Written by Peter Liu
Spoon Feed
The TOPPS trial showed that patients undergoing treatment for hematologic malignancy who develop thrombocytopenia <10 x109/L should receive prophylactic platelet transfusion to prevent bleeding.
Platelets under ten, transfuse again
The American Society of Clinical Oncology (ASCO) recommends daily prophylactic platelet transfusions for patients with hematologic malignancies and platelet counts < 10 x109/L. Other societies including CHEST and AABB have extended these guidelines to most inpatients, largely based on studies like the TOPPS trial.
TOPPS was a multicenter, randomized, open-label noninferiority trial of 600 patients with hematologic malignancies undergoing chemotherapy or stem-cell transplant across 14 centers in the UK and Australia. Patients in the prophylaxis arm received daily platelet transfusions when platelet counts fell below 10 x109/L. Those in the no-prophylaxis arm received platelet transfusions only with bleeding events or at the discretion of the clinician. WHO grade ≥2 bleeding occurred in 50% of the no-prophylaxis group vs. 43% with prophylaxis (adjusted difference 8.4%; 90%CI 1.7–15.2), failing to demonstrate non-inferiority. Bleeding occurred earlier in the no-prophylaxis group (HR 1.30; 95%CI 1.04–1.64; P = 0.02), and bleeding-day rates were higher (rate ratio 1.52; 95%CI 1.14–2.03; P = 0.004). One serious transfusion-related adverse event (urticaria and angioedema) occurred in the prophylaxis group, but safety was otherwise similar between arms.
Importantly, most bleeding events were WHO grade 2, and <2% were grade 3 or 4. Nonetheless, the results show clear bleeding-prevention effects of prophylactic platelet transfusion.
How does this change my practice?
In my inpatient practice, I typically manage prophylactic platelet transfusions in concordance with CHEST Guidelines, and I will typically give daily platelet transfusions for inpatients with platelets <10. This practice is based on extrapolation of results from studies such as TOPPS.
Source
A no-prophylaxis platelet-transfusion strategy for hematologic cancers. N Engl J Med. 2013 May 9;368(19):1771-80. doi: 10.1056/NEJMoa1212772. PMID: 23656642
