Implementing pre-procedural thrombopoietin receptor agonists in cirrhotic patients with severe thrombocytopenia: Indiscriminate, selective or unneeded?

Abstract

Recent studies promote thrombopoietin-receptor agonists (TRAs), instead of platelet transfusions, before elective invasive procedures in patients with cirrhosis and platelet count below 50 × 109/L [ 1 Afdhal N.H. Giannini E.G. Tayyab G. et al. Eltrombopag before procedures in patients with cirrhosis and thrombocytopenia. N Engl J Med. 2012; 367: 716-724 Crossref PubMed Scopus (214) Google Scholar , 2 Hidaka H. Kurosaki M. Tanaka H. et al. Lusutrombopag reduces need for platelet transfusion in patients with thrombocytopenia undergoing invasive procedures. Clin Gastroenterol Hepatol. 2019; 17: 1192-1200 Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar , 3 Tateishi R. Seike M. Kudo M. et al. A randomized controlled trial of lusutrombopag in Japanese patients with chronic liver disease undergoing radiofrequency ablation. Jpn J Gastroenterol. 2019; 54: 171-181 Crossref Scopus (53) Google Scholar , 4 Peck-Radosavljevic M. Simon K. Iacobellis A. et al. Lusutrombopag for the treatment of thrombocytopenia in patients with chronic liver disease undergoing invasive procedures (L-PLUS 2). Hepatology. 2019; 70: 1336-1348 Crossref PubMed Scopus (75) Google Scholar , 5 Terrault N. Chen Y.C. Izumi N. et al. Avatrombopag before procedures reduces need for platelet transfusion in patients with chronic liver disease and thrombocytopenia. Gastroenterology. 2018; 155: 705-718 Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar – [6] Terrault N.A. Hassanein T. Howell C.D. et al. Phase II study of avatrombopag in thrombocytopenic patients with cirrhosis undergoing an elective procedure. J Hepatol. 2014; 61: 1253-1259 Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar to prevent procedure-related bleeding. In the current issue of Digestive and Liver Disease the systematic review and meta-analysis by Rose and colleagues [ [7] Rose P.D. Au M. Woodman R.J. et al. Pre-procedural use of thrombopoietin-receptor agonists in cirrhosis and severe thrombocytopenia: a systematic review and meta-analysis. Dig Liver Dis. 2021; 53: 1396-1403 Abstract Full Text Full Text PDF Scopus (2) Google Scholar ] confirms that TRAs significantly decrease the amount of the supposed required platelet transfusions. At variance with platelet transfusions, which have a slight and short-term effect on the platelet count, second generation TRAs more often achieve a predictable and persistent increase of the platelet count above the conventional threshold of 50 × 109/L, thus allegedly providing higher protection against peri‑procedural and delayed bleeding. This benefit appears to occur without increasing the thrombotic risk as compared to placebo, and the risks related to platelet transfusion, as plasma volume expansion, transfusion reactions, infection, alloimmunization and refractoriness after repeated transfusions, are avoided. Pre-procedural use of thrombopoietin-receptor agonists in cirrhosis and severe thrombocytopenia: A systematic review and meta-analysisDigestive and Liver DiseaseVol. 53Issue 11PreviewSevere thrombocytopenia in cirrhosis can preclude invasive procedures. Platelet transfusion is recommended if platelet count pre-procedure is potential alternative to platelet transfusion is thrombopoietin-receptor (TPO) agonists. Full-Text PDF