Management of venous thromboembolism during thrombocytopenia after autologous hematopoietic cell transplantation

Cancer‐associated thrombosis in acute leukemia patients with severe thrombocytopenia (platelets ≤50 × 109/L) poses a management challenge due to competing risks of bleeding and recurrent thrombosis. A retrospective analysis was conducted to determine the occurrence of clinically relevant bleeding (CRB) rates during treatment for acute venous thromboembolic events (VTE) in thrombocytopenic acute leukemic patients. A cohort of 74 patients were subgrouped into three VTE‐treatment interventions: anticoagulation (n = 24), inferior vena cava filter placement (n = 22), and observation (n = 28). Multivariate analysis found a significant correlation between CRB occurrence and quantity of overall blood transfusions, chemotherapy administration, and relapsed leukemia presentation. There was no difference in the occurrence of CRB between VTE‐treatment subgroups, regardless of initial platelet count at the time of VTE diagnosis. Regarding the hematologic parameters, only the velocity of the platelet count recovery was associated with the risk of bleeding. From this analysis, it appears the trajectory of the platelet count and the factors associated with a slower recovery of it, are the main determinants for the occurrence of hemorrhagic complications during VTE treatment in acute leukemia.

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“…showed that there was no threshold at which higher platelet counts could predict a decreased risk of bleeding among these patients [32].…”

Section: Discussionmentioning

confidence: 97%

Bleeding outcomes in thrombocytopenic acute leukemic patients with venous thromboembolism

Wilson

Khan

Cox

et al. 2020

eJHaem

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“…Potential risks of increased transfusion targets include depletion of platelet supplies, increased costs, refractoriness to platelet transfusion and adverse effects, such as arterial and venous thrombosis, volume overload and non-haemolytic febrile transfusion reactions. [30][31][32][33] Furthermore, increased transfusion targets are often not met, resulting in high rates of anticoagulation discontinuation. 30,32 Importantly, there are no data on the efficacy of this transfusion strategy.…”

Section: Discussionmentioning

confidence: 99%

Managing Anti-Platelet Therapy in Thrombocytopaenic Patients with Haematological Malignancy: A Multinational Clinical Vignette-Based Experiment

et al. 2018

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Data on anti-platelet therapy (APT) for prevention of atherothrombotic events in thrombocytopaenic cancer patients is lacking. We aimed to identify patient and physician characteristics associated with APT management in thrombocytopaenic patients with haematological malignancy. A clinical vignette-based experiment was designed. Eleven haematologists were interviewed, identifying five variable categories. Next, 18 hypothetical vignettes were generated. Each physician received three vignettes and chose to: hold all APT; continue APT without platelet transfusion support; or continue APT with platelet transfusion support. The survey was distributed to haematologists and thrombosis specialists in three countries. Multivariate cluster robust Poisson regression models were used to calculate relative risks (RRs) of using one management option (over the other) for each variable in comparison to a reference variable. A total of 145 physicians answered 434 cases. Clinicians were more likely to hold APT in case of 20,000/µL platelets (vs. 40,000/µL; RR for continuing: 0.82 [95% confidence interval: 0.75–0.91]), recent major gastrointestinal bleeding (vs. none; RR 0.81 [0.72–0.92]) and when the physician worked at a university-affiliated community hospital (vs. non-academic community hospital; RR 0.84 [0.72–0.98]). Clinicians were more likely to continue APT in ST elevation myocardial infarction with dual APT (vs. unstable angina with single APT; RR 1.31 [1.18–1.45]) and when there were institutional protocols guiding management (vs. none; RR 1.15 [1.03–1.27]). When APT was continued, increased platelet transfusion targets were used in 34%. In summary, the decision process is complex and affected by multiple patient and physician characteristics. Platelet transfusions were frequently chosen to support APT, although no evidence supports this practice.

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“…Therefore, balancing the thrombotic and bleeding risk in thrombocytopenic risk remains a clinical challenge. Unfortunately, prospective data are scarce, meaning that management is currently informed mainly by expert opinion [ 112 ] and retrospective studies on VTE and ischemic heart disease [ 102 , 106 , 113 , 114 , 115 , 116 ], since clinical trials of anticoagulants in cancer-associated VTE exclude patients with thrombocytopenia (<50–100 × 10 9 /L) [ 117 , 118 , 119 , 120 , 121 ].…”

Section: Managing Antithrombotic Therapy In Thrombocytopenic Patiementioning

confidence: 99%

“…Of note, the vast majority of evidence pertains to short-term thrombocytopenia. We also identify additional factors associated with higher bleeding risk in this setting, including a history of bleeding, hematological malignancy and increasing bilirubin, creatinine, and prothrombin time [ 113 , 114 ]. An important concept guiding management decisions is that these patients have a high short-term risk of clinically significant bleeding, especially with full anticoagulation [ 22 , 24 , 102 , 113 , 123 , 124 , 125 ].…”

Section: Managing Antithrombotic Therapy In Thrombocytopenic Patiementioning

confidence: 99%

Challenges and Advances in Managing Thrombocytopenic Cancer Patients

Leader

Hofstetter

Spectre

2021

JCM

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Cancer patients have varying incidence, depth and duration of thrombocytopenia. The mainstay of managing severe chemotherapy-induced thrombocytopenia (CIT) in cancer is the use of platelet transfusions. While prophylactic platelet transfusions reduce the bleeding rate, multiple unmet needs remain, such as high residual rates of bleeding, and anticancer treatment dose reductions/delays. Accordingly, the following promising results in other settings, antifibrinolytic drugs have been evaluated for prevention and treatment of bleeding in patients with hematological malignancies and solid tumors. In addition, Thrombopoeitin receptor agonists have been studied for two major implications in cancer: treatment of severe thrombocytopenia associated with myelodysplastic syndrome and acute myeloid leukemia; primary and secondary prevention of CIT in solid tumors in order to maintain dose density and intensity of anti-cancer treatment. Furthermore, thrombocytopenic cancer patients are often prescribed antithrombotic medication for indications arising prior or post cancer diagnosis. Balancing the bleeding and thrombotic risks in such patients represents a unique clinical challenge. This review focuses upon non-transfusion-based approaches to managing thrombocytopenia and the associated bleeding risk in cancer, and also addresses the management of antithrombotic therapy in thrombocytopenic cancer patients.

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Management of venous thromboembolism during thrombocytopenia after autologous hematopoietic cell transplantation

Cited by 21 publications

References 22 publications

Bleeding outcomes in thrombocytopenic acute leukemic patients with venous thromboembolism

Bleeding outcomes in thrombocytopenic acute leukemic patients with venous thromboembolism

Managing Anti-Platelet Therapy in Thrombocytopaenic Patients with Haematological Malignancy: A Multinational Clinical Vignette-Based Experiment

Challenges and Advances in Managing Thrombocytopenic Cancer Patients

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