From the Guidelines
Persistent thrombocytopenia with a platelet count of 89 × 10^9/L in an otherwise healthy 64-year-old male requires further evaluation to determine the underlying cause, and I recommend a hematology consultation and additional testing including a complete blood count with peripheral smear, liver function tests, viral serologies (HCV, HIV), and consideration of a bone marrow biopsy, as suggested by the American Society of Hematology 2019 guidelines for immune thrombocytopenia 1. This level of thrombocytopenia is mild to moderate and may not require immediate treatment if the patient is asymptomatic without bleeding. The most common causes to consider include:
- Immune thrombocytopenia (ITP)
- Medication effects
- Viral infections
- Liver disease
- Early myelodysplastic syndrome The patient's history and physical examination should be directed at assessing the type and severity of bleeding, and at excluding other causes of thrombocytopenia, as outlined in the 1996 practice guideline developed by the American Society of Hematology 1. If ITP is diagnosed and treatment is needed, first-line therapy typically includes corticosteroids (prednisone 1 mg/kg daily for 2-4 weeks with taper) or intravenous immunoglobulin (1 g/kg for 1-2 days) for rapid platelet increase if bleeding is present, as recommended by the American Society of Hematology 2019 guidelines 1. The patient should avoid medications that affect platelet function (NSAIDs, aspirin) and contact a healthcare provider if experiencing unusual bruising, petechiae, or bleeding. Platelet transfusions are generally not indicated unless there is active bleeding or a platelet count below 10-20 × 10^9/L. The underlying mechanism of thrombocytopenia varies by cause but often involves either decreased production, increased destruction, or sequestration of platelets.
From the Research
Persistent Thrombocytopenia Diagnosis and Treatment
The patient's condition of persistent thrombocytopenia (89,10*9/L) in an otherwise healthy 64-year-old male can be approached by considering the following points:
- Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder that may be a potential cause of thrombocytopenia, affecting approximately 1 in 20,000 people 2.
- Diagnosis of ITP remains clinical and is possible only after ruling out other causes of thrombocytopenia through history and laboratory testing 2, 3.
- Treatment approaches for ITP include initial treatment with corticosteroids, intravenous immunoglobulin, or intravenous anti-RhD immune globulin, which are rapid-acting but may not result in durable remissions in most patients 2, 3.
- Subsequent treatment options for ITP include thrombopoietin receptor agonists (TPO-RAs), rituximab, or splenectomy, with the choice of treatment involving consideration of operative risk, risk of asplenia, drug side-effects, quality-of-life issues, and financial costs 2, 3.
Treatment Strategies for ITP
Some key points to consider when evaluating treatment strategies for ITP include:
- The use of corticosteroids as the mainstay of initial ITP treatment, with their use limited due to potential side effects 3.
- The role of TPO-RA agents, fostamatinib, and rituximab in subsequent treatment, which are supported by robust evidence 3.
- The potential for upfront treatment strategies to enhance remission rates and prevent relapse, taking into account the risks and benefits of each approach 4.
- The importance of considering patient-specific outcomes, such as quality of life, when making treatment decisions 3.
Other Considerations
It is also important to note that:
- The pathogenesis of ITP is complex and involves the interplay of autoimmunity, immunodeficiency, and cancer, implying a need for interdisciplinarity in daily care 5.
- There is no direct relevance of the study on rapid chemical dehydration of biologic samples for scanning electron microscopy using 2-dimethoxypropane to the diagnosis or treatment of ITP 6.