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Low Platelet Counts in Cancer Patients: Should Heparin for Venous Thromboembolism Prophylaxis Be Instituted?

Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, IL

To the Editor:

Dr Lyman and colleagues in the American Society of Clinical Oncology Guideline Recommendations for Prophylaxis of Venous Thromboembolism do not comment on the indications for heparin in patients with thrombocytopenia, which is common among patients with malignancy.¹

We recently witnessed a hospitalized patient with acute leukemia and platelet levels of 18,000/mm³ who developed an acute upper extremity deep vein thrombus. Although in her case, it was clearly related to a peripherally inserted central catheter in the affected limb, we wonder if it demonstrates her being at a considerably high risk for spontaneous thromboembolic events. The treating team could not gather sufficient evidence to institute prophylactic dosage of heparin in view of her high presumed risk of bleeding. Two out of the three major randomized, double-blind, placebo-controlled trials on thromboembolism prophylaxis in hospitalized patients (the Prophylaxis in Medical Patients with Enoxaparin trial and the Prevention of Recurrent Venous Thromboembolism study), have specifically excluded patients with platelet counts less than 100,000/mm³.^2,3 As such, evidence for thromboembolism prophylaxis in patients with platelet count less than 100,000/mm³ is probably not clear.

Should thrombocytopenia be a contraindication for heparin prophylaxis? At what level of the quantitative defect should prophylaxis be safely withheld? We seek authors' expert opinion on this matter of importance.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Lyman GH, Khorana AA, Falanga A, et al: American Society of Clinical Oncology guideline: Recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 25:5490-5505, 2007[Abstract/Free Full Text]

2. Samama MM, Cohen AT, Darmon J-Y, et al: A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. N Engl J Med 341:793-800, 1999[Abstract/Free Full Text]

3. Leizorovicz A, Cohen AT, Turpie AG, et al: Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. Circulation 110:874-879, 2004[Abstract/Free Full Text]

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  Alok A. Khorana, Charles W. Francis, Anna Falanga, and Gary H. Lyman
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