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SMJ // Article

Expired CME Article

Thrombocytopenia in Adults: A Practical Approach to Evaluation and Management

Authors: Sudhir S. Sekhon, MD, Vivek Roy, MD, FACP

Abstract

With the widespread use of automated cell counters, clinicians in any field of medicine may encounter thrombocytopenia. The symptomatology may vary greatly and the underlying cause may be either inconsequential (pseudothrombocytopenia) or life threatening. It is important to be aware of common conditions leading to thrombocytopenia and have a systematic approach to evaluation and management of these patients. In this review we highlight common etiologies seen in adult patients with thrombocytopenia. A brief description and management approach to common conditions, as well as to conditions that may be less frequent but require emergent intervention, is provided. Often the clinician is called upon to make a decision about platelet transfusions. The review also discusses the various types of platelet products available for transfusion and gives guidance regarding selection of the appropriate product, indications and contraindications, and suggested target platelet counts for various clinical situations.


Key Points


* Thrombocytopenia may confront any physician who orders blood counts, in any field of medicine.


* An evaluation algorithm and a listing of common causes will help clinicians diagnose thrombocytopenia and be able to triage life-threatening from less serious causes.


* In vitro platelet clumping (pseudothrombocytopenia) is common and must be differentiated from true thrombocytopenia.


* Physicians should be alert to the possibility of heparin-induced thrombocytopenia, as a delay in diagnosis can result in serious morbidity or mortality.


* A summary of indications and suggested thresholds for platelet transfusions in various clinical situations is included.

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References

1. Teo CP, Kueh YK. Incidence of thrombocytopenia in an acute care hospital. Ann Acad Med Singapore 1989;18:379–381.
 
2. Hanes SD, Quarles DA, Boucher BA. Incidence and risk factors of thrombocytopenia in critically ill trauma patients. Ann Pharmacother 1997;31:285–289.
 
3. Pegels JG, Bruynes EC, Engelfriet CP, et al. Pseudothrombocytopenia: an immunologic study on platelet antibodies dependent on ethylene diamine tetra-acetate. Blood 1982;59:157–161.
 
4. Silvestri F, Virgolini L, Savignano C, et al. Incidence and diagnosis of EDTA-dependent pseudothrombocytopenia in a consecutive outpatient population referred for isolated thrombocytopenia.Vox Sang 1995;68:35–39.
 
5. Frederiksen H, Schmidt K. The incidence of idiopathic thrombocytopenic purpura in adults increases with age. Blood 1999;94:909–913.
 
6. George JN, Woolf SH, Raskob GE, et al. Idiopathic thrombocytopenic purpura: a practice guideline developed by explicit methods for the American Society of Hematology. Blood 1996;88:3–40.
 
7. Cheng Y, Wong RSM, Soo YOY, et al. Initial treatment of immune thrombocytopenic purpura with high-dose dexamethasone. N Engl J Med 2003;349:831–836.
 
8. Godeau B, Caulier MT, Decuypere L, et al. Intravenous immunoglobulin for adults with autoimmune thrombocytopenic purpura: results of a randomized trial comparing 0.5 and 1 g/kg b.w. Br J Haematol1999;107:716–719.
 
9. Scaradavou A, Woo B, Woloski BM, et al. Intravenous anti-D treatment of immune thrombocytopenic purpura: experience in 272 patients. Blood 1997;89:2689–2700.
 
10. McMillan R. Therapy for adults with refractory chronic immune thrombocytopenic purpura. Ann Intern Med 1997;126:307–314.
 
11. Amorosi E, Ultmann J. Thrombotic thrombocytopenic purpura: report of 16 cases and review of the literature. Medicine 1966;45:139–159.
 
12. McCrae K, Cines D. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. In: Hoffman, R, Benz E, Shattil S, et al, eds. Hematology: Basic Principles and Practice. New York, NY, Churchill Livingstone, 2000, pp 2126–2135.
 
13. Rock GA, Shumak KH, Buskard NA, et al. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura: Canadian Apheresis Study Group. N Engl J Med1991;325:393–397.
 
14. Moake JL. Thrombotic microangiopathies. N Engl J Med 2002;347:589–600.
 
15. Cines DB, Konkle BA, Furlan M. Thrombotic thrombocytopenic purpura: a paradigm shift? Thromb Haemost 2000;84:528–535.
 
16. Tsai HM, Lian ECY. Antibodies to von Willebrand factor-cleaving protease in acute thrombotic thrombocytopenic purpura. N Engl J Med 1998;339:1585–1594.
 
17. George JN. How I treat patients with thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Blood 2000;96:1223–1229.
 
18. George JN, Raskob GE, Shah SR, et al. Drug-induced thrombocytopenia: a systematic review of published case reports. Ann Intern Med 1998;129:886–890.
 
19. Abrams CS, Cines DB. Thrombocytopenia after treatment with platelet glycoprotein IIb/IIIa inhibitors.Curr Hematol Rep 2004;3:143–147.
 
20. Bougie DW, Wilker PR, Wuitschick ED, et al. Acute thrombocytopenia after treatment with tirofiban or eptifibatide is associated with antibodies specific for ligand-occupied GPIIb/IIIa. Blood2002;100:2071–2076.
 
21. Visentin GP, Ford SE, Scott JP, et al. Antibodies from patients with heparin-induced thrombocytopenia/thrombosis are specific for platelet factor 4 complexed with heparin or bound to endothelial cells. J Clin Invest 1994;93:81–88.
 
22. Hirsh J, O'Donnell M, Weitz JI. New anticoagulants. Blood 2005;105:453–463.
 
23. Warkentin TE, Levine MN, Hirsh J, et al. Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin. N Engl J Med 1995;332:1330–1335.
 
24. Alving BM. How I treat heparin-induced thrombocytopenia and thrombosis. Blood 2003;101:31–37.
 
25. Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia: recognition, treatment, and prevention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest2004;126:311S–337S.
 
26. Scaradavou A. HIV-related thrombocytopenia. Blood Rev 2002;16:73–76.
 
27. Levi M, Ten Cate H. Disseminated intravascular coagulation. N Engl J Med 1999;341:586–592.
 
28. Gonzalez CE, Pengetze YM. Post-transfusion purpura. Curr Hematol Rep 2005;4:154–159.
 
29. British Committee for Standards in Haematology, Blood Transfusion Task Force: guidelines for the use of platelet transfusions. Br J Haematol 2003;122:10–23.
 
30. Rebulla P, Finazzi G, Marangoni F, et al. The threshold for prophylactic platelet transfusions in adults with acute myeloid leukemia: Gruppo Italiano Malattie Ematologiche Maligne dell'Adulto. N Engl J Med 1997;337:1870–1875.
 
31. Schiffer CA, Anderson KC, Bennett CL, et al. Platelet transfusion for patients with cancer: clinical practice guidelines of the American Society of Clinical Oncology. J Clin Oncol 2001;19:1519–1538.