Warnings and Precautions (5. 1)]. The FDA drug label does not answer the question.

From the Research

Management of Severe Thrombocytopenia Post Chemotherapy

• Severe thrombocytopenia is a common complication of chemotherapy, leading to increased risk of bleeding and delayed or reduced chemotherapy dose intensity 2, 3
• The management of chemotherapy-induced thrombocytopenia (CIT) involves reducing chemotherapy dose intensity or switching to other agents, as well as the use of thrombopoietic growth factors to improve platelet counts and reduce the need for platelet transfusions 2
• Thrombopoietic agents, such as recombinant human thrombopoietin, romiplostim, and eltrombopag, have been shown to improve platelet counts and reduce the need for platelet transfusions in some studies, but their use is not yet widely adopted due to the need for further research and consensus on their appropriate use 2, 4

Platelet Transfusion Therapy

• Platelet transfusion therapy is an integral part of the treatment of patients with hematological and solid tumor malignancies receiving chemotherapy 5
• The decision to transfuse platelets should be based on evidence-based guidelines, taking into account the patient's platelet count, clinical condition, and risk of bleeding 5
• Platelet transfusions are typically reserved for patients with severe thrombocytopenia (<10,000/mcL) or those with active bleeding, and are not recommended for patients with immune thrombocytopenia (ITP) unless there is catastrophic hemorrhage or an invasive surgical procedure 6

Current Research and Guidelines

• The National Comprehensive Cancer Network guidelines permit the use of thrombopoietic agents for CIT, but their widespread adoption awaits adequate phase III randomized, placebo-controlled studies demonstrating maintenance of relative dose intensity, reduction of platelet transfusions and bleeding, and possibly improved survival 2
• Further research is needed to explore the possible benefits of thrombopoietic agents for CIT, including well-characterized bleeding and platelet thresholds 4
• Current guidelines for platelet transfusion practices in ITP recommend reserving platelet transfusions for catastrophic hemorrhage or invasive surgical procedures, but a significant proportion of platelet transfusions are not concordant with these guidelines 6