Coping With Thrombocytopenia (Low Platelets) During Chemotherapy

Symptoms, Treatments, and Coping with a Low Platelet Count During Chemo

lab technician drawing blood
What is thrombocytopenia and what should you know about this condition during chemotherapy?. istockphoto.com

Thrombocytopenia (a low platelet count in the blood) occurring as a side effect of chemotherapy is less of a problem than in the past, but can still be a serious concern. What should you know about the symptoms of a low platelet level and what you can do yourself to reduce your risk from this complication of chemotherapy?

What Is Thrombocytopenia?

Thrombocytopenia is defined as a decreased number of platelets in the blood.

A low platelet count can, in turn, result in bleeding and/or the need to delay chemotherapy. Thrombocytopenia is usually defined as less than 150,000 platelets per cubic millimeter of blood, although significant bleeding does not usually occur until the level drops below 20,000 or even 10,000. That said, it is important to know that there is not a clear relationship between platelet level and the tendency to bleed. If you have any symptoms such as bleeding or bruising, it's important to let your doctor know, no matter the level of your platelet count. 

Normal and Abnormal Platelet Levels - Diagnosis

Your doctor will order a complete blood count (CBC) before and after chemotherapy to see if you have a low platelet level. A normal platelet count (thrombocyte count) is usually defined as having 150,000 to 400,000 platelets per cubic millimeter of blood. A level below 150,000 is considered abnormal, or thrombocytopenia.

Most of the time a level of platelets greater than 50,000 is not associated with any majopr problems. A level of 10,000 to 20,000 may sometimes cause bleeding, but most often counts can drop to 10,000 or less before causing significant bleeding.

In general, levels less than 10,000 are usually treated (most often with a platelet transfusion) but levels less than 20,000 may also be treated, especially if associated with a fever.

For those going through chemotherapy, levels of even 50,000 to 100,000 may result in a delay of chemotherapy. It's important to note that everyone is different, and the same count in two different people could be worrisome for one and of little concern in another.

Platelets in the bloodstream live approximately 8 to 10 days and are rapidly replenished.

What Causes Thrombocytopenia During Cancer Treatment?

The most common cause of thrombocytopenia in people with cancer is bone marrow suppression related to chemotherapy. (See other causes below.) Chemotherapy destroys rapidly dividing cells, such as those in the bone marrow which become platelets. In addition to thrombocytopenia, bone marrow suppression from chemotherapy may result in a low red blood cell count (chemotherapy-induced anemia) and a low level of the type of white blood cells known as neutrophils (chemotherapy-induced neutropenia) which defend against bacterial infections.

Many chemotherapy drugs do not affect platelet levels to a degree which is significant enough to require treatment, but some drugs are much more likely than others to reduce counts.

Drugs commonly associated with thrombocytopenia include:

  • Platinum-based drugs such as Paraplatin (carboplatin) and Platinol (cisplatin)
  • Gemzar (gemcitabine)
  • Taxol (paclitaxel) 

Thrombocytopenia related to chemotherapy is often a short term problem. Platelet levels begin to drop around one week after a chemotherapy session and reach the lowest level (the nadir) at around 14 days following an infusion. Levels return to normal in around 28 to 35 days following but may take up to 60 days to reach pre-treatment levels.

Other Causes of Thrombocytopenia in People with Cancer/Different Diagnosis

There are several other reasons that platelet counts may be lower in people with cancer. In addition to bone marrow suppression as noted above, these may include:

  • Immune thrombocytopenia (ITP) - Immune thrombocytopenia occurs when your body makes antibodies against your own platelets. This is most common with cancers such as Hodgkin disease and chronic lymphocytic leukemia
  • Infections, especially viral infections
  • Other medications which can cause low platelets such as the antibiotic vancomycin, and anti-viral medications
  • Tumor spread to the bone marrow (most commonly lymphomas, breast cancer, lung cancer)
  • Thrombotic microangiopathy (a condition in which the inner cell lining of blood vessels is damaged which sometimes occurs with chemotherapy drugs such as Mitomycin C and gemcitabine.)

Symptoms of Thrombocytopenia

Symptoms you might experience with thrombocytopenia include:

  • Easy bruising
  • Bleeding – From your nose, your mouth (especially with brushing,) rectum (black or bloody bowel movements), or stomach (vomiting blood or coffee-appearing material)
  • Petechiae – Red spots on your skin (most common on the lower legs), that do not turn white when you press on them with your fingers
  • Ecchymosis – Larger reddish-blue patches (bruises) on your skin
  • In women, periods that are heavier than normal
  • Joint and muscle pain
  • Weakness
  • Headaches

Treatment/Prevention

It's important to first determine the cause of your thrombocytopenia as there could be different reasons for your low platelet level which are treated in different ways. For example, if it is related to chemotherapy drugs, treatment may include delaying chemotherapy, whereas if it related to immune causes, steroids may be part of the recommended treatment.

Depending upon the level of your platelets, and whether or not you have any symptoms, your doctor may recommend treatment to raise your platelet count. Options include:

  • Platelet transfusions - Platelet transfusions are the most common method of treating thrombocytopenia, especially short-term thrombocytopenia related to chemotherapy drugs. Transfusions can be used as a therapy (to increase platelets in those who are actively bleeding) or preventatively (for those with a low or expected low platelet count but who are not bleeding). The most common side effect is a temporary fever. Rare side effects can include transfusion reactions or transmission of infections such as hepatitis.
  • Delaying chemotherapy - Delaying chemotherapy, or adjusting the dose may sometimes be necessary.
     
  • Medications that stimulate the formation of platelets - Medications are sometimes used to stimulate the bone marrow to make more platelets. The most common side effect is fluid retention (swelling). 
     
  • Clinical trialsClinical trials are ongoing, looking at other methods to lower the risk of thrombocytopenia during chemotherapy.

Coping with Thrombocytopenia/Prevention

In addition to any treatment recommended by your doctor, if you are at risk for thrombocytopenia try to:

  • Avoid aspirin and anti-inflammatory medications such as ibuprofen and naproxen. Ask your doctor about any over-the-counter or herbal medications you take, since some of these can increase bleeding.
  • Avoid alcohol as this can increase the risk of bleeding.
  • Use a gentle toothbrush. Many oncologists recommend that you avoid using dental floss as well, but this has not yet been proven to help.
  • Use an electric razor to avoid cuts.
  • Blow your nose gently.
  • Try not to become constipated, and if you do, avoid straining or using suppositories. Some pain medications, as well as dietary changes, can cause constipation, and your doctor may recommend a stool softener or other medications for you during chemotherapy to prevent this.
  • Avoid situations where you could be injured or otherwise hurt yourself. Take extra care when using scissors, while cooking, and using tools. Avoid contact sports.

When to Call the Doctor

You should let your doctor know if you develop any symptoms of thrombocytopenia. Call her immediately if you have bleeding that you are unable to stop, a new headache, blurred vision or weakness.

Sources:

Estcourt, L., Stanworth, S., Doree, C., Hopewell, S., Trivella, M., and M. Murphy. Comparison of Different Platelet Count Thresholds to Guide Administration of Prophylactic Platelet Transfusion for Preventing Bleeding in People with Haematological Disorders after Myelosuppressive Chemotherapy or Stem Cell Transplantation. Cochrane Database of Systematic Reviews. 2015. 18(11):CD010983.

Kuter, D. Managing Thrombocytopenia Associated with Cancer Chemotherapy. Oncology (Williston Park). 2015. 29(4):282-94.

Liebman, H. Thrombocytopenia in Cancer Patients. Thombosis Research. 2014. 133 Suppl 2:S63-9.

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