Existing guideline statements for the management of VTE in patients with thrombocytopenia
| Guidance . | Setting/topic . | Statement . |
|---|---|---|
| ISTH Scientific and Standardization Committee: Hemostasis and Malignancy, 201826 | CAT, nonsevere thrombocytopenia | “Recommend . . . full therapeutic anticoagulation without platelet transfusion to patients with CAT and a platelet count of ≥50 G/L.” |
| Acute CAT (within 30 days) + high risk of thrombus progressiona | “[For] severe thrombocytopenia (<50 G/L) and a higher risk of thrombus progression, we suggest full-dose anticoagulation (LMWH/UFH) with platelet transfusion support to maintain a platelet count of ≥40-50 G/L.” | |
| Acute CAT (within 30 days) + lower risk of thrombus progressiona | For severe thrombocytopenia (<50 G/L) and a lower risk of thrombus progression: a) Platelet count 25-50 G/L: suggest reducing the dose of LMWH to 50% of the therapeutic dose or using a prophylactic dose. b) Platelet count <25 G/L: suggest temporarily discontinuing anticoagulation. c) Recommend resuming full-dose LMWH when the platelet count >50 G/L. | |
| Subacute/chronic CAT (>30 days since the index VTE) | a) Platelet count 25-50 G/L: suggest reducing the dose of LMWH to 50% of the therapeutic dose or using a prophylactic dose. b) Platelet count <25 G/L: suggest temporarily discontinuing anticoagulation. c) Recommend resuming full-dose LMWH when the platelet count >50 G/L. | |
| American Society of Hematology 2021 guidelines | No specific statement regarding management of CAT in the setting of thrombocytopenia | |
| International Initiative on Thrombosis and Cancer guidelines 2019 and 202218,32 | Cancer-associated VTE (treatment) | “In patients with cancer with thrombocytopenia, full doses of anticoagulant can be used for the treatment of established venous thromboembolism if the platelet count is >50 G/L and there is no evidence of bleeding; for patients with a platelet count below 50 G/L, decisions on treatment and dosage should be made on a case-by-case basis with the utmost caution (guidance, in the absence of data and a balance between desirable and undesirable effects depending on the bleeding risk vs venous thromboembolism risk).” |
| Cancer-associated VTE (prophylaxis) | “In patients with cancer with mild thrombocytopenia with a platelet count >80 G/L, pharmacological prophylaxis can be used; if the platelet count is below 80 G/L, pharmacological prophylaxis can only be considered on a case-by-case basis and careful monitoring is recommended (guidance, in the absence of data and a balance between desirable and undesirable effects depending on the bleeding risk vs venous thromboembolism risk).” | |
| ESMO Clinical Practice Guideline 202315 | Cancer associated VTE, persistent, severe thrombocytopenia (<50 G/L), high risk of thrombus progressionb | “Full-dose anticoagulation may be considered in combination with platelet transfusion support aiming at platelet count >40-50 G/L.” |
| Cancer associated VTE, persistent, severe thrombocytopenia (<50 G/L), low risk of thrombus progressionb | “Intermediate- to prophylactic-dose LMWH may be considered with temporary discontinuation of anticoagulation if the platelet count falls below 25 G/L.” | |
| Cancer-associated VTE, platelet count >50 G/L | “Full therapeutic dose anticoagulation should be considered.” | |
| DOAC use | “Data on the use of DOACs for the treatment of CAT in the presence of severe thrombocytopaenia are lacking.” | |
| ASCO 2023 Guidelines17 | No specific statement regarding management of CAT in the setting of thrombocytopenia | |
| EHA Guidelines 2022.53 | Thrombocytopenia grade 1-2 (platelet count >50 G/L) | “Therapeutic-dose parenteral or oral anticoagulation according to the approved indications after a careful evaluation of bleeding and thrombotic risk in the individual patient” “Thrombocytopenia . . . which is not stable and acute VTE, LMWH should be preferred over DOACs and VKAs.” |
| Thrombocytopenia grade 3 (platelet count 25-50 G/L) | “We recommend against using DOACs and VKAs for VTE.” “LMWH, at doses either prophylactic or therapeutic reduced by 50%, should be used in patients with acute VTE, after balancing bleeding and thrombosis risk.” | |
