By James N. George, MD

2009-05-01

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 for print.)

The Question

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?

My Response

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.

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