Discontinue drugs that influence the functioning of platelets, as necessary.
If the thrombocytopenic patient has symptoms of bleeding, hospitalization is advisable.
Basic rules
The pathophysiological mechanism of thrombocytopenia (blood platelet count < 150 × 109 /l) may be
decreased production in the bone marrow
increasedconsumption
increased sequestration in the spleen.
When blood thrombocyte level < 100 × 109 /l is detected in a patient for the first time, examining blood smear or taking a sample in a citrate tube is recommended (investigation of pseudothrombocytopenia)..
Thrombocytopenia is a symptom, the cause of which should be clarified.
Typical manifestations of thrombocytopenia are skin bruising and petechiae and mucous membrane bleeding.
In particular, gum and nasal bleeding is common. Bleeding may also take place in the gastrointestinal and urinary tracts after surgery of the prostate gland or urinary tract.
Menorrhagia is also common.
A tendency towards bleeding is uncommon if the platelet count is 50-100 × 109 /l. Platelet concentrations of 10-50 × 109 /l are frequently associated with spontaneous bleeding and haemorrhages may be severe with platelet counts of < 10 × 109 /l. Drugs that affect the platelet function (ASA and ADP receptor blockers, e.g. clopidogrel, ticagrelor, prasugrel) increase bleeding tendency already in a rather moderate thrombocytopenia. Concurrent anticoagulation therapy also increases bleeding risk in a patient with thrombocytopenia.
Causes of thrombocytopenia
Decreased production
Inborn causes
Inherited thrombocytopenias (rare)
Acquired causes
Aplastic anaemia (rare)
Bone marrow infiltrates (carcinoma, leukaemias, myelofibrosis, myelodysplasia)
Radiotherapy, other causes of myelosuppression (cytotoxic chemotherapy)
The general practitioner can safely follow the situation, initially at intervals of a few months, if the blood picture otherwise is normal (no anaemia, no neutropenia etc.). If no underlying disease becomes evident and thrombocytopenia remains stable, no further follow-up is required. All drugs causing thrombocytopenia should be avoided if possible. Alcohol consumption habits should be discussed.
Many drugs cause thrombocytopenia relatively frequentlyhttp://www.ouhsc.edu/platelets/. These include heparin, quinidine, chloroquine, salicylates, sulphonamides, thiazides, allopurinol, phenytoin, carbamazepine and trimethoprim.
NSAIDs (especially acetosalicylic acid) and some other medicines (clopidrogel, ticagrelor, prasugrel) frequently impair platelet function and bring about a bleeding tendency. This tendency is disproportionately strong among thrombocytopenic patients.
Besides assessing the medication used by the patient, basic investigations are performed: complete blood count and, at discretion, bone marrow examination.
If the situation does not improve, referral to a specialist in haematology is advisable.
If a thrombocytopenia patient has symptoms of bleeding
He/she needs specialist care
It is important to detect the possible cause. Remember that the list of drugs possibly causing thrombocytopenia is very long. All these drugs should be avoided.
ITP
Treatment is planned by a haematologist, a specialist in internal medicine or a paediatrician.
In adults, prednisone or prednisolone is the first-line therapy. The starting dose is 1-2 mg/kg/day orally. Dexamethasone 40 mg/day for 4 days may be used as an alternative.
With a glucocorticoid, response to treatment is often achieved in 1-4 weeks. A partial response to treatment is achieved in 70-90% of cases, but a good one in only 30-50% of the patients.
After a response is observed, the drug is tapered to the smallest dose possible; the objective is a platelet count > 50 × 109 /l, with no symptoms of bleeding.
Fibrinolysis inhibitors (tranexamic acid) may be used to reduce menorrhagia, severe nasal bleeding, and bleeding in the gastrointestinal or urinary tracts. Massive bleeding is compensated with red cells, fresh-frozen plasma and platelet concentrates.
In hospital care, intravenous gammaglobulin infusions may induce a response faster than glucocorticoids. This is well suited for situations when it is necessary to normalize the platelet count quickly. As second-line treatment, non-responders are often treated with rituximab; splenectomy can also be considered. Thrombopoietin-receptor agonists (romiplostim, eltrombopag) represent one option for the management of chronic ITP. These treatments are decided by a physician well versed in haematology.