scholarly journals Challenges and Advances in Managing Thrombocytopenic Cancer Patients

2021 ◽  
Vol 10 (6) ◽  
pp. 1169
Author(s):  
Avi Leader ◽  
Liron Hofstetter ◽  
Galia Spectre
Keyword(s):  
Cancer Treatment ◽  
Cancer Patients ◽  
Solid Tumors ◽  
Bleeding Risk ◽  
Severe Thrombocytopenia ◽  
Treatment Dose ◽  
Antifibrinolytic Drugs ◽  
Anticancer Treatment ◽  
Antithrombotic Medication ◽  
Platelet Transfusions

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.

scholarly journals Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy

Hematology ◽  
2019 ◽  
Vol 2019 (1) ◽  
pp. 71-79 ◽  
Author(s):  
Hanny Al-Samkari ◽  
Jean M. Connors
Keyword(s):  
Cancer Patients ◽  
Competing Risks ◽  
Bleeding Risk ◽  
Patient Specific ◽  
Severe Thrombocytopenia ◽  
Recurrence Rates ◽  
Patients With Cancer ◽  
Clinical Scenarios ◽  
Increased Risk ◽  
Recurrent Vte

Abstract The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult, because management of cancer-associated thrombosis requires anticoagulation despite known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.

Thoracentesis in advanced cancer patients with severe thrombocytopenia: Ultrasound guide improves safety and reduces bleeding risk

2017 ◽  
Vol 12 (4) ◽  
pp. 1747-1752 ◽  
Author(s):  
Elena Orlandi ◽  
Chiara Citterio ◽  
Pietro Seghini ◽  
Camilla Di Nunzio ◽  
Patrizia Mordenti ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Advanced Cancer ◽  
Bleeding Risk ◽  
Severe Thrombocytopenia ◽  
Advanced Cancer Patients ◽  
Ultrasound Guide

scholarly journals Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy

2019 ◽  
Vol 3 (22) ◽  
pp. 3770-3779 ◽  
Author(s):  
Hanny Al-Samkari ◽  
Jean M. Connors
Keyword(s):  
Cancer Patients ◽  
Competing Risks ◽  
Bleeding Risk ◽  
Patient Specific ◽  
Severe Thrombocytopenia ◽  
Recurrence Rates ◽  
Patients With Cancer ◽  
Clinical Scenarios ◽  
Increased Risk ◽  
Recurrent Vte

Abstract The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult, because management of cancer-associated thrombosis requires anticoagulation despite known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.

Use of Romiplostim in a Hemodialysis Patient with Primary Immune Thrombocytopenia

2012 ◽  
Vol 46 (11) ◽  
pp. e31-e31 ◽  
Author(s):  
Hassan Al-Jafar ◽  
Aristoteles Giagounidis ◽  
Kamel El-Rashaid ◽  
Masouma Al-Ali ◽  
Abbas A Hakim
Keyword(s):  
Renal Impairment ◽  
Immune Thrombocytopenia ◽  
Bleeding Risk ◽  
Hcv Infection ◽  
Severe Thrombocytopenia ◽  
Platelet Counts ◽  
Primary Immune Thrombocytopenia ◽  
Chronic Hcv Infection ◽  
Chronic Hcv ◽  
Platelet Transfusions

