Review article: a treatment algorithm for patients with chronic liver disease and severe thrombocytopenia undergoing elective medical procedures in the United States

Aliment Pharmacol Ther. 2020 Oct;52(8):1311-1322. doi: 10.1111/apt.16044. Epub 2020 Aug 19.


Background: Thrombocytopenia is the most common haematological abnormality in patients with chronic liver disease in the United States. Severe thrombocytopenia (platelet count <50 × 109 /L) can complicate the management of patients with chronic liver disease by significantly increasing the potential risk of bleeding during or after invasive procedures. The current standard-of-care treatment for severe thrombocytopenia is platelet transfusion. Novel agents that target the thrombopoietin pathway, including receptor agonists avatrombopag and lusutrombopag, have recently shown promise in clinical trials as alternatives to platelet transfusion.

Aim: To review treatment options for severe thrombocytopenia, including platelet transfusion and thrombopoietin-receptor agonists, with the aim of producing a simplified treatment algorithm.

Methods: Five liver disease specialists were assigned sections of the manuscript to research and present at a consensus meeting in April 2019, with the goal of creating an easy-to-use, effective treatment plan for severe thrombocytopenia in patients with chronic liver disease.

Results: Through discussion and collaborative decision making, a simplified algorithm was developed to provide guidance to healthcare professionals on treating severe thrombocytopenia in patients with chronic liver disease undergoing elective medical procedures in the United States. As part of these guidelines, we outline the use of the US Food and Drug Administration-approved thrombopoietin receptor agonists avatrombopag and lusutrombopag as well tolerated and effective alternatives to platelet transfusion.

Conclusions: This algorithm provides guidance for the management of severe thrombocytopenia to reduce bleeding risks in patients with chronic liver disease undergoing elective procedures, while reducing requirement for platelet transfusion.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Algorithms*
  • Chronic Disease
  • Elective Surgical Procedures / adverse effects
  • Elective Surgical Procedures / methods*
  • Elective Surgical Procedures / standards
  • End Stage Liver Disease / complications
  • End Stage Liver Disease / epidemiology
  • End Stage Liver Disease / therapy
  • Hemorrhage / epidemiology
  • Hemorrhage / etiology
  • Hemorrhage / prevention & control
  • Humans
  • Liver Diseases / complications
  • Liver Diseases / epidemiology
  • Liver Diseases / therapy*
  • Postoperative Hemorrhage / epidemiology
  • Postoperative Hemorrhage / etiology
  • Postoperative Hemorrhage / prevention & control*
  • Risk Factors
  • Severity of Illness Index
  • Thrombocytopenia / complications
  • Thrombocytopenia / epidemiology
  • Thrombocytopenia / therapy*
  • Treatment Outcome
  • United States / epidemiology