The efficacy and safety of thrombopoietin receptor agonists in patients with chronic liver disease undergoing elective procedures: a systematic review and meta-analysis

Lindquist, Ingrid; Olson, Sven R.; Li, Ang; Al‐Samkari, Hanny; Jou, Janice H.; McCarty, Owen J. T.; Shatzel, Joseph J.

doi:10.1080/09537104.2020.1859102

Cited by 19 publications

(26 citation statements)

References 21 publications

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“…In terms of bleeding sequela, one particularly interesting area of continued investigation may be in further clarifying and expanding the use of TPO memetics. Evidence suggests that preprocedural TPO is associated with fewer platelet transfusions and less bleeding 89 . However, current data are limited by significant lack of standardization in transfusion practices, paucity of data prior to high‐risk surgeries or procedures, and concern regarding potential thrombosis‐related adverse events 89 .…”

Section: Discussionmentioning

confidence: 99%

“…Evidence suggests that preprocedural TPO is associated with fewer platelet transfusions and less bleeding 89 . However, current data are limited by significant lack of standardization in transfusion practices, paucity of data prior to high‐risk surgeries or procedures, and concern regarding potential thrombosis‐related adverse events 89 . Notably, minimization of transfusion burden is also beneficial in that it mitigates sensitization prior to transplant, which complicates cross‐matching for future transfusions.…”

Section: Discussionmentioning

confidence: 99%

“…TPO does not exacerbate portal hypertension, provides longer‐term platelet supplementation, and is significantly more cost‐effective than platelet transfusions (one course of avatrombopag costs approximately $3800, vs. one unit platelet transfusion costs approximately $9200) 84,85 . Beyond time constraints, the major hindrance of TPO in cirrhosis is a potential increased risk of PV, although newer agents including avatrombopag and lusutrombopag may have lesser or no risk 59,86‐89 . additionally, much is yet to be known regarding optimal dosing to minimize the adverse thrombotic effects 2,86,87 .…”

Section: Hemostatic Derangementsmentioning

confidence: 99%

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The hemostatic and thrombotic complications of liver disease

McMurry

Jou

Shatzel

2021

European J of Haematology

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Hepatic cirrhosis leads to numerous hematologic derangements resulting in a complex and tenuously rebalanced hemostatic milieu. The utility of common hematologic tests including the INR and aPTT in assessing hemostatic and thrombotic risk in patients with cirrhosis is limited, and consensus on transfusion thresholds and proper management of thrombotic complications continues to evolve. This review summarizes the pathophysiology of key derangements of hemostasis including those of platelets, von Willebrand factor, pro‐ and anticoagulation factors, and fibrin. Additionally, the pathogenesis, consequences, optimal management, and prevention of major thrombotic and bleeding complications in cirrhosis arte discussed.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Hemostatic Derangementsmentioning

confidence: 99%

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The hemostatic and thrombotic complications of liver disease

McMurry

Jou

Shatzel

2021

European J of Haematology

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“…25 In a recent systematic review, the use of TPORAs in patients with CLD undergoing planned procedures was reported to significantly increase platelet counts and decrease the incidence of platelet transfusions versus placebo. 26 In addition, TPORA therapy also decreased the incidence of total periprocedural bleeding without increasing the rate of thrombosis. In the US algorithm for thrombocytopenia in patients with CLD, TPORAs are recommended as first-line treatment for patients with CLD and severe thrombocytopenia (platelet count <50 � 10 9 /L) who are planned to undergo invasive procedures.…”

Section: Treatment Of Thrombocytopenia In Patients With Cldmentioning

confidence: 99%

Treatment algorithm for thrombocytopenia in patients with chronic liver disease undergoing planned invasive procedures

Yoshiji

Ueno

Kurosaki

et al. 2021

Hepatology Research

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Thrombocytopenia is highly prevalent in patients with chronic liver disease (CLD) and these patients often require invasive procedures that carry a risk of bleeding. To prevent bleeding, guidelines recommend increasing platelet counts in patients with CLD who have thrombocytopenia and are planned to undergo invasive procedures. There are currently two options to increase platelet counts in patients in this setting: platelet transfusion or thrombopoietin receptor agonists (TPORAs). Several treatment algorithms have been developed in the US to help physicians choose the best course of treatment for each patient; however, to date, no such algorithm has been proposed in other countries, where the choice of treatment has been based on each physician's judgment and experience. Here, we discuss the pathogenesis and treatment of thrombocytopenia in patients with CLD, we review and present current evidence of the efficacy of TPORAs for the treatment of thrombocytopenia in patients with CLD, and we present our expert opinion on a Japanese treatment algorithm for thrombocytopenia in patients with CLD who are planned to undergo invasive procedures.

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“…Therefore, their role in reducing periprocedural bleeding remains uncertain 52,53 . A subsequent meta‐analysis reported a 35% relative risk reduction in periprocedural bleeding 54 . These agents may thus be useful in patients with marked thrombocytopenia (<30 000/µl) or with additional bleeding risk factors.…”

Section: Case 2: Dental Extractions and Risk Of Bleedingmentioning

confidence: 99%

Treatment of bleeding in patients with liver disease

Lisman

Roberts

2021

Journal of Thrombosis and Haemostasis

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Patients with cirrhosis frequently have complex alterations in their hemostatic system. Although routine diagnostic tests of hemostasis in cirrhosis (platelet count, prothrombin time, fibrinogen level) are suggestive of a bleeding tendency, it is now widely accepted that these tests do not reflect hemostatic competence in this population. Rather, patients with cirrhosis appear to have a rebalanced hemostatic system with hypercoagulable elements. Therefore, routine correction of hemostasis laboratory values, for example by fresh frozen plasma or platelet concentrates, with the aim to avoid spontaneous or procedure‐related bleeding is not indicated as is outlined in recent clinical guidance documents. However, little guidance on how to manage patients with cirrhosis that are actively bleeding is available. Here we present three common bleeding scenarios, variceal bleeding, post‐procedural bleeding and bleeding in a critically ill cirrhosis patient, with specific management suggestions. As patients with cirrhosis generally have adequate hemostatic competence and as bleeding complications may be unrelated to hemostatic failure, prohemostatic therapy is not the first line of management in bleeding patients with cirrhosis, even in the presence of markedly abnormal platelet counts and/or prothrombin times. We provide a rationale for the restrictive approach to prohemostatic therapy in bleeding patients with cirrhosis.

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The efficacy and safety of thrombopoietin receptor agonists in patients with chronic liver disease undergoing elective procedures: a systematic review and meta-analysis

Cited by 19 publications

References 21 publications

The hemostatic and thrombotic complications of liver disease

The hemostatic and thrombotic complications of liver disease

Treatment algorithm for thrombocytopenia in patients with chronic liver disease undergoing planned invasive procedures

Treatment of bleeding in patients with liver disease

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