Transfusion Notes

Clinical Practice Guidelines:

• Prophylactic transfusions are generally not recommended in ITP patients without life-threatening hemorrhage.
• While there may not be direct adverse events linked to platelet transfusions in ITP, there is questionable benefit with this therapy. Therefore, risks become a predominant concern.
• Medical management of the underlying disease process is the recommended therapeutic strategy.

References:

• Goel R et al. Platelet transfusion practices in immune thrombocytopenia related hospitalizations. Transfusion 2019;59:169-176.
• Neunert C et al. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv 2019;23): 3829–3866.

Practical Guidance:

Immune Thrombocytopenia (ITP) is an autoimmune disease characterized by low platelets counts without a known cause for their destruction. Patients can present asymptomatically (an incidental finding) or with bleeding episodes. ITP can be primary or secondary, and typically is a diagnosis of exclusion. Some patients will receive platelet transfusions prior to clinical diagnosis, classically without a robust count response.

In general, it is best not to follow a specific threshold when guiding prophylactic platelet transfusions in ITP. It is important to remember that platelet transfusions typically do not substantially increase platelet counts in this population – the platelets have shortened survival after they are transfused. Therefore, risks of transfusion can easily outweigh the benefits in an otherwise stable patient. It is not hard to imagine a scenario in which a stable ITP patient receives countless platelet transfusions to “fix” their platelet count without any success – this patient is at risk for all the complications associated with blood product transfusions, without seeing the benefit of a platelet response.  Platelets are available for those patients with life-threatening bleeding, but this decision should be made on a case-by-case basis. Otherwise, the stable ITP patient should be managed conservatively and clinically from a transfusion perspective.

KEY TAKE AWAYS:

• Platelet transfusions may not cause harm, but have questionable (at best) benefit to a stable patient with ITP.
• There is no role for prophylactic platelet transfusions, as the risk may outweigh the harm in an otherwise stable ITP patient.
• Platelets may be used in emergent settings for life-threatening bleeds, although they may not prove to be useful. This should be assessed on a case-by-case basis.
• The underlying process should be the target of therapy.