OBJECTIVE: To present the case of a patient with primary immune thrombocytopenia (ITP), renal impairment, and chronic hepatitis C virus (HCV) infection who was treated with platelet transfusions, intravenous immunoglobulin (IVIG), corticosteroids, eltrombopag, rituximab, and romiplostim in an attempt to raise platelet counts to a clinically acceptable level. CASE SUMMARY: A 71-year-old man with end-stage renal disease (ESRD) was on maintenance hemodialysis and had long-term diabetes mellitus, chronic obstructive pulmonary disease, and other comorbidities. He was admitted with epistaxis, severe thrombocytopenia, and a platelet count of 4 × 109/L. Platelet transfusions, treatment with IVIG, corticosteroids, eltrombopag, and rituximab resulted in transient and inadequate increases in platelet counts. Further bleeding manifestations, including epistaxis, melena, hematomas, and ecchymotic patches prompted treatment with blood product concentrates and a higher dose of eltrombopag, resulting in a further lack of clinical response. After 6 weeks of failed treatment attempts, initiation of weekly treatment with romiplostim 5 μg/kg resulted in rapid stabilization (within a week) of platelet counts in the range of 200 × 109/L. The patient was discharged, with subsequent dose adjustment of weekly romiplostim treatment to 2.5 μg/kg, continued hemodialysis, and a return to normal daily activities. DISCUSSION: The primary clinical concern in this elderly patient with multiple comorbidities was to lower the bleeding risk associated with consistent thrombocytopenia. Despite the lack of clinical data to support the efficacy and safety of romiplostim in patients with ITP and renal impairment, stimulation of platelet production with romiplostim was a reasonable approach in view of the bleeding risk and following nonresponse to treatment with corticosteroids, IVIG, eltrombopag, and rituximab. To our knowledge, this case represents the first successful use of romiplostim to manage primary ITP in the presence of ESRD and concurrent chronic HCV infection in a patient on hemodialysis. CONCLUSIONS: Romiplostim appears to be a viable option for treatment of ITP in a patient with ESRD and chronic HCV infection following nonresponse to treatment with corticosteroids, IVIG, eltrombopag, and rituximab.

scholarly journals Thrombocytopenia Among Patients with Hematologic Malignancies and Solid Tumors: Risk and Prognosis

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 3156-3156
Author(s):  
Kasper Adelborg ◽  
Katalin Veres ◽  
Erzsébet Horváth-Puhó ◽  
Mary Clouser ◽  
Hossam A Saad ◽  
...  
Keyword(s):  
Platelet Count ◽  
Cancer Patients ◽  
Solid Tumors ◽  
Clinical Outcomes ◽  
Cancer Diagnosis ◽  
Hematologic Malignancies ◽  
Severe Thrombocytopenia ◽  
Cancer Type ◽  
Risk Of Death ◽  
Study Inclusion

