How should I manage a patient with thrombocytopenia who is also on anticoagulant therapy?

Managing a patient with thrombocytopenia who is also receiving anticoagulant therapy requires careful assessment due to the increased risk of bleeding ¹,³.

Immediate Actions and Referrals based on Platelet Count:

• If the platelet count is less than 20 × 10⁹/L, or if there is active bleeding, arrange immediate referral or seek urgent specialist advice for direct assessment ¹. The risk of spontaneous haemorrhage significantly increases below 20 × 10⁹/L ¹.
• If the platelet count is less than 50 × 10⁹/L, arrange urgent referral ¹.
• For platelet counts within the range of 50–100 × 10⁹/L, arrange urgent referral if associated with evidence of pancytopenia (haemoglobin less than 100 g/L, neutrophils less than 1 × 10⁹/L), splenomegaly or lymphadenopathy, pregnancy, or upcoming surgical or interventional procedures ¹.
• If the platelet count is less than 100 × 10⁹/L and persistent and unexplained (on at least two occasions 4–6 weeks apart), refer to haematology in accordance with local guidelines ¹.

Review of Anticoagulant Therapy:

• When thrombocytopenia is identified in a patient on anticoagulant therapy, it is crucial to conduct an assessment to determine the possible underlying cause of the thrombocytopenia ¹.
• If a medicine is associated with thrombocytopenia, consider stopping the medicine in consultation with any relevant specialist, and review and repeat the platelet count in 1–2 weeks ¹.
• For patients on long-term anticoagulation, review their general health, risk of venous thromboembolism (VTE) recurrence, bleeding risk, and treatment preferences at least once a year ⁵. Thrombocytopenia significantly impacts the bleeding risk assessment ¹,⁵.
• In cases of acute upper gastrointestinal bleeding, non-steroidal anti-inflammatory drugs (NSAIDs) should be stopped during the acute phase ⁷. The risks and benefits of continuing antiplatelet agents (and by extension, anticoagulants) in patients with upper gastrointestinal bleeding should be discussed with the appropriate specialist (e.g., a cardiologist or stroke specialist) and the patient ⁷.
• Consider advising or prescribing a proton pump inhibitor (PPI) for patients on antiplatelet therapy with gastrointestinal risk factors to reduce the risk of gastrointestinal adverse effects ⁴. PPIs are also offered for primary prevention of upper gastrointestinal bleeding in acutely ill patients in critical care ⁷.

Patient Information:

• Ensure the patient receives verbal and written information about how to use anticoagulants, possible side effects (including bleeding), and what to do if these occur ⁵.
• Advise the patient to carry an 'anticoagulant alert card' at all times ³,⁵.