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Jordan A, Jain AG, Koipallil GK, Reddy M, Chakkoli S, Midha S, Phuoc V, Eatrides J, Erhardt C, Patel AK, Rico J, Visweshar N, Mhaskar R, Parikh N, Laber D, Jaglal M. Can we lower the platelet threshold of ≥ 50 × 10 9/L for performing a lumbar puncture safely in patients with hematological malignancies? Ann Hematol 2023; 102:663-668. [PMID: 36534146 DOI: 10.1007/s00277-022-05073-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
Lumbar punctures (LP) are routinely used to administer intrathecal chemotherapy for children and adults with hematologic malignancies. The current guidelines suggest a platelet threshold of ≥ 50 × 109/L prior to LP for intrathecal chemotherapy (ITC). This can be challenging in patients with hematological malignancies who are thrombocytopenic. We conducted a retrospective chart review of 900 LPs for ITC and compared adverse events in patients with a platelet count of ≥ 50 × 109/L and < 50 × 109/L. Cohort 1 included 682 LPs (75.8%) with a pre-procedure platelet count ≥ 50 × 109/L, and cohort 2 included 218 LPs (24.2%) with a pre-procedure platelet count < 50 × 109/L. Cohort 2 was further subdivided into pre-procedure platelet counts of 41 × 109/L-49 × 109/L (n = 43), 31 × 109/L-40 × 109/L (n = 77), 21 × 109/L-30 × 109/L (n = 84), and 11 × 109/L-20 × 109/L (n = 14). Among 900 LP procedures, a pre-procedure platelet count < 50 × 109/L did not demonstrate a higher rate of post-procedure adverse events (6.5% vs 6.8%, p = 0.8237). When cohort 2 was further stratified, the cohort with a pre-procedure platelet count of 21 × 109/L-30 × 109/L had the highest percentage of complications from LP (9.5%) and the highest rates of traumatic taps with observed LP RBC count > 200 (35.7%, p = 0.0015). The rate of red blood cells (RBC) in the CSF was significantly higher in the group with platelets < 50 × 109/L with observed LP RBC count ≥ 200 (31.2% vs 20.5%, p = 0.0016), ≥ 500 (27.1% vs 14.6%, p < 0.0001), and ≥ 1000 (23% vs 11.6%, p < 0.0001). No instances of epidural hematomas were seen. We found no significant difference in bleeding complications between patients undergoing LPs for ITC with a platelet count above or below 50 × 109/L.
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Affiliation(s)
- Aryanna Jordan
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA.
| | - Akriti G Jain
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Meghana Reddy
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Sanjay Chakkoli
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Shonali Midha
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Vania Phuoc
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jennifer Eatrides
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Crystal Erhardt
- H. Lee Moffitt Center and Research Institute, Tampa, FL, USA
| | - Ankita K Patel
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Juan Rico
- Department of Pediatrics, University of South Florida, Tampa, FL, USA
| | - Nathan Visweshar
- Department of Internal Medicine, Division of Hematology and Oncology, University of South Florida, Tampa, FL, USA
| | - Rahul Mhaskar
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Nainesh Parikh
- H. Lee Moffitt Center and Research Institute, Tampa, FL, USA
| | - Damian Laber
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Michael Jaglal
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Desai R, Koipallil GK, Thomas N, Mhaskar R, Visweshwar N, Laber D, Patel A, Jaglal M. Efficacy and safety of direct oral anticoagulants for secondary prevention of cancer associated thrombosis: a meta-analysis of randomized controlled trials. Sci Rep 2020; 10:18945. [PMID: 33144679 PMCID: PMC7642281 DOI: 10.1038/s41598-020-75863-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/13/2020] [Indexed: 12/29/2022] Open
Abstract
Direct oral anticoagulants (DOACs) may be good alternatives to low molecular weight heparin (LMWH) or vitamin K antagonists (VKA) for treatment of cancer associated thrombosis (CAT). We conducted a meta-analysis of ten randomized clinical trials to evaluate the efficacy and safety of DOACs in patients with CAT. All had study populations composed in entirety or in part of patients with CAT. The primary outcome (efficacy) was recurrent VTE and the secondary outcomes (safety outcomes) included major bleeding, clinically relevant non-major bleeding (CRNMB), and all bleeding (major bleeding + CRNMB). Participants treated with DOACs had lower risk of recurrent VTE, overall (RR 0.63; 95% CI 0.51-0.79; p < 0.0001), compared to LMWH (RR 0.57; 95% CI 0.40-0.83; p = 0.003), but not compared to VKA (RR 0.69; 95% CI 0.44-1.06; p = 0.09). Compared to LMWH, DOACs showed no difference in major bleeding risk (RR 1.31; 95% CI 0.78-2.18; p = 0.31), though had higher risk of CRNMB (RR 1.60; 95% CI 1.13-2.26; p = 0.008) and all bleeding (RR 1.49; 95% CI 1.10-2.01; p = 0.010). These results indicate that DOACs are more effective than LMWH for prevention of recurrent VTE with CAT though carry an increased risk for non-major bleeding compared to standard of care, LMWH.
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Affiliation(s)
- Ruchi Desai
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Division of Hematology, The Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Gautam Krishna Koipallil
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Nelson Thomas
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Nathan Visweshwar
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Damian Laber
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Division of Hematology, The Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Ankita Patel
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Division of Hematology, The Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Michael Jaglal
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA.
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA.
- Division of Hematology, The Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA.
- Tampa General, 3 Tampa General Circle, Tampa, FL, 33606, USA.
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