Abstract Introduction: Despite the large body of research in cancer and increasing numbers of cancer survivors, knowledge about the risks and prognoses related to thrombocytopenia in the clinical care setting is scarce. Such information is important to understanding the need and potential impact of platelet transfusion and emerging drug therapies for thrombocytopenia. In this study, we examined the risk of thrombocytopenia among patients with incident cancer. Further, we studied the extent to which thrombocytopenia was associated with adverse clinical outcomes. Methods: This population-based cohort study was conducted using data from the Danish Cancer Registry. All patients diagnosed with incident hematologic malignancies and solid tumors (age of ≥18 years) during 2015─2018 were identified. Data were linked with routine laboratory test results from the primary care and hospital settings, as recorded in the Danish Register of Laboratory Results for Research. Based on platelet count levels (x 10 9/L), thrombocytopenia was categorized as grade 0 (any count)<150; grade 1:<100; grade 2:<75; grade 3:<50; and grade 4: <25. We tabulated the prevalence of thrombocytopenia at study inclusion and calculated the cumulative incidence proportion (risk) of thrombocytopenia, accounting for the competing risk of death. Each patient with thrombocytopenia was matched up to 5 cancer patients without thrombocytopenia by age, sex, cancer type, cancer stage, and time from cancer diagnosis and index date. Cox proportional hazards regression analysis was used to compute hazard ratios (HRs) with 95% confidence intervals (CIs) of adverse clinical outcomes, including any bleeding leading to hospitalization, site-specific bleeding leading to hospitalization, transfusion (red blood cell, platelet, or fresh frozen plasma), and death. HRs were adjusted for Charlson Comorbidity Index scores and matching factors by design. Results: The analytic cohort comprised 11,785 patients with hematologic malignancies and 57,600 patients with solid tumors (median age=70 years). Any thrombocytopenia was observed during the 6 months preceding study inclusion among 18% of patients with hematologic malignancies (grades 1-2: 6% and grades 3-4: 5%) and 4% of patients with solid tumors (grades 1-2: 1% and grades 3-4: 0%). The 1-year and 4-year risks of new-onset thrombocytopenia were 30% and 40% for hematologic malignancies and 21% and 28% for solid tumors, respectively (Figure 1). Among patients who initiated chemotherapy following their cancer diagnosis (n=33,165), the 1-year and 4-year risks of thrombocytopenia were 50% and 62% for hematologic malignancies and 39% and 49% for solid tumors, respectively (Figure 2). Patients with grade 4 thrombocytopenia had higher rates of any bleeding leading to hospitalization than patients without thrombocytopenia [hematologic malignancies: HR=2.31 (95% CI: 1.43-3.73) and solid tumors: HR=4.52 (95% CI: 2.00-10.24)], while grades 1-3 thrombocytopenia did not confer a significantly increased rate of hospitalization for bleeding (Table 1). All grades of thrombocytopenia were associated with an increased rate of transfusion [overall for hematologic malignancies: HR=2.06 (95% CI: 1.91-2.23), and overall for solid tumors: HR=2.13 (95% CI: 1.83-2.48)] and with death [overall for hematologic malignancies: HR=2.01 (95% CI: 1.84-2.20), and overall for solid tumors: HR=1.44 (95% CI: 1.39-1.49)]. These associations increased in magnitude with decreasing platelet count levels. Conclusions: The risk of thrombocytopenia was substantial following a diagnosis of incident hematologic malignancy and solid tumors, with higher risks among patients who initiated chemotherapy. While only severe thrombocytopenia was a predictor of any hospitalization for bleeding, all grades of thrombocytopenia were associated with increased rates of transfusion and death. Our findings support the need for regular assessment of platelet count levels to identify cancer patients at risk of serious clinical outcomes. Figure 1 Figure 1. Disclosures Clouser: Amgen: Current Employment, Other: This work is related to Chemotherapy Induced Thrombocytopenia as a disease state, in this essence it is not directly related to an Amgen product; CIT is an area of scientific interest to Amgen with Romiplostim under development for this potential indicati. Saad: Amgen: Current Employment, Current equity holder in publicly-traded company.

scholarly journals Atrial Fibrillation and Cancer

2021 ◽  
Vol 8 ◽  
Author(s):  
Ludhmila Abrahao Hajjar ◽  
Silvia Moulin Ribeiro Fonseca ◽  
Theuran Inahja Vicente Machado
Keyword(s):  
Atrial Fibrillation ◽  
Immune System ◽  
General Population ◽  
Inflammatory Response ◽  
Cancer Treatment ◽  
Cancer Patients ◽  
Bleeding Risk ◽  
Morbidity And Mortality ◽  
Inflammatory Status ◽  
Adequate Management

Cancer patients have a higher risk of atrial fibrillation (AF) than general population, the pathophysiology mechanisms involves the pro inflammatory status of immune system in these patients and the exacerbated inflammatory response to cancer treatment and surgeries. Adequate management and prophylaxis for its occurrence are important and reduce morbidity and mortality in this population. There is a challenge in AF related to cancer to predict thromboembolic and bleeding risk in these patients, once standard stroke and hemorrhagic prediction scores are not validated for them. It is used CHA2DS2-VASc and HAS-BLED scores, the same as used in general population. In this review, we demonstrate correlated mechanisms to occurrence AF in cancer patients as well as therapeutic challenges in this population.

The Role of Platelets in Cancer-Related Bleeding Risk: A Systematic Review

2019 ◽  
Vol 46 (03) ◽  
pp. 328-341
Author(s):  
Julie Brogaard Larsen ◽  
Johanne Andersen Hojbjerg ◽  
Anne-Mette Hvas
Keyword(s):  
Systematic Review ◽  
Risk Assessment ◽  
Platelet Count ◽  
Cancer Patients ◽  
Solid Tumors ◽  
Platelet Function ◽  
Function Analysis ◽  
Bleeding Risk ◽  
National Heart Lung ◽  
Meta Analyses

