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 NICE CKS,NICE CKS.

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 NICE CKS. The risk of spontaneous haemorrhage significantly increases below 20 × 109/L NICE CKS.


• If the platelet count is less than 50 × 109/L, arrange urgent referral NICE CKS.


• 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 NICE CKS.


• 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 NICE CKS.

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 NICE CKS.


• 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 NICE CKS.


• 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 NICE NG158. Thrombocytopenia significantly impacts the bleeding risk assessment NICE CKS,NICE NG158.


• In cases of acute upper gastrointestinal bleeding, non-steroidal anti-inflammatory drugs (NSAIDs) should be stopped during the acute phase NICE CG141. 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 NICE CG141.


• 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 NICE CKS. PPIs are also offered for primary prevention of upper gastrointestinal bleeding in acutely ill patients in critical care NICE CG141.

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 NICE NG158.


• Advise the patient to carry an 'anticoagulant alert card' at all times NICE CKS,NICE NG158.