By James N. George, MD
Dr. George is George Lynn Cross Professor in the
Hematology-Oncology section of the Department of Medicine at the
University of Oklahoma Health Sciences Center. He is also a past
president of ASH.
The ASH program Consult a Colleague has become successful because it
facilitates what we all do every day: consult our colleagues about the
care of patients whose problems and management aren’t clear. Even when
patient problems have no clear answers, the experience and thoughts of
a colleague can provide comfort that you’re not veering off course.
Here is a recent exchange through Consult a Colleague.
(Note: The original question was submitted to Dr. George through
Consult a Colleague; he updated the question and expanded his answer
A patient with myelodysplasia and thrombocytopenia has a coronary
artery stent. Recently, platelets have decreased to 35,000/μL (from
60,000/μL), and the patient has had some gum bleeding (not severe). The
cardiologist insists on aspirin and clopidogrel. Is this advisable from
the hematology point of view? The attending hematologist wants to give
platelets because he’s worried about the possibility of more serious
bleeding. Is a platelet transfusion warranted while the patient is
still on clopidogrel plus aspirin? Should we stop the anti-platelet
agents first? What would you recommend regarding stent prophylaxis and
treatment of gum bleeding?
There are multiple questions here. First, is it appropriate to
provide antithrombotic therapy for a patient with moderate
thrombocytopenia? There are no guidelines for this situation, but the
answer is usually “yes.” The question, what platelet count is safe for
anticoagulant/antithrombotic therapy, has been debated among people
whom I consider to be true experts — with no resolution. The result of
these discussions is always that there are too many clinical variables
to create rules, such as the strength of the indication for
antithrombotic therapy, the magnitude of risk of thrombosis if the
therapy was discontinued, and the magnitude of risk of bleeding if the
therapy was continued. These discussions always end by recommending
clinical decisions on a case-by-case basis — not very satisfying for
clinicians facing these problems. For this patient, I think that the
aspirin/clopidogrel treatment is appropriate. Stent thrombosis is a
great risk, and excessive bleeding with a platelet count more than
30,000/μL should be a lesser risk.
Second, the patient is already demonstrating extra bleeding! I’m surprised, as his
platelet count should prevent this. A simple suggestion is to be sure
that his dental care is good and that his bleeding can’t be corrected
by correcting gingivitis. It is very common for patients with chronic
thrombocytopenia (as well as other bleeding disorders) to have poor
dental care. You would have to postulate a platelet function defect to
justify platelet transfusions in a patient with a count of 35,000/μL;
this count is sufficient to prevent and stop almost all bleeding
problems. Poor platelet function has been reported in patients with
myelodysplasia, but this must be very rare and probably is not the
basis for this patient’s bleeding. I’d try local measures first, such
as aminocaproic acid, which is effective for management of oral
bleeding in patients with hemophilia.
What happened next?
To learn what happened, I contacted Dr. Irwin Nash, the hospital
blood bank director who had submitted the question. The patient had
received platelet transfusions because the minor bleeding had caused
concern for critical bleeding. Later, the platelet count increased,
gingival bleeding stopped, and concern for critical bleeding decreased.
The cardiologist stopped both aspirin and clopidogrel because the
patient had already received six months of treatment, a sufficient
duration for dual anti-platelet treatment following stent placement.
What are the lessons from this exchange of questions and my responses (that weren’t exactly answers)?
First, the occurrence of thrombocytopenia in patients who need
anti-platelet treatment will become increasingly common.
Thrombocytopenia is not itself antithrombotic, and, therefore,
anti-platelet treatment may be necessary to prevent catastrophic
thrombotic events in thrombocytopenic patients. When
antithrombotic/anti-platelet treatment is required, moderate
thrombocytopenia (reasonably defined as platelet counts greater than
20,000/μL) may not be a contraindication. But, of course, these
decisions are still “case by case.” Second, local problems (such as
poor dental hygiene) may cause localized bleeding that is best
controlled by local measures. This issue became moot in this patient,
but it needs to be considered in all patients.
ASH does not recommend or endorse any specific tests, physicians, products,
procedures, or opinions, and disclaims any representation, warranty, or
guaranty as to the same. Reliance on any information provided in this
article is solely at your own risk.
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