AbstractCancer patients face an elevated risk of bleeding, and here platelets play a pivotal role. The association between platelet count and bleeding, as well as safe thresholds for prophylactic platelet transfusion, is described mainly in hematological malignancies, and knowledge is sparse for patients with solid tumors. Platelet function tests may further improve bleeding risk assessment in cancer patients. This study provides a systematic review of the available literature on associations between platelet count and/or function and bleeding in adult cancer patients. The review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. PubMed, Embase, and Web of Science were searched up to August 2019. The National Heart, Lung, and Blood Institute's tools were used for quality assessment. In total, 52 studies investigated associations between bleeding and platelet count (n = 40) or function (n = 12) in patients with hematological malignancy (n = 31), solid tumors (n = 11), or both (n = 10). The majority of included studies rated good (n = 23) or fair (n = 25). The association between platelet count and bleeding was most pronounced at platelet counts ≤ 10 × 109/L but was less evident for solid tumors. Overall, reduced platelet function was significantly associated with bleeding risk. Thus, the available evidence supports current guidelines for prophylactic platelet transfusions at platelet count ≤ 10 × 109/L in hematological cancer patients, whereas more evidence is needed in patients with solid tumors. Platelet function analysis may be valuable in assisting bleeding risk assessment in cancer patients but is sparsely investigated so far.

scholarly journals Current management of cancer-associated venous thromboembolism in patients with thrombocytopenia: a retrospective cohort study

2021 ◽  
Author(s):  
Alessandro Squizzato ◽  
Silvia Galliazzo ◽  
Elena Rancan ◽  
Marina Di Pilla ◽  
Giorgia Micucci ◽  
...  
Keyword(s):  
Platelet Count ◽  
Venous Thromboembolism ◽  
Cancer Patients ◽  
Cerebral Metastasis ◽  
Bleeding Complications ◽  
Severe Thrombocytopenia ◽  
Regression Analyses ◽  
Multivariate Logistic Regression ◽  
Current Management

AbstractOptimal management of venous thromboembolism (VTE) in cancer patients with thrombocytopenia is uncertain. We described current management and clinical outcomes of these patients. We retrospectively included a cohort of cancer patients with acute VTE and concomitant mild (platelet count 100,000–150,000/mm3), moderate (50,000–99,000/mm3), or severe thrombocytopenia (< 50,000/mm3). Univariate and multivariate logistic regression analyses explored the association between different therapeutic strategies and thrombocytopenia. The incidence of VTE and bleeding complications was collected at a 3-month follow-up. A total of 194 patients of whom 122 (62.89%) had mild, 51 (26.29%) moderate, and 22 (11.34%) severe thrombocytopenia were involved. At VTE diagnosis, a full therapeutic dose of LMWH was administered in 79.3, 62.8 and 4.6% of patients, respectively. Moderate (OR 0.30; 95% CI 0.12–0.75), severe thrombocytopenia (OR 0.01; 95% CI 0.00–0.08), and the presence of cerebral metastasis (OR 0.06; 95% CI 0.01–0.30) were independently associated with the prescription of subtherapeutic LMWH doses. Symptomatic VTE (OR 4.46; 95% CI 1.85–10.80) and pulmonary embolism (OR 2.76; 95% CI 1.09–6.94) were associated with the prescription of full therapeutic LMWH doses. Three-month incidence of VTE was 3.9% (95% CI 1.3–10.1), 8.5% (95% CI 2.8–21.3), 0% (95% CI 0.0–20.0) in patients with mild, moderate, and severe thrombocytopenia, respectively. The corresponding values for major bleeding and mortality were 1.9% (95% CI 0.3–7.4), 6.4% (95% CI 1.7–18.6), 0% (95% CI 0.0–20.0) and 9.6% (95% CI 5.0–17.4), 48.2% (95% CI 16.1–42.9), 20% (95% CI 6.6–44.3). In the absence of sound evidence, anticoagulation strategy of VTE in cancer patients with thrombocytopenia was tailored on an individual basis, taking into account not only the platelet count but also VTE presentation and the presence of cerebral metastasis.

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