| Thrombocytopenia grade 3-4 (platelet count <50 G/L) | “In case of very-high-thrombotic risk, we suggest continuing anticoagulation and increase platelet counts by platelet transfusion or use of TPO-RA.” “We recommend resuming the appropriate dose of anticoagulation as soon as platelet count allows.” | |
| UpToDate—anticoagulation in individuals with thrombocytopenia10 | Cancer-associated VTE, platelet count >50 G/L | “Full-dose anticoagulation is generally appropriate, as in nonthrombocytopenic populations. . . . Close monitoring of the platelet count is warranted, especially if the nadir of chemotherapy-induced thrombocytopenia has not yet occurred.” |
| Cancer-associated VTE, platelet count <50 G/L | platelet count 25-50 G/L: without strong bleeding risk factorsc: • higher risk for VTE progression or recurrenced: “full-dose anticoagulation with platelet transfusion support (typically, platelet transfusions to raise the platelet count to ≥50 G/L), especially in the presence of another thromboembolic risk factor.” • lower/intermediate risk for VTE progression or recurrencee or high risk of bleeding: half-dose anticoagulation is the preferred treatment approach for platelet counts between 25-50 G/L; holding anticoagulation is appropriate for platelet counts <25 G/L. other options include prophylactic-dose anticoagulation or temporarily holding anticoagulation.” |
| Guidance . | Setting/topic . | Statement . |
|---|---|---|
| ISTH Scientific and Standardization Committee: Hemostasis and Malignancy, 201826 | CAT, nonsevere thrombocytopenia | “Recommend . . . full therapeutic anticoagulation without platelet transfusion to patients with CAT and a platelet count of ≥50 G/L.” |
| Acute CAT (within 30 days) + high risk of thrombus progressiona | “[For] severe thrombocytopenia (<50 G/L) and a higher risk of thrombus progression, we suggest full-dose anticoagulation (LMWH/UFH) with platelet transfusion support to maintain a platelet count of ≥40-50 G/L.” | |
| Acute CAT (within 30 days) + lower risk of thrombus progressiona | For severe thrombocytopenia (<50 G/L) and a lower risk of thrombus progression: a) Platelet count 25-50 G/L: suggest reducing the dose of LMWH to 50% of the therapeutic dose or using a prophylactic dose. b) Platelet count <25 G/L: suggest temporarily discontinuing anticoagulation. c) Recommend resuming full-dose LMWH when the platelet count >50 G/L. | |
| Subacute/chronic CAT (>30 days since the index VTE) | a) Platelet count 25-50 G/L: suggest reducing the dose of LMWH to 50% of the therapeutic dose or using a prophylactic dose. b) Platelet count <25 G/L: suggest temporarily discontinuing anticoagulation. c) Recommend resuming full-dose LMWH when the platelet count >50 G/L. | |
| American Society of Hematology 2021 guidelines | No specific statement regarding management of CAT in the setting of thrombocytopenia | |
| International Initiative on Thrombosis and Cancer guidelines 2019 and 202218,32 | Cancer-associated VTE (treatment) | “In patients with cancer with thrombocytopenia, full doses of anticoagulant can be used for the treatment of established venous thromboembolism if the platelet count is >50 G/L and there is no evidence of bleeding; for patients with a platelet count below 50 G/L, decisions on treatment and dosage should be made on a case-by-case basis with the utmost caution (guidance, in the absence of data and a balance between desirable and undesirable effects depending on the bleeding risk vs venous thromboembolism risk).” |
| Cancer-associated VTE (prophylaxis) | “In patients with cancer with mild thrombocytopenia with a platelet count >80 G/L, pharmacological prophylaxis can be used; if the platelet count is below 80 G/L, pharmacological prophylaxis can only be considered on a case-by-case basis and careful monitoring is recommended (guidance, in the absence of data and a balance between desirable and undesirable effects depending on the bleeding risk vs venous thromboembolism risk).” | |
