TPO-RAs

Q: 58 years old male with a history of end-stage liver cirrhosis is admitted to the ICU with upper gastrointestinal bleed (UGIB) due to esophageal varices. Labs showed a platelet count of only 10K PLT/µL. Before placing a large-bore central line, a medical student suggested administering thrombopoietin receptor agonists (TPO-RA). Considering the risk of bleeding and ongoing hematemesis, this appears to be a good idea.

A) True

B) False

Answer: B (False)

The FDA has approved two TPO-RAs for use in patients with chronic liver disease and thrombocytopenia who are undergoing high-risk invasive surgeries, such as spinal or cardiac surgery. However, there are many caveats regarding the use of TPO-RA.

It needs to be administered 10 to 13 days before the procedure. The total course time is 5 to 7 days, administered daily. The effect is transient.

It is not used in emergent and low-risk procedures such as central line placement, thoracentesis, paracentesis, or pigtail placements.

Two commercial TPO-RAs approved in the USA are Avatrombopag and Lusutrombopag.

#hematology

#procedures

References:

1. Nanchal R, Subramanian R, Karvellas CJ, et al. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations. Crit Care Med 2020; 48:e173.

2. O'Shea RS, Davitkov P, Ko CW, et al. AGA Clinical Practice Guideline on the Management of Coagulation Disorders in Patients With Cirrhosis. Gastroenterology 2021; 161:1615.

3. Terrault N, Chen YC, Izumi N, et al. Avatrombopag Before Procedures Reduces Need for Platelet Transfusion in Patients With Chronic Liver Disease and Thrombocytopenia. Gastroenterology 2018; 155:705.