| ESMO Clinical Practice Guideline 202315 | Cancer associated VTE, persistent, severe thrombocytopenia (<50 G/L), high risk of thrombus progressionb | “Full-dose anticoagulation may be considered in combination with platelet transfusion support aiming at platelet count >40-50 G/L.” |
| Cancer associated VTE, persistent, severe thrombocytopenia (<50 G/L), low risk of thrombus progressionb | “Intermediate- to prophylactic-dose LMWH may be considered with temporary discontinuation of anticoagulation if the platelet count falls below 25 G/L.” | |
| Cancer-associated VTE, platelet count >50 G/L | “Full therapeutic dose anticoagulation should be considered.” | |
| DOAC use | “Data on the use of DOACs for the treatment of CAT in the presence of severe thrombocytopaenia are lacking.” | |
| ASCO 2023 Guidelines17 | No specific statement regarding management of CAT in the setting of thrombocytopenia | |
| EHA Guidelines 2022.53 | Thrombocytopenia grade 1-2 (platelet count >50 G/L) | “Therapeutic-dose parenteral or oral anticoagulation according to the approved indications after a careful evaluation of bleeding and thrombotic risk in the individual patient” “Thrombocytopenia . . . which is not stable and acute VTE, LMWH should be preferred over DOACs and VKAs.” |
| Thrombocytopenia grade 3 (platelet count 25-50 G/L) | “We recommend against using DOACs and VKAs for VTE.” “LMWH, at doses either prophylactic or therapeutic reduced by 50%, should be used in patients with acute VTE, after balancing bleeding and thrombosis risk.” | |
| Thrombocytopenia grade 3-4 (platelet count <50 G/L) | “In case of very-high-thrombotic risk, we suggest continuing anticoagulation and increase platelet counts by platelet transfusion or use of TPO-RA.” “We recommend resuming the appropriate dose of anticoagulation as soon as platelet count allows.” | |
| UpToDate—anticoagulation in individuals with thrombocytopenia10 | Cancer-associated VTE, platelet count >50 G/L | “Full-dose anticoagulation is generally appropriate, as in nonthrombocytopenic populations. . . . Close monitoring of the platelet count is warranted, especially if the nadir of chemotherapy-induced thrombocytopenia has not yet occurred.” |
| Cancer-associated VTE, platelet count <50 G/L | platelet count 25-50 G/L: without strong bleeding risk factorsc: • higher risk for VTE progression or recurrenced: “full-dose anticoagulation with platelet transfusion support (typically, platelet transfusions to raise the platelet count to ≥50 G/L), especially in the presence of another thromboembolic risk factor.” • lower/intermediate risk for VTE progression or recurrencee or high risk of bleeding: half-dose anticoagulation is the preferred treatment approach for platelet counts between 25-50 G/L; holding anticoagulation is appropriate for platelet counts <25 G/L. other options include prophylactic-dose anticoagulation or temporarily holding anticoagulation.” |
Listed high-risk features: segmental or more proximal PE, proximal DVT, history of recurrent VTE. Listed lower-risk features: distal DVT, incidental subsegmental PE, CRT.
Listed high-risk features: first 30 days from thromboembolic event, segmental or more proximal PE, proximal DVT or a history of recurrent thrombosis. Listed low-risk features: more than 30 days from thromboembolic event, distal DVT, isolated subsegmental PE.
Listed bleeding risk factors: age over 75 years, recent severe bleeding, hematopoietic SCT, coagulation or platelet function abnormality, kidney/liver failure, increased risk for falls.
Listed factors for higher risk: VTE within 30 days, proximal DVT, segmental or more proximal PE. Listed factors for lower risk: isolated distal DVT, isolated subsegmental PE, central-line–associated DVT, or a subacute presentation (ie, >30 days since the acute VTE).
ASCO, American Society of Clinical Oncology; CAT, cancer-associated thrombosis; EHA, European Hematology Association; ESMO, European Society for Medical Oncology; ISTH, International Society on Thrombosis and Haemostasis; TPO-RA, thrombopoietin receptor agonists; UFH, unfractionated heparin; VKA, vitamin K antagonist.